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Evaluation the current approach of war on diabetes in Singapore, in terms of the continuum of care:
1. the strength of the current practice
2. identify the gaps
3. recommendation to address the gaps
|1.||Diabetes Prevention and Care Taskforce
· led by Minister for Health Mr Gan and Minister for education and Senior Minister of State for Transport Mr Ng; includes representatives from the government sector, healthcare arena, academia, employers’ associations, unions, and non-profit organisations
· was set up in June 2016 to spearhead a whole-of-nation initiative to tackle diabetes
· its objectives:
1. Reach out to the public and engage stakeholders to mobilise a whole-of-nation effort to fight diabetes
2. Develop and implement a multi-year Diabetes Action Plan;
3. Monitor progress and evaluate the outcomes of our efforts
· Will be supported by three workgroups
1. The Healthy Living and Prevention workgroup
2. The Disease Management workgroup
3. The Public Education and Stakeholder Engagement workgroup
|2.||Public Engagement Exercise
· six-month long
· feedback contributed to the Diabetes Action Plan
|3||High-profile public education campaign
· targeting people from different age groups
· its key messages are to slash sugar intake, to eat less and to move more
· included a video “Kungfu Fighter, Hidden Sugar” and a diabetes prevention mobile app
|4||Cheap or Free Health Screening ($5 and below): Screen for Life & enhanced Screen for Life (11 Sep 2017)
· national screening programme by HPB
· Covers up to 5 chronic diseases, including diabetes, cervical cancer, colorectal cancer and cardiovascular risks
|5||Multimedia campaign against diabetes
· Exhibition: “Let’s BEAT diabetes” Be aware of the risks, Eat right, Adopt an active lifestyle and Take control of health by getting regular health checks
· Diabetes Risk Assessment on HealthHub website and mobile app: for 18-39 yrs old ($2 cashback from ShopBack)
· HealthHub Track mobile app
· Health Peers Programme: volunteers reach out to residents who are diabetic or may be at risk of DM, to create awareness of DM prevention and management
|7||Changes to lifestyle and dietary preferences
· Healthier Dinner Programme
· Healthier Ingredient Development Scheme
· Healthier choice symbol Identifier
· Eat, Drink, Shop Healthy Campaign
· Beverage manufactures to reduce the amount of sugar in packaged sugar-sweetened beverages
· National Step Challenge
· Free community exercise and sports programmes
|8||Primary Care Networks (PCNs)
· MOH working with GPs to provide support in the community
MOH is reviewing key flagship programmes to prevent and retard diabetes-related complication, such as eye and kidney diseases.
· Holistic Approach in Lowering and Tracking Chronic Kidney Disease (HALT-CKD) PROGRAMME
|9||New Devices (innovation)
· flash glucose monitoring system
– Self-scan, without pricking / no pain
– Informative: show history & trends
– Slight discrepancy (recommended to co-relate with a blood glucose meter
Summary: How an integrated care approach help meet the challenges ahead
- There is an underappreciation of the role of patient education. Many diabetic patients still lack important self-management skills despite multiple efforts at education.
- The failure of patients to adequately control their diabetes mellitus can be attributed to a plethora of reasons. One of these may be technical issues with the administration of medication
- for example, a patient with retinopathy and poor visual acuity may face difficulties drawing insulin from a vial and performing self-injection. Other reasons could be a lack of social support or care at home, the patient’s beliefs and attitudes, financial constraints, comorbidities, lack of understanding leading to poor compliance, or psychological issues
Solution proposed: An integrated approach
A system that enables patients’ education to be intensified in a conducive environment, incorporates monitoring with appropriate intervention and facilitates an overview of patients’ multiple medical, logistic and administrative issues, and thereafter, to streamline care and reinforce consistent practice while adhering to the current standards of diabetes care.
In 2010, the Health Management Unit (HMU) was set up in Changi General Hospital (CGH) to fulfill the abovementioned role. HMU is a telehealth service supported by a Patient Relationship Management (PRM) IT system. The PRM IT system enables tele-nurses to access relevant clinical indicators and information, as well as capture all telephone interactions with the patient.
How it works:
- Patients who have been treated for diabetes mellitus within the CGH healthcare system and who fulfill the inclusion criteria are recruited into the programme based on their International Classification of Disease (ICD) code
- The system is inbuilt with scripts that cover various aspects of diabetes education.
The topics of the script are covered in a systematic way, which allows for feedback in order to check that the patient understands, through a series of scheduled telephone calls to the patient.
The programme also include encouragement of self-monitoring, recording of such monitoring, coaching to overcome barriers, collection and monitoring of clinical markers of the patient, and care coordination.
