text:
care for you
90 Yishun Central Singapore 768828 www.alexandrahealth.com.sg
Alexandra Health
Annual Report 2011-12
OUR Help our people live a long, healthy life and support them with thoughtful, dignified care to the end.
OUR Provide good-quality, affordable and hassle-free healthcare with science, love and wisdom.
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Message from Chairman, Alexandra Health Board of Directors Senior Management Clinical Heads of Departments Getting a Bed to You on Time Making It Better, Faster, Cheaper and Safer for You Helping You to Stay Healthy Caring for You Beyond the Hospital Walls Building a New Community Hospital for You Investing in the People Who Serve You Operational Highlights
from CHAIRMAN,
Alexandra HEALTH
Khoo Teck Puat Hospital (KTPH) successfully opened in 2010 and has since been serving the community in Northern Singapore as a flagship acute care provider. The hospital was planned and designed with the patient at the centre of everything we do. In the second year of operation, KTPH has overcome most of its teething challenges and continues to be committed to providing quality service for all our patients. Workload continued to increase steadily with A&E attendances growing by 30% and outpatient attendances by 47% yearon-year. Inpatient days increased by 24%. Staff training was and remains a high priority to ensure we maintain good patient safety and a high standard of care. Despite the higher workload, the team continued to pursue learning, research and innovation. Whether it is in genome research for diabetic patients, using business analytics to study patient behaviour, or harnessing IT to strengthen efficiency, the aim is to deliver better, faster, cheaper and safer medical care. While KTPH continued to enhance the hospital's services and processes, Alexandra Health took the next steps toward designing a holistic healthcare hub in the North. Faced with overwhelming demand for hospital beds, it became apparent to us that we needed a more sustainable model for healthcare. We sought to get a deeper understanding of the evolving medical and healthcare needs of the community by conducting ground research and studying the behaviour pattern of our patients. From this, we realised that medical care must go beyond treating an illness episode. We need to embrace care integration by providing seamless medical care for patients and ensuring its continuity outside the hospital. Only when it is integrated into the life of the patient can medical care be truly relevant and impactful. Care integration is not a new concept to the healthcare industry, but has become extremely crucial to an ageing population. This not only refers to unifying key components of patient care delivery across the respective healthcare
agencies, but is also about looking at the healthcare needs of the person in an integrated, holistic manner. Alexandra Health's approach was two-pronged - keeping the population healthy and providing better support for post-illness care. We spearheaded programmes to raise awareness for individuals to take better care of their health. And based on the analysis of patients' needs, we designed and piloted a homecare intervention programme involving nurses, therapists, social workers as well as other healthcare partners to enable and support the aged at home. At the same time, Alexandra Health has begun planning and designing the new community hospital at Yishun for intermediate and rehabilitative care. The new community hospital, when ready in 2015, will enable patients to step appropriately from acute care to recover and rehabilitate in a comfortable and healing environment. We are thankful to like-minded partners from within and outside the healthcare industry who were willing to pilot programmes with us. At the community level, we strengthened collaborations with different agencies, including the Agency for Integrated Care (AIC), as well as constituency leaders and advisors. It is through their support and collective wisdom that progress had been made. The journey to redesigning better patient care is one of continuous improvement and collaboration. The Alexandra Health Board and management team look forward to the continued support from the Ministry of Health, community leaders in the North, various government agencies, our friends and partners, who are walking alongside with us in this journey.
Ms Jennie Chua
Chairman Alexandra Health Board
Alexandra Health Annual Report 2011-12
of DIRECTORS
Ms Jennie Chua Chairman, Alexandra Health Board
Mr Robert Chew
Mr Douglas Foo
Mr Roy Quek
Mr Seah Moon Ming
Ms Mavis Khoo
Mr Ramlee Bin Buang
Mr Tan Boon Khai
Mr Anthony Seah
Dr Quek Peng Kiang
Mr Ong Ye Kung
Mr Liak Teng Lit
Ms Irene Png Company Secretary
Alexandra Health Annual Report 2011-12
Senior MANAGEMENT Mr Liak Teng Lit
A/Prof Pang Weng Sun
Chief Executive Officer
Chairman Medical Board, Chairman Medical Board Yishun Community Hospital
A/Prof Kenneth Mak
Dr Wong Moh Sim Dy CMB, Head & Senior Consultant, Laboratory Medicine
Dr Francis Lee
Dr Ong Hean Yee
Dr Wu Loo Cheng
Prof Wilfred Peh
Dr Pek Wee Yang
Dr James Low
Dr Yip Chee Chew
Dr Chin Thaim Wai
Dr Paul Mok
Head & Senior Consultant, Acute & Emergency Care Centre
A/Prof Koh Kwong Fah
Dr Michael Wong
Dr Christopher Cheok
Mrs Chew Kwee Tiang
Ms Irene Png
Dy CMB, Head & Senior Consultant, Anaesthesia
Dy CMB, Head & Senior Consultant, Health for Life Centre
Dy CMB, Head & Senior Consultant, Psychological Medicine
Chief Operation Officer
Chief Financial Officer
Head & Senior Consultant, Diagnostic Radiology
Ms Lynn Gan
Mr Alvin Ong
Mr Lau Wing Chew
Chief Human Resource Officer
Chief Information Officer, IT & Systems
Chief Transformation Officer Director, Nursing
Ms Low Beng Hoi
Mdm Chua Gek Choo
Dr Eugene Shum
Director, Nursing, Yishun Community Hospital
Director, Medical Affairs & Innovation
Head & Senior Consultant, Ophthalmology & Visual Sciences (Eye)
Heads OF DEPARTMENTS
Ms Cecilia Pang
Ms Cheong Choy Fong
Mr Donald Wai
Ms Yen Tan
Ms Winifred Lau
Ms Fatimah Moideen Kutty
Director, Corporate Communications
Director, Quality Management Office
Director, Hospital Planning
Director, Operations
Director, Operations
Dy Director, Operations
Head & Senior Consultant, Cardiology
Head & Senior Consultant, General Medicine
Head & Senior Consultant, Orthopaedic Surgery
Head & Senior Consultant, Dental Surgery
A/Prof Sum Chee Fang Head & Senior Consultant, Diabetes Centre
Head & Senior Consultant, Geriatric Medicine
Head & Senior Consultant, Otolaryngology
Alexandra Health Annual Report 2011-12
a bed to you ON TIME
Alexandra Health Annual Report 2011-12
"Already, we are seeing signs of capacity constraints across the system – from high bed occupancy rates to long waiting times for appointments." – Health Minister Mr Gan Kim Yong's MOH 2012 Committee of Supply Speech on Healthcare 2020: Improving Accessibility, Quality and Affordability for Tomorrow's Challenges, 6 March 2012
In the second year of Khoo Teck Puat Hospital's (KTPH) operation, demand for subsidised hospital beds continued to remain extremely high at above 95% over the past year. Average bed occupancy across all bed classes was a high 86%. Bed demand is expected to continue to rise over the next few years with the increase in the national population and the ageing population.
