Chronic Disease Management The Challenge of Shifting Care from Hospitals to the Community in Singapore

1. Chronic Disease Management – The Challenge of Shifting Care from Hospitals to the Community in Singapore Special attention to diabetes services.Special attention to diabetes services.

3. ESTABLISHMENT OF TWO HEALTH CLUSTERS IS AN OPPORTUNITY FOR SPECIALISTS TO INTEGRATE CARE WITH PRIMARY CARE DOCTORS We have set up a governance structure to push disease management and “right-siting” since 2002 Clinical leaders oversee conceptualization and implementation of key relevant HMP projects Facilitate pilots on chronic disease management programs Primary and community care is the most cost effective and affordable setting for CDM Shifting of care between hospitals and community care Challenge is how the resources of the healthcare team (comprising nursing and allied health manpower) can be mobilized where needed

4. INFLUENCE THE EFFICIENCY AND EFFECTIVENESS OF HOSPITAL OUTPATIENT SERVICES – 4 STRATEGIES INVOLVING PRIMARY CARE1 Transfer of services from hospital to community-primary care (changing the people who deliver the care); Interventions to alter the referral behaviour of primary care practitioners [referral guidelines (inappropriate referral SGH DBC 13%; NHC 14.5%)2, audit-and-feedback, education and financial incentives]; Relocation of hospital services to primary care (without changing the people who deliver the care); Joint working between primary and secondary care (share care). Apart from increasing hospital outpatient capacity the other is to find alternatives to hospital outpatient treatment. Relocating specialists to primary care, and shared care improved access without detriment to quality.   Apart from increasing hospital outpatient capacity the other is to find alternatives to hospital outpatient treatment. Relocating specialists to primary care, and shared care improved access without detriment to quality.  

5. REPRESENTATIVE SHS HMP AND “RIGHT SITING” PROJECTS BEFORE 2005 (EGS INVOLVING PRIMARY CARE) Cardiovascular HMP NHC shared care and fast track Secondary prevention in polyclinics Integrated Heart Failure Program at Outram Campus SHP Cardiovascular Collaborative Screening, Preventive – primary or secondary. Shifting care. Will highlight those on shifting care involving primary care.Screening, Preventive – primary or secondary. Shifting care. Will highlight those on shifting care involving primary care.

6. PMP first piloted in Mar 2003 after a study revealed inappropriate distribution of care provided to people with diabetes within the cluster. PMP consulted and then set out clinical criteria for referral and transfers between diabetes centres and polyclinics. An “intermediate” between the polyclinic and diabetes centre was also introduced to cater to polyclinic patients with poor glycaemic control or complicated cases. EPC are appointment based and run by doctors with advanced training in family medicine or internal medicine with more dedicated time with the patients but at no extra charge to the patients. Since November 2003, PMP had been extended all SingHealth polyclinics. Up to July 2004, 1440 patients have been transferred from SGH and CGH diabetes centre to the polyclinics for continuation of diabetes management and more than 1500 patients enrolled into the EPC. The introduction of the Family Physician clinics at the public primary care this year have made it possible to introduce a higher pricing for EPC type clinic or Family Physician clinic as it is now known. While some right siting of patients have been effected, there are still significant proportions of patients from SGH and CGH diabetes centres who remained to be right sited. The hard to sustain increase of subsidised outpatients with chronic conditions for specialities like diabetes, cardiology and renal strongly calls for stepped up efforts in better vascular risk factors prevention and control, more coordinated and integrative care and vascular risk factors control. PMP first piloted in Mar 2003 after a study revealed inappropriate distribution of care provided to people with diabetes within the cluster. PMP consulted and then set out clinical criteria for referral and transfers between diabetes centres and polyclinics. An “intermediate” between the polyclinic and diabetes centre was also introduced to cater to polyclinic patients with poor glycaemic control or complicated cases. EPC are appointment based and run by doctors with advanced training in family medicine or internal medicine with more dedicated time with the patients but at no extra charge to the patients. Since November 2003, PMP had been extended all SingHealth polyclinics. Up to July 2004, 1440 patients have been transferred from SGH and CGH diabetes centre to the polyclinics for continuation of diabetes management and more than 1500 patients enrolled into the EPC. The introduction of the Family Physician clinics at the public primary care this year have made it possible to introduce a higher pricing for EPC type clinic or Family Physician clinic as it is now known. While some right siting of patients have been effected, there are still significant proportions of patients from SGH and CGH diabetes centres who remained to be right sited. The hard to sustain increase of subsidised outpatients with chronic conditions for specialities like diabetes, cardiology and renal strongly calls for stepped up efforts in better vascular risk factors prevention and control, more coordinated and integrative care and vascular risk factors control.

