PROFESSIONAL PRACTICE
Chronic Disease Management IN Singapore Polyclinics
Verna Lee Kar Mun1 MMed(FamMed UKM), Tan Ngiap Chuan2 MMed(FamMed Singapore), FCFP(Singapore),
Chow Mun Hong2 MMed(FamMed Singapore), FCFP(Singapore)
1Department of Family Medicine, Universiti Kebangsaan Malaysia; 2SingHealth Polyclinics, Ministry of Health Singapore.
Address for correspondence: Dr Verna Lee Kar Mun, Senior Lecturer, Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur. Tel: 603-91733333, Fax: 603-91738153, verna@mail.hukm.ukm.my
Lee VKM, Tan NC, Chow MH. Chronic disease management in Singapore polyclinics. Malaysian Family Physician. 2006;1(2&3):94-96
INTRODUCTION
Singapore is a small country with a total population of 4.4 million (2005). It has a relatively young population with 8.3% of the population above 65 years of age.1 However, in 2006 there are about 1 million Singaporeans who are affected by four common chronic diseases, i.e. diabetes mellitus, hypertension, hyperlipidemia and stroke.2 These non-communicable diseases, together with cancers, account for more than 60% of all deaths and a high burden of disability and healthcare expenditures. The burden of these diseases is likely to rise with the rapidly ageing population and changing lifestyles, and will present profound challenges to healthcare delivery and financing systems over the next 20 years.
RESTRUCTURING OF GOVERNMENT HEALTH CARE SYSTEM
The public health care delivery system in Singapore also faces the challenges of rising expectations with demand for better health services and shortage of human resources. It was also fragmented, resulting in duplication and lack of coordination between institutions. There is general consensus among various medical experts that for these chronic diseases, patients achieve better health outcomes if they: (a) take co-responsibility of their health (self-management); and (b) receive structured evidence-based treatment by good family physicians working in partnership with hospital specialists (structured disease management programme).2
Restructuring of the public healthcare institutions took place in year 2000 to forge vertical and horizontal integration between hospitals and primary healthcare facilities. It consists of two integrated networks, the western cluster (National Healthcare Group) and the eastern cluster (Singapore Health Services), each comprising a network of primary health care polyclinics, regional hospitals and tertiary institutions. This is also to prevent healthcare monopoly and to encourage healthy corporate competition between the two clusters.Primary health care in Singapore is similar to Malaysia: the government polyclinics are publicly funded restructured primary care institutions and the other major stakeholder is the private general practitioner. The Primary Care Survey 2005 done by the Ministry of Health3 has reported lower patient loads (number of patients seen divided by total number of doctors employed) in the polyclinics as 22% compared to the private clinics (78%), and the percentage of patients with chronic diseases followed up in the polyclinics were 43%.
CHRONIC DISEASE MANAGEMENT PROGRAMMES IN POLYCLINICS
Multi-disciplinary team
The framework in the development of the disease management programme included identifying the diseases and defining the target population, organising a multi-disciplinary team led by a clinician champion, defining the core components, treatment protocols and evaluation methods, defining the goals, and measuring and managing the outcomes.4 Primary healthcare centres, or polyclinics, are run by teams of family physicians, medical officers, nurses, case managers, health educators, dieticians, pharmacists, clinical administrators and medical social workers. The establishment of the clusters has provided a setting in which structured disease management could be readily implemented.
All the current 18 government polyclinics have structured disease management programmes that are team-based and led by family physicians (known as clinician champions). The functional integration of these healthcare elements within each cluster under a common administrative and professional management, and the development of common clinical information systems greatly facilitate implementation of the disease management programmes. Multi-disciplinary decision support protocols have been developed in conjunction with hospital specialists to provide consistent integrated pathway and to facilitate the referral systems.5 Case managers have been recruited and trained in developing clinical pathways and performing discharge planning for inpatients and utilisation review for outpatient care in the hospitals. Clinical case managers in primary care, recently introduced into polyclinics, work closely with patients on the lifestyle and medication changes required to achieve target, is a prominent feature of most successful chronic disease programs. The case manager is usually a nurse or nurse practitioner with additional training or experience in a particular chronic disease care and in techniques to help patients become more capable self-managers of their illness. The nurses personally “manage” patients by protocol, adding clinical and self-management skills as well as greater intensity of care.
Chronic disease management
There are currently two established disease management programmes in the polyclinics, i.e. Enhanced Primary Care Asthma Clinic6 and Family Physician Clinic (also known as Diabetes, Hypertension and Lipid or DHL Clinic).7 In the polyclinics, infrastructures built for the chronic disease management programmes would include well-equipped consultation rooms for individual (one-to-one) health counselling/education, smoking cessation counselling, fundus camera for diabetic retinal photography, diet counselling, feet check; each man by a trained nurse. Spacious air-conditioned waiting areas with educational video presentations and printed materials readily available for patients to consume. Not all patients with chronic diseases are seen in these clinics. Patients are stratified and those with sub optimal control who fulfil criteria in their decision support tool are given appointment to follow-up in these chronic care clinics, for example asthmatic patients on regular high dose steroid inhalers or recently admitted for acute exacerbation, diabetic patients with HbA1c of 8% or more, and complicated patients with two or more chronic conditions. Once their conditions are stabilised, patients have an option to be referred back to their previous primary care doctors.
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