A Bed for You When You Need It To pre-empt and prevent the scenario of our patients having to wait and possibly be turned away because of the unavailability of beds, KTPH focused our efforts in the past year into managing admission and discharge processes so as to ensure effective use of bed resources. Bed demand is expected to continue to rise over the next few years
The priority was to reduce the average length of stay and improve bed turnaround time so that we can speed up admission for acutely ill patients.
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Demand for subsidised beds continued to rise steadily, hitting close to 120% as at end-March 2012. Average bed occupancy across both subsidised and private classes was a high 86% in FY 2011-12.
Managing Admissions KTPH studied patterns of patient admissions and reviewed our internal processes to accurately diagnose and make appropriate referrals for outpatient treatment. We also collaborated with various community partners to manage non-urgent or unnecessary transfers.
Bed days saved per month
Bed days saved per month
By collaborating with Alexandra Hospital, Institute of Mental Health and the Destitute Homes to manage non-urgent admissions.
By referring patients directly to KTPH's Short Stay Surgical Unit (SSSU) for minor operations.
No. of patients per month
Bed days saved per month
Referred directly to KTPH's Specialist Outpatient Clinics (SOCs) on the direct access scheme. This included same-day access and outpatient appointments within a few days for urgent consultations with specialists.
By placing patients requiring antibiotics treatment on the Outpatient Parenteral Antibiotic Service (OPAT) in the comfort of their own homes.
Innovating for Faster Bed Turnaround KTPH also leveraged on innovation to enhance communication flow for timely information on bed availability. Working with Singapore Polytechnic (SP) and SciMed (Asia) Pte Ltd, we developed a web-based program that provides realtime updates on bed availability status. When a bed is ready, housekeeping staff will press a conveniently located button by the bed to alert our Admissions staff immediately of bed availability. Previously, the housekeeping staff would notify the ward nurse after a few beds had been cleaned. The ward nurse would then log into the system to inform Admissions of bed availability. This process led to a delay of a few hours in bed turnaround.
Faster Discharges To ensure faster bed turnaround and availability, KTPH also looked into ways of facilitating the timely and faster discharge of patients without compromising patient safety and quality of patient care.
Building More Capacity
More Subsidised Beds In constructing KTPH, our idea was to build a healing environment with several rooftop gardens across the hospital. Selected gardens were reserved spaces to cater for future expansion.
No. of days for transfer
Beds turned around daily at a faster time
Of a KTPH patient to Ang Mo Kio Community Hospital for rehabilitation and sub-acute care. This is an improvement from the previous 14 days.
With ambulatory patients directed to the discharge lounge while waiting to be brought home by their loved ones. This means their beds can be cleaned and prepared for the next patient about two hours ahead of time.
Thus, when KTPH's study of admissions patterns showed that 47% of our total inpatient admissions required C-class beds, we decided to convert the rooftop garden on Level 10 of Tower B to a new subsidised ward. Our expansion plans were brought forward and construction for the new ward will begin in July 2012. When fully operational in January 2013, the new ward will add another 32 C-class beds to capacity.
Patients waiting in the comfort of the discharge lounge
Bed availability information is relayed to the Admissions staff with the push of a button
Converting one of the garden spaces into a new ward in 2013
Alexandra Health Annual Report 2011-12
better, faster, cheaper and safer FOR YOU
"We are what we repeatedly do. Excellence, then, is not an act, but a habit." – Aristotle
As a new hospital faced with an incessantly heavy workload, one of our main challenges was in the training of new staff. We had to bring new employees up to speed quickly and instil in them the high quality of patient care that has placed Alexandra Health (AH) at the top in patient satisfaction surveys by the Ministry of Health for seven successive years. Many fundamental practices that had become the "DNA" of AH were reinforced with our staff so that we can consistently deliver "care that is good enough for our own mothers, without the need for special arrangements". Dr. Michael Brennan, co-founder of Mayo Clinic's Center for Innovation, presented his lecture on "Reflections on the Fruits of Innovation". He reminded us that "a good innovator should also love observing their surroundings, asking questions when in doubt, and applying associative thinking to join the dots in the puzzles effectively".
Whether it was through Quality Conventions, participation in Learning Journeys, improvement projects, innovation and research, our goal was to make it better, faster, cheaper and safer for our patients. Reinforcing Patient Care and Safety through Quality Conventions We doubled the frequency of our Quality Conventions to further strengthen staff's attention to quality care and patient safety in the hospital.
Learning from Healthcare Providers Globally In FY 2011-12, two cross-disciplinary teams visited Aravind Hospital in India and Mayo Clinic's Center for Innovation in the USA on Learning Journeys.
At AH's Quality Convention in October 2011, safety in patient care was re-emphasised. A/Prof Paul Barach from the University of South Florida, US, reminded us of the necessity for strict adherence to standard protocols and continuous selfassessment. "Being anxious, aware of problems and looking for trouble are fundamental principles of high-reliability organisations," he said.
A team of nine Senior Management members, including CEO Mr Liak Teng Lit, visited Aravind Eye Hospital in India, from 20 to 24 February 2012.