- Upon the identification of a problem, a series of pathways can be activated to bring about timely and appropriate intervention. Various activation pathways have been built in the system, including escalation to dietitians, clinical psychologists, medical social workers, all of which support the patient and provide timely intervention between doctor’s visits
- The system auto-extracts and condenses the patient’s information together with the problems identified during the interaction between the patient and tele-nurse, into an easy-to-read format for the principal doctor’s reference during consultation. Additionally, a multidisciplinary case conference is held every month to discuss specific cases with worsening clinical indicators and frequent readmissions for diabetes-related conditions despite HMU education and support
The challenge lies in how to further adapt this evolving model of care to the cultural background and social circumstances specific to the local setting, so that its maximum potential can be realised. It remains to be determined how such a telehealth service can impact diabetes outcome in the long term and whether it can be justified based on cost effectiveness. Given the current challenges facing diabetes care in the country, an integrated approach utilising such a system might just be the answer to the problems.
Summary: Integrated Care in Singapore
- Definition of integrated care: an organisational process of coordination which seeks to achieve seamless and continuous care, tailored to the patients’ needs and based on a holistic view of the patient
- Approach by SGH for diabetic patients: Delivering on Target (DOT) Programme
- Aim: To actively support the right-siting of clinically stable patients from the SGH Diabetes Centre to private DOT GPs to reduce unnecessary utilisation of expensive specialist resources, and to reduce waiting times for the large numbers of diabetic patients with complications who need medical care from hospital endocrinologists.
- Stakeholders: SingHealth, SGH Diabetes Centre, College of Family Physicians Singapore Diabetic Society of Singapore (DSS), GPs, pharmaceutical industry such as Johnson & Johnson Medical Singapre, Chronic Disease Management Office
- The DOT IT system incorporates an e-referral system for GPs, it supports informed care, and the system facilitates receiving of regular updates from the GPs of rightsited patients
- Two core components of the DOT Programme are the DOT Symposia and the DOT Optimisation
|DOT Symposia||To enhance GPs’ awareness of the benefits of the DOT programme by continuing medical education in key aspects of chronic disease management covered in four modular sessions: (i) lifestyle behaviour modification, (ii) healthy eating, (iii) medication and compliance and managing complications, and (iv) special needs in diabetes
The training sessions are sponsored by pharmaceutical companies, and 50% can be done via e-learning
|DOT Optimisation||Supports GPs in managing people with diabetes, and is a partnership between SingHealth, Johnson & Johnson Medical Singapore and the DSS.
Each participating GP to enrol three people with diabetes into the programme, and work towards achieving the DOT performance measures. The GPs have to sign up their enrolled patients for three customised education and counselling sessions by nurse educators from the DSS
This diabetes education service sponsored by Johnson & Johnson covers diet, lifestyle modification, medication, and insulin therapy and skills
- How it works:
Step 1: Specialists from the SGH Diabetes Centre refer clinically stable patients to Right siting Officers (RSOs) located in the Diabetes Centre
Step 2: The RSOs explain the DOT Programme to the referred patients. If the patient agrees to participate in the programme, RSOs will arrange for the patient to be followed-up by a private DOT GP
Step 3: The DOT GP will develop a one-year patient management plan and send updates on the patient’s health to the referring specialist for shared care follow-up.
RSOs monitor right-sited patients and the DOT GPs for about a year.
CDMO developed three incentive initiatives to support patients choosing to participate in the programme:
- Subsidised Drug Delivery Programme,:
Right-sited patients can continue to purchase subsidised drugs from the hospital even when under the care of private GPs
- Diagnostic Tests Incentive Programme
Right-sited patients do not have to pay for retinal and foot screening, but do have to pay for other optional services, such as lipid measurement and specialised care by a dietician
- Allied Healthcare Incentive Programme
DOT patients are given blood test vouchers upon discharge, which are redeemed by the private DOT GP when blood tests are requested. The test results enable DOT GPs to provide the appropriate follow-up care when the patient next visits and CDMO receives timely data to develop patient-centric programmes
- Advantages of DOT
The shift of patient care from tertiary to primary care released resources for more complex cases to be dealt with and engaged a cadre of primary care professional that had operated in general outside of the public system.
The type of integration that occurred with the SGH DOT Programme could be defined as functional, clinical, normative, horizontal, virtual and coordinated—improving ways of working across traditional health service boundaries
- Lessons learnt
- Little incentives for public hospital.
Estimated that the revenue of the hospital would drop by S$1.9 million (£0.97 million) per year if simple cases were replaced with complex cases . If simple cases were right-sited and time freed up was used by staff to conduct teaching and research, this would lead to an even greater fall in revenue by S$5.2 million. This has been noted by the Health Minister who mentioned that there is a need for additional incentives to fund preventive care, integration and right-site patients
- Potential cost savings can probably only be evaluated after a long period of providing integrated care as diabetes is a chronic disease, and the potential benefits of minimising complications, hospital admissions and utilisation of specialist care will be observed only in the long-term