PROFESSIONAL PRACTICE

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Chronic Disease Management IN Singapore Polyclinics

Clinical information system

The health care team in these programmes is continuously trained and supported with practical decision protocols, which are constantly updated by the team. Feedback and comments from the team members are always taken into consideration. The team conducts monthly plan-do-study-act (PDSA) cycles looking at clinical outcome (disease control) indicators, such as reductions in HbA1c, blood pressure, microalbuminuria, as well as improvement in care processes, such as performance of retinal or feet examinations in diabetics and peak expiratory flow rate in asthmatics. This is possible because all patients with chronic disease have their socio-demographic data documented in the highly secured web-based information system that is linked to the clinical information system and accessible to all polyclinics and hospitals from the same cluster. The all-in-one information system registers the patient flow from appointment system to consultation rooms (the queue management system and scheduled examinations), laboratory (reminder system and clinical laboratory indicators), radiology, pharmacy and consolidated payment at the end of each clinic visit. 

Self management tool

Patients with one or more chronic diseases are encouraged to purchase a self-management booklet (S$5 each). A trained nurse clinician demonstrates the usefulness of the booklet via video presentation and counselling, and teaches the patient individually how to use it at home for self-monitoring and management. All asthmatic patients are taught to use the practical and patient-friendly asthma action plans and diaries.

Clinical vs organisational management skills

There is another new paradigm shift in the polyclinic management in conjunction with chronic disease management. In the past family physicians were primarily focusing on polishing clinical skills and updating clinical management. From what a family physician can do for his circle of patients, they are now trained to bring better care to masses of people through improved management skills. Directors of polyclinics who are usually senior consultant family physicians are now regularly attending management and leadership courses.

SUPPORT FROM MINISTRY OF HEALTH

The Ministry of Health Singapore establishes National Disease Registries in coronary heart disease, cancer, stroke, myopia and kidney failure, which become valuable sources of clinical and outcomes data.² In partnership with expert groups, national committees and professional agencies, the Ministry produces clinical practice guidelines that assist doctors and healthcare professionals to better manage important aspects of the key diseases.⁴ Most importantly, the Ministry has committed funds to support selected National Disease Management programmes and allows qualified patients to utilise their national health insurance scheme, Medisave to help pay for these disease management programmes, up to a maximum S$300 annually.⁸

The Ministry monitors and publishes regularly the performance, cost and effectiveness of these disease management programmes so that patients can make informed choices when selecting their health providers. This steers patients and doctors towards the strategy of preventive maintenance to stop or slow down the deterioration of chronic medical conditions. All registered government family physicians and private general practitioners that have interest in chronic care are encouraged to participate in these disease management programmes. The list of doctors’ names and their effectiveness are published in the ministry’s website. Patients with any of these chronic diseases are advised to register with these doctors, who will presumably be their Family Physicians. The cost and health outcomes of these patients are monitored and important data is published at the website for both patients and doctors to learn from one another. 

CHALLENGES

The Singapore Polyclinics Chronic Disease Management Model demonstrates a programme that is fully computerized and transparent. It prioritizes patients’ problems, trains multidisciplinary team players, practices individual nurse counselling with motivational interviewing method, utilizes easy-to-follow modified decision support protocols based on the clinical practice guidelines, and constantly checking on quality improvements. Nevertheless, they need a huge numbers of human resource especially trained nurses; generally each government polyclinic has about 20 primary care trained staff nurses and almost half of them are involved in chronic care. Another challenge is cost. They are evolving from a previous single charge “buffet” where patients do not have a sense of the value of what they are consuming. Many services are chargeable but subsidised by government; patients with chronic diseases are now paying for each of the clinical services in the polyclinics, S$8 each for doctor consultation, an annual feet check and annual eye screen. Nurse counselling is now chargeable at minimal cost as nurse clinician (case manager) is introduced into the clinics. Many medications for chronic diseases are non-standard items and are not subsidised. Another major challenge in Singapore is to engage the capacity of private primary care sector into improving chronic care.

In conclusion, Singapore health care has taken a major leap and invested a large amount of money and work force in chronic disease management. These changes attempt to integrate population perspectives and person-centred perspectives. Primary health care team can play a lead role in chronic illness care, but health care organisation system support and policy are critical to its success.  

ACKNOWLEDGEMENT
Verna Lee wishes to thank Universiti Kebangasaan Malaysia for supporting her sabbatical leave in Singapore from June to October 2006.

REFERENCES

1. Ministry of Health Singapore. Population and vital statistics. Health Facts Singapore 2005. MOH. [HTML]
2. Tan CC. National disease management plans for key chronic non-communicable diseases in Singapore. Ann Acad Med Singapore. 2002;31(4):415-8 [PubMed]
3. Ministry of Health Singapore. Primary Care Survey 2005. MOH. [PDF]
4. Cheah J. Chronic disease management: a Singapore perspective. BMJ. 2001;323:990-3 [PubMed]
5. Cheah J, Heng BH. Implementing chronic disease management in the public healthcare sector in Singapore: the role of hospitals. World Hosp Health Serv. 2001;37(3):19-23, 40-3 [PubMed]
6. Abisheganaden J. Asthma disease management: a provider's perspective. Ann Acad Med Singapore. 2002;31(4):467-73 [PubMed]
7. Lim FS, Toh MP, Emmanuel SC, Chan SP, Lim G. A preliminary evaluation of a disease management programme for patients with diabetes mellitus and hypertension in a primary healthcare setting. Ann Acad Med Singapore. 2002;31(4):431-9 [PubMed]
8. Ministry of Health Singapore. Medisave for Chronic Disease Management Programme. [HTML]

 

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