A/Prof Paul Barach speaking about safety in patient care at AH's Quality Convention
In January 2012, AH's Quality Convention focused on innovation as one of the key pillars in improving quality care and patient experience. Our staff proudly displayed the innovations that we had implemented across the hospital. Many of these innovations were done by frontline staff who had observed the needs of their patients and experimented with simple solutions to help them overcome their difficulties. 16
Dr Michael Brennan, co-founder of Mayo Clinic's Center for Innovation, (centre) looking at one of the innovations by Senior Nurse Clinician Toh Hai Moy (left)
At Aravind, the team learned how a far-sighted vision, deep culture and passionate leadership can rally people towards the vision of eliminating unnecessary blindness. We also studied their model of providing quality and patient-centric care to a high volume of patients. The Aravind Team also shared their strategies on recruitment, training, and development of paramedical staff and how mass outreach activities are conducted to reach underserved villages in India. A team of seven including Mrs Chew Kwee Tiang, Chief Operating Officer (COO), Kenneth Mak, Chairman, Medical Board (CMB) and other clinicians visited Mayo Clinic's Center for Innovation (CFI) in Minnesota, USA, from 11 to 16 September 2011.
The objective of the trip was to learn about CFI's tools and approaches that AH can adopt to facilitate healthcare innovation. Upon return, the team enhanced our own Innovation Lab and refined our focus areas in healthcare innovation. Top:
Drawing inspiration from Mayo Clinic's Center for Innovation, we conducted our own Design Thinking workshops to ensure the innovative spirit pervades across the organisation. (Inset) Visiting and learning from Mayo Clinic's Center for Innovation in September 2011 Bottom:
Learning lessons in leadership, simplicity and high impact outreach from Aravind Hospital
Transforming and Improving through Kaikaku and Kaizen FY 2011-12 also saw the strong revival of establishing improvement teams across all levels of the hospital. Three Kaikaku (改革) teams led by the most senior leaders as well as six high-level Kaizen (改善) teams were formed. Kaikaku and Kaizen are Japanese terms used in the Toyota Production System to refer to transformative change and continuous improvement projects respectively. The teams brainstormed and developed sub-strategies and roadmaps to address four key strategic thrusts for the healthcare cluster. We specifically looked at processes to ensure safe care for patients around the clock, especially in the middle of the night.
Innovating for Patient Safety through Integrated Information Flow Doctors, nurses and other healthcare professionals use different electronic systems to update various types of information for each patient. Vital information could be omitted while cross-referencing different systems.
Provide quality healthcare that is comprehensive and affordable
Four Key Strategic Thrusts:
To improve patient safety, KTPH customised an "Andon Board" to provide simplified visual management of each patient's condition and status updates. The Andon Board integrates information from different sources (medication dispensation, laboratory and diagnostic radiology results) with each patient's electronic medical record (EMR).
Keep patients in the North healthy and out of the hospital
Provide hassle-free healthcare experiences
Build an organisation with emphasis on people excellence to realise Alexandra Health's Vision and Mission
Creating an Orderly Work Environment with the 5-S 5-S (Sort, Set in order, Shine, Standardise, Sustain) is a systematic way of creating a safe, clean and orderly workplace with good visual management so that we can reduce waste and enhance efficiency.
Research Points the Way for the Future of Medicine Clinical Research plays an important part in enhancing care for our patients. For example, patients who present the same symptoms are traditionally given similar diagnosis and offered standardised drug prescriptions. However, due to inherited and acquired variations in their genetic makeup, patients can respond differently to the same drugs.
With new staff joining the organisation, we conducted several workshops throughout the year to inculcate the 5-S concepts. To ensure implementation and consistency, we also trained 120 volunteer staff as auditors. They conducted quarterly audits in 67 areas/departments throughout the hospital in 2011.
Hence, one of the most significant research in the past year was in the field of pharmacogenetics and personalised medicine, i.e. how genes could affect the way that doctors treat patients and prescribe their medication.
5-S ensures predictability and reliability:
• Items needed for patient care are neatly pre-packed.
A nurses' admissions trolley that is neatly systemised and standardised in accordance with the principles of 5-S
• Proper labelling of boxes and shelves provides good visibility for staff to retrieve items easily and quickly.
This "single view" enables doctors, nurses and pharmacists to access patients' critical results, urgent doctors' orders and latest health updates in real-time. The Andon Board has eliminated 700 phone calls each month from the wards to different departments to check on status updates.
The team of researchers from Alexandra Health found that for a particular group of diabetic patients, accurate genetic diagnosis could make a tremendous impact on their care and outcome. Mrs Tan's (not her real name) case presented a unique clinical backdrop for research in the area of genomic medicine.
Diagnostic molecular gene testing of Mrs Tan showed that because of her genes, she did not respond as positively to the diabetes treatment. Results also suggested that she could potentially benefit more from oral diabetic medication, instead of insulin injections. This oral treatment would be cheaper for Mrs Tan and give her a higher quality of life.
• Aids in the timely replenishment of items.
How Genes Can Affect a Diabetic Patient's Response to Insulin
31-year-old Mrs Tan was diagnosed with Diabetes Mellitus when she was 12. Since then, she needed painful insulin injections several times a day for many years.
• Enables the return of items to their proper places for the next user. • When an item is readily available, care for patient would not be compromised.
Research forums are held annually for our doctors to share learning and best practices in clinical research
Alexandra Health Annual Report 2011-12
stay healthy
Alexandra Health Annual Report 2011-12
Community Outreach
"The community and environment are powerful influences on individual behaviour, and we have [to tap] on these to further our health promotion objectives." – Minister of State for Health Dr Amy Khor's Committee of Supply Speech – Community Health: Working with and through the Community for Better Health Outcomes, 7 March 2012
18,000 Screened
2,000 individuals
Elderly Households
From April 2011 to March 2012, KTPH's Health For Life (HFL) team screened approximately 18,000 individuals in 20 communities and 54 workplaces
Patients who are determined to keep fit and healthy have a ready partner in Alexandra Health (AH). As demand for healthcare surges, we are focusing our efforts on increasing awareness of preventive and pre-illness care, to minimise unnecessary admission to the hospital.
Nipping Illness in the Bud Early detection and intervention of illness is crucial to ensuring a healthy population. Pre-emptive care management can reduce the possibility of hospital admission in your lifetime. In FY 2011–12, KTPH increased our health screening outreach to workplaces and communities in the North. These health screenings enable us to detect the risk factors such as obesity that could lead to common chronic diseases like diabetes and hypertension.