7. August 2002, NHC introduced a new approach in collaboration with SingHealth polyclinics (SHP) comprising several measures: Referral guideline - regular joint education sessions; 2) A “fast-track” priority appointment system; 3) A shared care scheme, rapid refer back to promote follow-up of patients with primary care physicians, thus freeing capacity to see new referrals. Patients with suspected serious heart disease (but not acute coronary syndrome) would be given fast-track cardiology appointments within 2 weeks, and all other patients would be given routine appointments. The utilization of “fast-track” was routinely audited for its WT. The scheme was generally successful, with appointments given within 14 days for over 95% of fast-track requests from 2002 to 2006. There were guidelines which patients should be fast-tracked, but no audit, left to docs’ discretion. In the initial 2 years of its inception, fast-track appointments comprised <10% of all referrals and WT targets were easily met, suggesting that the majority of patients did not require “fast-track” appointments, based on the primary care physician’s assessment. This initiative addressed the concern that patients were not being provided with timely access to cardiac care, using an approach that went outside the more conventional response to a long waiting time, i.e. increasing capacity to meet demand as measured by a single indicator. With these results, NHC successfully sought approval from the Ministry of Health to modify the target for cardiology waiting times from a single indicator for all patients (target median: 14 days, 95th percentile: 28 days) to 2 separate targets for priority (fast-track) appointments (95th percentile 14 days) and routine appointments (95th percentile 42 days). One additional benefit of the scheme was that stable patients under the care of NHC could be referred back to the polyclinics with the reassurance that they could be sent back within 2 weeks should their symptoms recur. Previously, one reason for reluctance to be referred to polyclinics was the long waiting time for a referral back to NHC, should their condition worsen. Although the fast-track initiative helped to allay concerns regarding access to care for more serious conditions, it did not address the long waiting times for routine appointments. Despite the fast-track program and the increased volume of patients seen (a 37% rise in the number of patients seen from 2001 to 2002), waiting time for routine appointments continued to be long. The most important factor that became apparent in attempts to resolve waiting time was the increasing demand and the distribution of that demand across different institutions. Distribution of demand Ideally, to minimize waiting time, each institution should plan manpower and capacity requirements based on the projected demand from historical data, and workload should be distributed based on capacity. However, the public health referral system is open-ended, and there is currently no specific policy channeling the patient’s choice of specialist center for subsidized patients. August 2002, NHC introduced a new approach in collaboration with SingHealth polyclinics (SHP) comprising several measures: Referral guideline - regular joint education sessions; 2) A “fast-track” priority appointment system; 3) A shared care scheme, rapid refer back to promote follow-up of patients with primary care physicians, thus freeing capacity to see new referrals. Patients with suspected serious heart disease (but not acute coronary syndrome) would be given fast-track cardiology appointments within 2 weeks, and all other patients would be given routine appointments. The utilization of “fast-track” was routinely audited for its WT. The scheme was generally successful, with appointments given within 14 days for over 95% of fast-track requests from 2002 to 2006. There were guidelines which patients should be fast-tracked, but no audit, left to docs’ discretion. In the initial 2 years of its inception, fast-track appointments comprised <10% of all referrals and WT targets were easily met, suggesting that the majority of patients did not require “fast-track” appointments, based on the primary care physician’s assessment. This initiative addressed the concern that patients were not being provided with timely access to cardiac care, using an approach that went outside the more conventional response to a long waiting time, i.e. increasing capacity to meet demand as measured by a single indicator. With these results, NHC successfully sought approval from the Ministry of Health to modify the target for cardiology waiting times from a single indicator for all patients (target median: 14 days, 95th percentile: 28 days) to 2 separate targets for priority (fast-track) appointments (95th percentile 14 days) and routine appointments (95th percentile 42 days). One additional benefit of the scheme was that stable patients under the care of NHC could be referred back to the polyclinics with the reassurance that they could be sent back within 2 weeks should their symptoms recur. Previously, one reason for reluctance to be referred to polyclinics was the long waiting time for a referral back to NHC, should their condition worsen. Although the fast-track initiative helped to allay concerns regarding access to care for more serious conditions, it did not address the long waiting times for routine appointments. Despite the fast-track program and the increased volume of patients seen (a 37% rise in the number of patients seen from 2001 to 2002), waiting time for routine appointments continued to be long. The most important factor that became apparent in attempts to resolve waiting time was the increasing demand and the distribution of that demand across different institutions. Distribution of demand Ideally, to minimize waiting time, each institution should plan manpower and capacity requirements based on the projected demand from historical data, and workload should be distributed based on capacity. However, the public health referral system is open-ended, and there is currently no specific policy channeling the patient’s choice of specialist center for subsidized patients.

