Integration of care has become a major theme of healthcare organizations throughout the world and Singapore is no exception. The Agency for Integrated Care (AIC) plays the role of National Integrator in this endeavour. By and large the healthcare model in Singapore today is an acute care centric model. This has strengths but also has weaknesses and gaps that must be addressed through health care integration. Hence, Singapore is moving towards a new model of care — managing holistic approach of care for service needs and taking a patient-centric approach. We need to leverage on the multidisciplinary base of acute care healthcare providers to form the multidisciplinary base for intermediate care and long term care integration. For patients with complex medical and social needs, the ACTION Team project seeks to develop referral management teams to enable and support care integration and transition care for these patients.