Outreach to the Workplace
We spend a large part of our day at work. Long hours at work and a hectic schedule often lead to a sedentary lifestyle and unhealthy eating habits. Colleagues can play an important role in helping each other to maintain healthy habits and practices through peer influence and mutual support. To help corporations keep employees healthy, the KTPH's HFL team was at various workplaces to offer: • specific health programmes for employees based on organisational needs and goals; • onsite health screenings and appropriate intervention programmes; and • talks to raise awareness of and educate individuals on chronic illnesses and travel health. Outreach to the Community Improving the population's health is one of the key goals of the HFL team in KTPH. By collecting adequate health statistics through health screenings in the community, we hope to identify the prevalent health issues in the North. • Working with People's Association (PA), the HFL team screens about 2,000 residents over 50 years of age at more than 10 PA's wellness centres islandwide. • Post screening, the team conducts follow-up calls to remind residents to encourage them to seek help from their general practitioners early. • Appropriate intervention programmes are then tailored to address targeted needs.
Innovating to 'Sneak' Exercise into Your Life
Outreach to the Home As part of a nationwide programme to study the impact of home modifications in the homes of elderly, KTPH was invited to pilot a study project involving 300 elderly.
We all know we need to exercise three times a week, 20 minutes each time. But not many people do it. Alexandra Health worked at reframing exercise as fun activities so that people will unconsciously 'exercise'.
Our multi-faceted intervention strategy included: • pre-intervention falls assessment • falls education • exercise programmes to improve strength and mobility • home modifications for the participants • post-intervention survey
Exercising on a stationary bike in the gym is boring and daunting. However, cycling and using your pedal power to propel water jets to hit targets in the pond is novel and exciting. Meet KTPH's specially retrofitted stationary bike.
KTPH also educated contractors from the Housing and Development Board (HDB) on appropriate home modifications and the correct placement of safety aids for the elderly.
The bike draws water from the pond as you pedal, and shoots the water back out through an attached nozzle. The harder you pedal, the farther you shoot the water jets. The bike has attracted residents passing by the Promenade to jump on, and do their bit of "stealth" exercise.
ABLE Studio Expands Outreach ABLE studio, a one-stop concept shop and a platform for sharing ideas for independent living, underwent a makeover in FY 2011–12. It doubled its original size to better cater to customer needs. With a wider range of products, tested and selected by KTPH therapists, patients can easily find equipment and aids that are suited to their needs and budgets. The shop has also extended its services to include home assessments and recommendations to make it safer for patients rehabilitating in the comfort of their own homes.
The old Yishun Pond in 2007 before redevelopment
We Shape our Environment and then the Environment Shapes Us In November 2011, the transformation of the adjacent Yishun Pond and its surroundings into a beautiful waterfront and health-promoting park was completed. The creation of this new health and recreational area adopts the concept of "placemaking" and is part of AH's efforts to foster the spirit of staying active and keeping fit amongst staff and residents in the vicinity. "I've been staying in Yishun for about 25 years. With the recent changes to this area, it has become a lot more beautiful. I also see more people taking evening strolls and cycling around Yishun Pond. Sometimes, this area can get quite crowded, which is an encouraging sign! I would strongly encourage more people to take up some form of exercise to keep themselves fit." – Mr Richard Chew, 59, Yishun resident and regular runner
Yishun Pond with the new promenade Middle: Top:
A KTPH physiotherapist explaining home modification possibilities to an elderly resident Left:
The new and improved ABLE Studio offers a range of home care products for recovering patients and the elderly
CEOs from AH, HDB, PUB, NParks, URA launching the all-new Yishun Pond in November 2011 with Guest-of-Honour National Development Minister Khaw Boon Wan Bottom left:
Having fun with kampong games like hopscotch at the timber decking area Bottom right:
Mr Richard Chew jogging at the promenade
Alexandra Health Annual Report 2011-12
Caring for you BEYOND THE HOSPITAL WALLS
Photo used with consent from patient
Alexandra Health Annual Report 2011-12
"…through team-based care, we can help patients slow down their disease progression, reduce complication rates and in turn, minimise referrals to hospitals." – Health Minister Mr Gan Kim Yong's MOH 2012 Committee of Supply Speech on Healthcare 2020: Improving Accessibility, Quality and Affordability for Tomorrow's Challenges, 7 March 2012
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Singapore's rapidly ageing population requires Alexandra Health (AH) to develop a new model of care to cope with the increased demand for healthcare services. KTPH's overwhelming workload at A&E and demand for subsidised beds underscored the need to look for solutions beyond the hospital's walls.
Identifying "Frequent Flyers" In FY 2011–12, we used health analytics and hot-spotting to identify a pattern of frequent readmissions to the hospital, which contributed to the high demand for subsidised beds. We identified a group of 300 patients with an average of 3.6 admissions per patient, taking up a total of 7,900 bed days over a six-month period. We affectionately termed these patients "Frequent Flyers".
What is health analytics? Applying business analytics tools to patient data in order to forecast healthcare usage patterns and behaviour. What is hot-spotting? Segmenting at-risk patients to apply focused intervention that prevents the problem from escalating into a crisis.
Northern region of Singapore
Legend (Zone with "Frequent Flyers")
Locating "Frequent Flyers" KTPH plotted the locations of "Frequent Flyers" living in Nee Soon South and Sembawang Group Representation Constituencies to enable us to link patients to the nearest available community resources such as day care centres, community centres and general practitioners. From the map on page 29, we could pinpoint the exact addresses of the "Frequent Flyers", and group them for intervention programmes. We were also able to share data with the Members of Parliament (MPs) on the profile of their constituents and garner their support to collaborate with us.
NS South
NS Central
NS East
Chong Pang
Red Pin denotes one "Frequent Flyer" living in a block/property Blue Pin denotes multiple "Frequent Flyers" living in the same block/property
Home visits by nurses enable hot-spotting of at-risk patients for focused intervention
Identifying their Needs We found many readmissions could have been prevented if the patient or family had adequate after-discharge care support within their homes. KTPH developed several key initiatives under the "Ageing-in-Place" (AIP) Programme to address gaps in this support framework. "Frequent Flyers" were first categorised according to the intensity of care that they required post-discharge. Those who required high intensity or end-of-life care were placed under Transitional and Palliative Care Services respectively. Those requiring lower intensity care were visited by Community Nurses in their homes to understand their needs better. From the visits by Community Nurses, many lapses in care continuity were observed and uncovered through interviews.
