Sir,
Ten years ago, the World Health Organization in its 2008 report ‘Primary Health Care—Now More Than Ever’ espoused the effectiveness of primary health care to reorientate national health systems in achieving equity and efficiency in health care resource utilization (1). In Singapore, a South-East Asian city state, primary care is delivered by private general practitioners and publicly funded polyclinics. Whilst Singapore was ranked first with the most efficient healthcare in 2014 (2), experts when applying the primary care framework by Starfield, categorized the strength of its primary care system as low (3). With Singapore’s rapidly ageing population and increasing healthcare needs, a robust primary care is critical to continue providing good quality and efficient health care. The National Healthcare Group Polyclinics (NHGP) comprises six polyclinics in Singapore. Each polyclinic is a ‘one-stop’ facility that houses physicians, nurses and allied health professionals who provide publicly funded primary care ranging from treatment of acute medical conditions, chronic disease management, women and child health services and dental care. To address the increasing burden of our health care needs, NHGP embarked on a primary care transformation journey. Building upon the four pillars of primary care described by Dr Barbara Starfield (4), namely Continuity of care, Comprehensiveness, Coordination of care and first Contact of care, NHGP has developed a 6-pronged strategy, summarized in the mnemonic: ‘TEAMS2’.
Telehealth
Telehealth improves access, continuity, comprehensiveness and coordination of healthcare, especially for the elderly and patients with mobility issues. At NHGP, a variety of telehealth modalities are used. In our Telecare programme for patients with hypertension and diabetes mellitus, patients regularly upload their home blood pressure and blood glucose readings onto an online portal. These readings are reviewed by nurses at the polyclinic, enabling the monitoring of the patient’s blood pressure and blood sugar levels without patients leaving their homes. In our Tele-dermatology and Tele-ECG programmes, images of dermatological skin lesions and electrocardiograms are transmitted via a secure portal from the polyclinics to specialists in tertiary care centres for their review and expert advice. This collaboration between family physicians and specialists allows clinical inputs from specialists without the patients having to make a physical trip to the Specialist Outpatient Clinics.
Empanelment
The empanelment of a patient to a team comprising family physicians, a nurse trained in chronic disease management and a care coordinator provide patients with longitudinal and interpersonal continuity of care, addressing a fundamental tenet of good primary care. Empanelment also fosters a provider-patient relationship over time, allowing the healthcare team to integrate a patients’ physical and mental health with social care issues in the comprehensive care of the patient.
Activation of patients
Patient activation has been shown to improve health outcomes, care experiences and reduces healthcare costs. In the Chronic Care Model, ‘activated patients’ who have the motivation, knowledge and skills to make an effective decision regarding their health (5)—play a key role in interactions with clinical teams to determine both their care needs and outcomes. Having patients empaneled to teams facilitates goal-setting and shared decision-making by patients and healthcare providers. This partnership recognizes the expertise patients bring to the medical encounter and sets the stage for the skill and knowledge acquisition needed in chronic disease management.
Models of care delivery
The doctor-centric model of care that previously characterized polyclinic care delivery is being replaced by a team-oriented model involving family physicians, nurses, allied health professionals and other healthcare providers. This facilitates synergy and inter-collaboration between healthcare professionals, leading to more comprehensive, coordinated and continuous care for patients.
Stratification of risk
Instead of a one-size-fits-all model of care, the empanelment model considers the individual’s health risk by stratifying risk based on patients’ medical conditions. By stratifying risk based on disease types and their complexity, and tailoring care bundles using a team-based approach for each risk stratum, patient care is customized to need, optimizing resource allocation.
Strategic partnership with General Practitioners (GPs)
With GPs providing 80% of primary health care in Singapore, strong partnerships with GPs are essential. NHGP supports GPs in chronic disease management through sharing clinical protocols, providing nursing, allied healthcare, diagnostic and pharmacy services. Funding models remain critical to the success of this endeavour with portable subsidies like the Community Health Assist Scheme (CHAS) facilitating NHGP-GP partnerships. From 2015 to 2017, NHGP transferred more than 27000 patients to the care of partnering GPs.
With the TEAMS2 approach, NHGP has transformed care delivery within NHGP. We will be reporting results from the pilot polyclinic that adopted the empanelment care model. A robust primary care evolves with the population needs. To meet the needs of a rapidly ageing population, primary care in Singapore has to transform. We trust that the TEAMS2 approach will find applications in other primary care systems striving to provide primary care that is accessible, coordinated, comprehensive and continuous.
Declaration
Ethical approval: Ethics approval for the preparation of this article was not required.
Funding: The article was funded by departmental resources.
Conflict of interest: The authors declare that they do not have any conflict of interest with regards to the preparation of this article.
References
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