8. There are many players in the healthcare system from private GPs, polyclinics, specialist outpatient clinics, acute hospitals and national specialty centers to community hospitals, nursing homes and day care centers. Each has it cost structure and area of expertise. The patient can benefit if he seeks treatment in the most effective setting that provides him with the optimal health outcome.There are many players in the healthcare system from private GPs, polyclinics, specialist outpatient clinics, acute hospitals and national specialty centers to community hospitals, nursing homes and day care centers. Each has it cost structure and area of expertise. The patient can benefit if he seeks treatment in the most effective setting that provides him with the optimal health outcome.

9. ALTHOUGH THE PUBLIC SYSTEM PROVIDE 20% OF PRIMARY CARE, IT PROVIDES ABOUT 50% OF THE CHRONIC CARE. % CHRONIC LOAD OF POLYCLINICS HAS INCREASED SLIGHTLY IN 2006 Can there ever be a level playing field between private and public primary care for chronic care. So should go about it to engage and enable the private GPs? Can there ever be a level playing field between private and public primary care for chronic care. So should go about it to engage and enable the private GPs?

10. IMPORTANT AREAS THAT NEED TO BE ADDRESSED FOR PATIENT FLOW FROM PUBLIC HOSPITALS TO COMMUNITY-BASED CARE Healthcare providers typically get paid when people come to hospitals or clinics to make use of our services. The more people the healthcare workers work harder. While the healthcare burden is lower when we get people to stay out of hospital, it is not easy to find a good way to pay healthcare providers to do that.Healthcare providers typically get paid when people come to hospitals or clinics to make use of our services. The more people the healthcare workers work harder. While the healthcare burden is lower when we get people to stay out of hospital, it is not easy to find a good way to pay healthcare providers to do that.

11. SHS COMMUNITY DISEASE MANAGEMENT NETWORK LINK STAKEHOLDERS AND SUPPORT COMMUNITY PROVIDERS TO IMPROVE CHRONIC CARE AND RIGHT SITING Delivering on Target (DOT) launched and conversations with GPs held in August 2005. DOT provides a platform of common goals linking public, private and community health providers for integrated and community-based chronic disease care. Elements included provider and patients training and engagement, community based DM program, clinical and psychosocial outcomes tracking and right siting to GPs pilot programs E.g. Worked with DSS and TDS to direct patients to their DM programs and support groups Worked with Renci-Code 4 & Home Health Care Association to run a series of Eldercare Skills Workshop for GPs Worked with NCSS & ICS to print and distribute community service map Together with other statutory providers, ongoing efforts to educate GPs and patients on community resources – removing information and attitudinal barriers. Programs to transfer care from SOC to GP - Renal piloted in Oct 06; Diabetes - Jan 07; Cardiology - soon. Some of the key programs received industry funding and support. More recently the programs received MOH funding We started work to extend the clinical network through collaboration to facilitate integration and patient flow.We started work to extend the clinical network through collaboration to facilitate integration and patient flow.