Developing Care Plans to Address Specific Gaps From the home visits, KTPH found that besides medical issues, other factors contributed to these frequent readmissions. These included unsafe home environments, financial problems, poor nutrition and activity patterns, inadequate caregiver training, and lack of companionship. Our Community Nurses developed care plans to address the following needs: • Clinical – Proper wound care, proper adherence to medication prescriptions, rehabilitation and dietary routines • Environmental – Home modifications • Social – Referral for financial assistance, activation of community resources, caregiver training
The chart below illustrates the needs of a group of 100 households visited:
N = 100. Percentage does not add up to 100% because some "Frequent Flyers" had multiple needs
Needs of a group of 100 households visited
I need a community nurse.
The Ageing-In-Place Programme: Going Forward
CASE STUDY How KTPH Prevented Readmission and Promoted Recovery for A Patient Madam Goh, 60, lives with her son and a domestic helper in a four-room flat in Nee Soon Central. She was admitted to KTPH three times over six months. Her condition requires her to undergo dialysis three times weekly. Under the AIP Programme, our Community Nurses followed up on her recovery progress at home. Mdm Goh was encouraged to monitor her blood pressure daily. As she could not afford a blood pressure monitor, KTPH's medical social worker provided assistance to buy one for her. The Community Nurses also taught her caregiver how to check and record the readings daily. Madam Goh was also under a lot of mental strain because of her deteriorating health. Our Community Nurses motivated her and watched for signs of depression. In between visits, the Community Nurses also phoned Madam Goh regularly to ensure she was coping well and provided support where appropriate. Madam Goh's mental health subsequently improved. After a six-month period on the AIP Programme, she was readmitted to KTPH only once for a procedure related to her dialysis.*
I need allied health services. I need home modification. I need a volunteer campanion.
I need a clinician at home.
AH is working with the Hospice Care Association (HCA) on in-home palliative care. We are also working closely with the Agency for Integrated Care (AIC), North West Community Development Council (NWCDC), Moral Thye Hua Kwan, SWAMI, Comfort Keepers, Home Nursing Foundation and Citizens' Consultative Committees (CCC) in the North to provide a wide range of services for patients. These include home improvement support, befriender services, meal delivery services, medical packing and home (domestic) help. We hold quarterly discussion forums with these partners to align our collective efforts, and strengthen working relationships. We are also working with Singapore Polytechnic and Temasek Polytechnic on design research to understand our patients' needs and design our services accordingly.
Initiatives in the Pipeline Ensuring Proper Medication Compliance Poor medication compliance was a common problem for many patients. Often, these elderly patients had more than 10 types of medication stored haphazardly. Many were also unsure of the dosage to be taken for each type of medication. To address the medication issue, plans are being made to involve pharmacists in the Community Nurse Programme.
I don't need help.
I need medical social service.
The Ageing-In-Place (AIP) Programme is AH's first step in developing a new care model in the community. It forms the foundation of the cluster's increasing focus on post-illness care after patients have been discharged from KTPH. We are actively working with different community partners to integrate services and bridge the gap between the social and health needs of patients.
37% I need home monitoring. KTPH Community Nurse visiting Mdm Goh in her home
Ensuring Safety at Home Home safety was another common problem. Of the 100 homes visited, over 50% of the older residents were exposed to high risk of falls. As part of the AIP Programme, KTPH's therapists will conduct assessments for home modification and educate caregivers on falls prevention.
* Story shared with consent from the patient
6% 3%
Alexandra Health Annual Report 2011-12
Building A NEW COMMUNITY HOSPITAL for you
"The increase in Community Hospital beds will allow the more stable patients to receive the appropriate level of care at a less costly setting. At the same time, it will relieve our general hospitals and allow them to focus on the more acutely ill patients." – Health Minister Mr Gan Kim Yong's MOH 2012 Committee of Supply Speech on Healthcare 2020: Improving Accessibility, Quality and Affordability for Tomorrow's Challenges, 6 March 2012
428 Beds • Rehabilitation • Sub-acute care • Dementia care • Palliative care
To complement the acute care hospital services at KTPH, Alexandra Health (AH), as part of its regional health's mandate, will build a new community hospital, CH@Yishun, to cater to sub-acute and rehabilitation needs.
Services • Transitional care • Ageing-In-Place programmes • Telemedicine
Purpose-built with Patient Needs in Mind
GERI • Education • Research
The initial plan was to build a 300-bed community hospital. However, considering the high demand for subsidised beds and the ageing population, AH worked with the Ministry of Health (MOH) to increase the bed complement to 428, with close to 40% of the beds being planned for sub-acute care. Artist impression of the new CH@Yishun
As we did for KTPH, we once again sought help and advice from industry experts in design, architecture, and placemaking. They worked alongside our hospital planning team to define the environment that would be conducive for step-down care and recovery.
Seamless Transfer between Hospital and Step-down Care
Twelve renowned architectural firms competed in the tender, out of which six were shortlisted for submission of their detailed design proposals. The winning design would be announced in the second quarter of 2012.
AH worked with industry experts to plan the new CH@Yishun Bottom:
AH staff at a value mapping workshop to plan the patient's journey process in the new community hospital
Located next to KTPH, CH@Yishun will allow a seamless and faster transfer of patients from acute to step-down care. This will relieve acute-care resources at KTPH and enable patients who require a longer stay to rehabilitate and recover in a clean and green environment. Scheduled to open in the third quarter of 2015, CH@Yishun will cater for rehabilitation and sub-acute needs, including dedicated beds for dementia and palliative care. A geriatric clinic will provide comprehensive evaluation and management of older people. The hospital will be a base for our wide range of initiatives including transitional home care, telemedicine with community and nursing homes and ageing-in-Place programmes to support intermediate and long-term care in
A/Prof Pang Weng Sun (left), Chairman, Medical Board, and Mdm Chua Gek Choo (right), Director of Nursing, will oversee the clinical and nursing aspects of the new community hospital respectively
the community. It will also house the new national Geriatric Education & Research Institute (GERI), which will drive clinical, ageing and health service research, and inter-professional education to meet national needs. 35
Alexandra Health Annual Report 2011-12
Serve you
Alexandra Health Annual Report 2011-12
"As we invest in hardware by building new hospitals and adding more beds, we also have to invest in people, which is equally, if not more, important."
The good work of our staff in the past year was recognised in the form of national and internal awards. National Awards
– Health Minister Mr Gan Kim Yong's MOH 2012 Committee of Supply Speech on Healthcare 2020: Improving Accessibility, Quality and Affordability for Tomorrow's Challenges, 6 March 2012
National Outstanding Clinical Educator Award In July 2011, Professor C. Rajasoorya was awarded the prestigious inaugural National Outstanding Clinical Educator Award by the Ministry of Health. This award is part of the annual National Medical Excellence Awards. It recognises the tireless efforts of senior clinician educators who teach, guide and inspire the next generation of clinicians.
Staff development and training is a core focus at Alexandra Health (AH). Our staff strength grew 10% from 2,680 employees in FY 2010–11 to 2,956 employees in FY 2011-12. We believe that continuous learning and upgrading of skills for our staff are the keys to ensuring a high standard of quality care for patients. As AH grows, we also want our staff to grow with us.
Other Recipients of National Awards: National Day Awards Public Administration Medal (Bronze) Mrs Chew Kwee Tiang, Chief Operating Officer Commendation Medal Mr Aznan Omar, Principal Medical Technologist Ms Jessie Tan Joon Cheen, Nurse Clinician
Nurturing Our Talent Pool In FY 2011–12, we invested an average of 124 training hours per staff, and sponsored 78 staff for formal education programmes under AH and the Ministry of Health.
Efficiency Medal Ms Ho Siew Liene, Senior Staff Nurse
We also organised internal training, such as supervisory programmes, to equip supervisors and managers with the skills to perform and excel in their roles. To help our overseas staff integrate better, we organised acculturation workshops to help them understand and appreciate local culture. Changes in Senior Management Appointments Several key appointments in AH's senior management were made as we shifted our focus from illness care to build up capabilities in the areas of pre-illness healthcare and ageingin-place programmes. In July 2011, A/Prof Kenneth Mak took over the reins from A/Prof Pang Weng Sun as Chairman, Medical Board (CMB) for KTPH. Dr Michael Wong, Head and Senior Consultant, Family and Community Medicine, and Dr Christopher Cheok, Head and Senior Consultant of Psychological Medicine, were appointed Deputy Chairmen, Medical Board. Dr Wong will focus on preventive and pre-illness care while Dr Cheok will focus on post-discharge and community care.
Healthcare Humanity Award Ms Lee Soo Cheow, Senior Staff Nurse Ms Samsinah Binte Mohd Yusof, Senior Staff Nurse A/Prof Kenneth Mak
Dr Michael Wong
Dr Christopher Cheok
Our Growing Family The AH family of more than 3,000 staff (as at 31 March 2012).
Courage Fund Ms Lim Siew Teng Cinthia, Senior Staff Nurse MOH Nurses' Merit Award Ms Pang Ai Cheen, Nurse Manager Ms Noribah Bte Abdul Rahman, Nurse Manager Ms Linda Liau Kuan Cheong, Nurse Manager Ms Lim Shui Ling, Senior Staff Nurse Ms Chionh Hui Ling, Senior Staff Nurse 14th Asian Musculoskeletal Association Annual Scientific Meeting 2012 – AMS Best Paper Award Dr See Poh Lye Paul, Consultant
Allied Health
Top: Prof C. Rajasoorya receiving the Outstanding Clinical Educator Award from Health Minister Mr Gan Kim Yong Bottom: The Dental Department won the Outstanding Department Award in AH's CEO Awards of Excellence
CEO Awards of Excellence
Working Hard and Keeping Fit
AH also presented the inaugural CEO Awards of Excellence for individuals and the most outstanding department. These awards are in recognition of outstanding performance and exceptional commitment to patient care as well as mentorship to junior staff in their respective areas of work.
At AH, we also aim to foster a positive work-life balance by organising social and physical activities to enliven the workplace.
The winners were: A/Prof Sin Fai Lam Khim Nian – Outstanding Clinician Award Senior Nurse Manager, Yiap Pok Ling – Outstanding Nurse Award Manager for Laboratory Medicine, Lim Tau Cheng – Outstanding Allied Health Award Senior Patient Greeter, Sockalingam S/O Ramalingam – Outstanding Ancillary Staff Award
Keeping Fit and Healthy As a health-promoting hospital, we encourage our staff to keep fit and healthy to be positive role models for our patients. Over the past year, staff participated actively in our regular fitness classes, gym inductions, annual health screening, Fitness Challenge, ACTIVE Day and locally-organised runs. Building Bonds In FY 2011–12, we introduced new interest groups such as performing arts, open water swimming, bowling and line dancing. We also organised life enrichment and social interaction activities like financial management talks, festive celebrations, bazaars and short day trips to build and foster stronger bonds.
Dental Department – Outstanding Department Award
Closewise from top left: Yiap Pok Ling, Lim Tau Cheng, Sockalingam S/O Ramalingam and A/Prof Sin Fai Lam Khim Nian
Top: AH staff regularly take part in local sports events such as the JP Morgan Corporate Challenge Middle: Staff keeping fit through in-house yoga sessions Bottom: Social activities like the lantern-making workshop foster staff bonding
"Friends of KTPH" Lend a Helping Hand Friendly faces of volunteers are often seen throughout KTPH. They lend a helping hand in various parts of the hospital, including taking calls at the call centre or tending to the gardens. They also bring cheer to patients and visitors by helping them find their way around the hospital, providing information to loved ones waiting anxiously at A&E, reading to patients by their bedside and simply lending a listening ear to elderly patients. Groups from the community or schools would often perform at the hospital lobby and at the promenade, bringing music and entertainment to stimulate the senses. Over the past
year, our "Friends of KTPH" programme had grown steadily in numbers. Orientation sessions were conducted every quarter to help our volunteers understand our care philosophy and service standards. We also involved them in hospital celebrations and thank-you events to make them feel a part of the AH's family.