12. 464 patients referral from GPs to DSS in the first 6 months as of end Jun 06 compared to 202 visits in 2002/031 Growing enthusiasm from GPs - increased patient recruitment More GPs have signed up for the DOT (Diabetes) Optimisation Programme Cohort 4 Commenced in Aug 200530 Jun 06:- 63 GPs enrolled, 28 DOT GPs and 242 patients 30 Apr 07:- 110 GPs enrolled, 28+27=55 DOT GPs and 494 patients Commenced in Aug 200530 Jun 06:- 63 GPs enrolled, 28 DOT GPs and 242 patients 30 Apr 07:- 110 GPs enrolled, 28+27=55 DOT GPs and 494 patients

13. We learnt much from the patients themselves about the psychosocial elements of diabetes management. The patient voice is crucial in our program. A patient community directed program is better than a provider directed program because it is more sustainable and we intend to extend our support to TDS in this respect.We learnt much from the patients themselves about the psychosocial elements of diabetes management. The patient voice is crucial in our program. A patient community directed program is better than a provider directed program because it is more sustainable and we intend to extend our support to TDS in this respect.

18. NOT SURPRISINGLY, THE MOST PREFERRED PRIMARY CARE PROVIDER IS THE POLYCLINIC

19. Right siting all simple cases with replacement with complex cases would result in revenue decline of $1.9M and decrease of patient volume of 9,339 annually. Diverting low cost cases, on which hospitals make a profit, while leaving them with the complex and expensive cases, on which they make a loss, is unsustainable. Assess financial and volume impacts of ‘right-siting’ of endocrinology outpatients at SGH through modelling and simulation. Data was collected prospectively on patient casemix including complexity (‘complex’ defined as requiring specialist care), time required for consultations and revenues garnered. The data was used to simulate extreme two scenarios: ‘right-siting’ of all simple cases with freed up resources directed to research and teaching (research scenario) and ‘right-siting’ of all simple cases with replacement by complex cases (service scenario). The department sees an estimated 33,000 outpatients per year with total annual outpatient revenues of $8.6 million.Diverting low cost cases, on which hospitals make a profit, while leaving them with the complex and expensive cases, on which they make a loss, is unsustainable. Assess financial and volume impacts of ‘right-siting’ of endocrinology outpatients at SGH through modelling and simulation. Data was collected prospectively on patient casemix including complexity (‘complex’ defined as requiring specialist care), time required for consultations and revenues garnered. The data was used to simulate extreme two scenarios: ‘right-siting’ of all simple cases with freed up resources directed to research and teaching (research scenario) and ‘right-siting’ of all simple cases with replacement by complex cases (service scenario). The department sees an estimated 33,000 outpatients per year with total annual outpatient revenues of $8.6 million.

20. While the principle of transfer of care is sound question on cost and quality remain In UK NHS, structured clinics for a range of chronically ill patients were introduced following the 1990 GP contract. Most general practices now have clinics for managing asthma, diabetes and heart disease. Health outcomes are as good in primary care as in hospital; well structured GP clinics can reduce hospital outpatient visits. But cost of transferring care in this way is largely unknown. Medisave libreralization for use in outpatient chronic is a crucial step Community based chronic care Will be popular as patients find it beneficial (cost and perception of quality) Diverting low cost cases, on which hospitals make a profit, while leaving them with the complex and expensive cases, on which they make a loss, is unsustainable. Still less than 10% of people in Singapore with diabetes are seen by Specialists (NHS 2004, unpublished data) Primary care reform in the areas :- Ability of GP sector to provide quality, holistic chronic care together with community Financing - Subsidy to follow patients instead of sites, clearer incentive for prevention Diverting low cost cases, on which hospitals make a profit, while leaving them with the complex and expensive cases, on which they make a loss, is unsustainable. Diverting low cost cases, on which hospitals make a profit, while leaving them with the complex and expensive cases, on which they make a loss, is unsustainable.

21. Acknowledgement Clinician leaders – Drs Daphne Khoo, Tan Hwee Huan, Terrence Chua, Bernard Kwok, Chris Lien, Wong Kok Seng, Tan Chee Beng SHS QMD CDM and Integration team Community partners – DSS, TDS, Tsao Foundation, Ren-Ci Code 4, HHCA, CHSR – Dr Jeremy Lim and team Industry partners and support – J&J, GSK, Pfizer etc MOH funding