Top: Students from Riverside Secondary School performing at the hospital lobby Bottom left: Ms Jean Teo (left) volunteers once weekly at KTPH as a patient greeter Bottom right: Mr Raphael Nyoe (left), a volunteer patient ambassador in KTPH's A&E department
Alexandra Health Annual Report 2011-12
12,000 No. of A&E Attendances
10.0 8.0 6.0 4.0 2.0
HD/ICU/ISO 10 bedded 5 bedded 4 bedded 1 bedded Deluxe/ VIP Suite Total
73 180 150 72 27 1
66 180 150 60 19 1
8,000 6,000
4,000 2,000
1 bedded 4 bedded 5 bedded 10 bedded HD/ICU/ISO
Bed complement increased 6% to cater to increased demand
A&E Apr
Attendances FY10
Sep Oct Month
Attendances FY11
A&E demand rose by 30%
Overall patient days increased due to geriatric cases and general surgery
No. of SOC Attendances
25,000 20,000
15,000 10,000 5,000 0
Non-Subsidised FY10
Sep Oct Month
Subsidised FY10
No. of Surgeries
Day Surgeries
Inpatient Surgeries Total
500 0
Inpatient Surgery FY10
Sep Oct Month
Inpatient Surgery FY11
Day Surgery FY10
Day Surgery FY11
Day surgeries rose 40%
The highest volumes were from Dental, Otolaryngology and General Surgery.
Non-Subsidised FY11
Subsidised FY11
Outpatient attendances at our Specialist Clinics increased by 47%, mainly from subsidised patients The top 3 highest increases in volume were from: Orthopaedic 42
19,499 (60%)
17,436 (47%)
13,307 (43%) 43
90 Yishun Central Singapore 768828 www.alexandrahealth.com.sg


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Welcome to EagleFlight Wealth Management's website, where you'll find a wealth of information in the form of newsletter articles, calculators, and research reports.
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The mission of Adversity to Prosperity is to uplift communities through youth athletic programs, service and education. We are dedicated to helping inner city residents financially with their educational needs by granting scholarships and/or supplying funding for school-related expenses such as books and supplies. We are fully committed to provide fiscal sponsorship to struggling athletic programs in the state of Connecticut in an effort to uplift & give back to our struggling communities. We are a recognized 501(c)(3) as of April 4th, 2014
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Goal: To fulfill each scholarship for $1,000 for 2017-2018 school year to help offset books and supplies totaling $3,000


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System.NullReferenceException: Object reference not set to an instance of an object.
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OPEC extends agreement on oil production cutBusiness & Economy May 25, 17:16
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MOSCOW, December 15 (Itar-Tass) —— What Russia needs is not the fear of Stalin's time, but effective laws and ability to observe them, Russia's Prime Minister Vladimir Putin said on Thursday during a call-in session.
"We should manage everything so that law were fair, and demands from the power were proportionate to the objectives the people are facing," he said. "We do not need fear."


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Today, my ex girlfriend that I still love sent me a text, quote "I still love you, but i'm not IN love with you" Um, what? FML
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Today, my coworkers were bored. To solve this, they taped me to a chair and tried tickling me to death. My boss joined in. FML
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Today, I confessed to my boyfriend that I was in love with his best friend. He confessed that he was too. FML
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Today, after a night of heavy drinking, I woke up handcuffed to my bed. My friends who are responsible for this think it's hilarious and claimed not to remember where they put the keys. They took pictures, then left. FML
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Today, while going down on my girlfriend, I finally managed to give her an orgasm. During that orgasm, she tore out a clump of my hair, causing me to scream in pain. She scowled and said, "Ah shut it, ya little bitch." FML
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Pain in left leg
Pain started in left heel a year ago Initially took foot massage that helped but it was never gone completely.these days I am not feeling pain in heel but there is a constant numbness in leg from thigh to ankle.whenever I walk or sit it always there.in morning it feels some stiffness but after walking a bit that goes but a pain and numbness remains whole day.leg feels weak.
Answers (1)
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Hello It is suggested to get MRI scan done of your lumber spine. This symptoms may be due to pressure on the nerves in lumber region. MRI scan will give exact picture. Get it done ASAP. Till then it is suggested to take cap lumbaton 2 cap + tab rasarajeshwar ras 1 tab before food with sahacharadi kashayam 3 tsf + warn water. As the problem is in lumber region suggested for application of Sahacharadi tailam. It will give you relief. I will suggest you to visit a nearest ayurveda doctor as you may need paanchakarma treatment and allied treatment long time.
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1 July 2008,
London, King Street
Price realised GBP 11,250
Estimate GBP 10,000 - GBP 15,000
Slawomir Elsner (b. 1976)
Kalifornien II
signed, titled and dated 'Slawomir Elsner "Kalifornien" II 2004' (on the reverse)
acrylic on canvas
39½ x 59 1/8in. (100.4 x 150cm.)
Painted in 2004
New York +1 212 636 2000
London +44 (0)20 7839 9060
Hong Kong +852 2760 1766
Shanghai +86 21 6355 1766
Special Notice
No VAT will be charged on the hammer price, but VAT at 15% will be added to the buyer's premium which is invoiced on a VAT inclusive basis.Artist's Resale Right ("Droit de Suite"). Artist's Resale Right Regulations 2006 apply to this lot, the buyer agrees to pay us an amount equal to the resale royalty provided for in those Regulations, and we undertake to the buyer to pay such amount to the artist's collection agent.
Galerie Rüdiger Schöttle, Munich.
Acquired from the above by the present owner.
Pre-Lot Text
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Not many people like packing for a move, especially fragile items. Often fragile items are packed by movers, but if you are planning to do it yourself, here are some helpful packing tips.
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This has to be my favorite restaurant! (As well as my whole family's!) It's known as a pizza place, however all of their food is delicious. They have the best crab cakes around the area, and everything else I've tried (ribs, tuna sub, fried shrimp, shrimp and scallop alfredo) was also all excellent. The place is very small (only has about 10 tables inside) but it's definitely worth a try. Also, two free glasses of wine OR beer?! That's only the plus. ;)
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1. Little Caesars Pizza
waited 45 mins for a hot and ready pizza
2. Little Caesars Pizza
friendly staff, quick service However the pizza looks good but it has very little sauce and cheese just alot of bread this store …
3. Little Caesars Pizza
2701 Eastern BlvdYork, PA 17402
4. Little Caesar's Pizza
1094 Haines RdYork, PA 17402
5. Little Caesars
6. Little Caesars
680 Shrewsbury Commons AveShrewsbury, PA 17361
7. Little Caesars
846 Lancaster AveColumbia, PA 17512
8. Little Caesars Pizza
3975 Columbia AveColumbia, PA 17512
9. Little Caesars Pizza
1405 N Market StElizabethtown, PA 17022
10. Little Caesars Pizza
1605 S Market StElizabethtown, PA 17022
11. Little Caesars
854 N Us Route 15Dillsburg, PA 17019
12. Little Caesars
pizza always hot and ready
13. Little Caesars Pizza
Yes their prices are low, but there must be something wrong with the pizza for the prices to be low. I wouldn't go there.
14. Little Caesars
I went to this pizza place for the first time ever for dinner tonight because I was running late getting home. I placed my order for a lg pepperoni …
15. Little Caesars Pizza
had my first experience at this little ceasars today and it took 20 mins in order to get a hot and ready pizza
16. Little Caesars
4955 Carlisle PikeMechanicsburg, PA 17050
17. Little Caesars Pizza
119 Bridge StNew Cumberland, PA 17070
18. Little Caesars Pizza
1963 Fruitville PikeLancaster, PA 17601
19. Little Caesars Pizza
Can't beat the value here, I stopped in for a $5 large pizza and was on my way almost immediatly with a fresh, large pepperoni pizza right out of th…
20. Little Caesars Pizza
This location is now a K-Cafe. Please update.
21. Little Caesars Pizza
Great pizza for a great price, always hot n ready so you don't have to wait around or order ahead. The crazy breadsticks and sauce are also very goo…
22. Little Caesars Pizza
30 S 8th St # 34Lebanon, PA 17042
23. Little Caesars Pizza
650 E High StCarlisle, PA 17013
24. Little Caesars Pizza
10 Westminster Shop CtrWestminster, MD 21157
25. Little Caesars Pizza
836 W Main StNew Holland, PA 17557
26. Little Caesars Lebanon
720 Quentin RdLebanon, PA 17042
Showing1-26 of 26results
Everything on the menu is made from scratch! Its the best Italian food in town and the prices are very reasonable. Great place to take the entire family. Oh and dont be surprised when the owner steps out of kitchen to talk to his guests to make sure he and his staff are doing everything they can to make your dining experience special! That's a level of service you rarely get to experience anymore.
Tnt wings and pizza is the bomb!!! Now they are starting to add entertainment,wow this is just what York,pa needs. Food is great,prices are good,service is great and friendly,just a great place to enjoy a nite out.they have an arcade,pool tables.
Great selection of sandwiches, subs and pizza. Friendly owner and staff. Clean and very reasonable prices. Favorite side is their Onion Rings...favorite hot subs are the Philly Cheesesteak and the Chicken Philly.
Best pizza by far! I have daily cravings..lol the staff is great and the owner Vito is awesome!! My family enjoys after softball dinners there quite often and they always make us feel like family!
LOVE their pizza! I'm a women, and 1 slice is good for two meals. My husband loves their pizza too, but he finishes a slice in 1 meal ;-)
We frequently eat at Marcellos Downtown on Saturdays and their food is awesome. Decent price for great food
I got a cheese steak and the only complaint I have is they didn't put enough meat on the sub.
I live outside there delivery area, but we always choose Marcos. Best food
I am a pizza lover and Palumbos pizza the best pizza I have ever had!


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Black faux leather
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Experience in Extension Forestry in Wurttemberg, Southern Germany
Abstract:How a German forester went after the individual forest owners to make them forest conscious and to get them to practice forest management. The article proves that there was no widespread concerted action insofar as practical forest management is concerned in the State of Wurttemberg prior to the World War. Dr. K. Danneker started the idea on a state-wide scope. He is not employed by the State, but gets his salary from the landowners.
Document Type: Journal Article
Affiliations: Translated by Charles F. Evans and A. O. Weidelich
Publication date: 1934-11-01
More about this publication?
- The Journal of Forestry is the most widely circulated scholarly forestry journal in the world. In print since 1902, the Journal has received several national awards for excellence. The mission of the Journal of Forestry is to advance the profession of forestry by keeping forest management professionals informed about significant developments and ideas in the many facets of forestry: economics, education and communication, entomology and pathology, fire, forest ecology, geospatial technologies, history, international forestry, measurements, policy, recreation, silviculture, social sciences, soils and hydrology, urban and community forestry, utilization and engineering, and wildlife management. The Journal is published bimonthly: January, March, May, July, September, and November.
2015 Impact Factor: 1.476
Ranking: 22 of 66 in forestry
Average time from submission to first decision: 39.6 days*
June 1, 2016 to Feb. 28, 2017
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Forest Science
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- Ingenta Connect is not responsible for the content or availability of external websites


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Spring, 2015 finds a double homozygous buckskin tobiano colt by her side! He is by the dble hz dunskin stallion: Pepsis Color Master. She will be rebred…$3,500
Flash is a 2004 registered APHA (Paint) gelding, standing at 15 hands. Flash came to Gable Stables in the fall of 2016 and has taken to training, showing…$7,500
Shiners Solid Clue APHA # 923545 AKA SUNDAE is for sale ! She is a good mare coming 10 in June this year. She is a solid Bay in color, has excellent feet…$4,000
Kovu is a Bay Overo Paint Stallion who is 2 years of age. He has a black main and tail, 3 black sock, 1 white sock and a white blaze. He is halter and…$2,500
5 Panel and LWLs negative. Scout is sired by the great Color Me Smart and out of the only paint daughter that Dual Pep ever produced. Both sire and dam…Stud Fee: $500
Rainbow is an excellent trail horse. He is 12 yrs young and is for a beginner. He is friendly and neck reins. You can ride him on trails. He loads…$2,500
4 year old, 14.2hh bay overo mare. She is currently in training, going w/t and will be easy to finish. Brave with no spook or vices. She will make a gorgeous…$2,500
Molsan is a very sweet and lovable horse, he always puts all of his effort into everything. He is fully broke to do showmanship, english and western pleasure…$6,000 CAD


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