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Shared care for more patients

with stable chronic conditions

Joyce Teo on 04 Jul 2020

The Straits Times


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Seventy-year-old Chua Kee Huat was due for his half-yearly consultation for rheumatoid arthritis at the National University Hospital (NUH) in March.


Instead, Mr Chua headed to Frontier Family Medicine Clinic in Clementi to do a blood test and collect his medication, as the consultation was rescheduled to this month because of the Covid-19 pandemic.


This shared care arrangement with his family physician, which allowed his care to continue, is not new, having started in 2014, said his specialist, Dr Anita Lim, a senior consultant at NUH's Division of Rheumatology.


The challenge has been to get patients to accept seeing someone other than their specialist, she added.


In Covid-19 times, though, it is an option for patients with stable chronic conditions, many of whom may not want to go to a hospital.


Ms Joanne Yap, executive director of the National University Health System's (NUHS) Regional Health System Office, said: "We have hope that the Covid-19 pandemic may drive changes in patient preferences for safety and convenience over choice of a specialist setting only.


"We intend to ride on the expediency of Covid-19 to expand the number of conditions managed through the shared care programme and to involve more specialists in NUHS-managed hospitals."


Ng Teng Fong General Hospital came on board the shared care programme at the end of last year, and Alexandra Hospital will start to enrol patients for the programme from this month, Ms Yap added.


"The clinic norm in the future is definitely increased shared care, staying nimble in the structure of the care plan without compromising patient care," she said.


Last year, NUHS enrolled 188 new shared programme cases, exceeding the set target of 170. This year, it has raised its target to 200, given its expansion plans ahead.


SingHealth has a similar shared care programme for patients with stable chronic conditions, though it currently does not have plans to ramp it up. Instead, it is busy with two other programmes that help to minimise hospital visits - telemedicine and community nursing service.


At Tan Tock Seng Hospital, its Community Right-Siting Programme provides patients with stable chronic conditions, such as atrial fibrillation or ischaemic heart disease, asthma or chronic obstructive pulmonary disease, and geriatric conditions, with a good care option that does not require unnecessary travel to the hospital during this period.


Since May, the programme has been expanded to include more patients from the hospital's specialist outpatient clinics, with more than 70 patients now under this expanded care model with general practitioners (GPs), said Adjunct Associate Professor David Foo, clinical director of the programme and a senior consultant at the hospital's cardiology department.


Under a shared care programme, the specialist can handle the more challenging aspects of the illness, while the family physician or GP will monitor the patient and manage his other medical problems.


Dr Kok Zi Yin, a family physician at Keat Hong Family Medicine, said: "Family physicians tend to manage patients from a 'broader' perspective.


"For instance, some patients have coexisting chronic conditions like hypertension, diabetes and/or hyperlipidemia. We tend to assess their control of these chronic conditions during the consultation too."


They may also advise patients on getting a flu vaccine, for example.


Also, in a shared care programme, the primary care doctors can fall back on specialist support.


Dr Kok said that challenges can arise when patients experience a change in or worsening of their conditions.


The family physician or GP may then need the specialist's advice in adjusting the patient's joints medication, for instance, and may thus refer the patient back to the specialist for an earlier assessment, she said.


But not all patients can be on a shared care programme. They "must have been stable for a period of time, hold a Community Health Assist Scheme card for subsidised care in a family clinic, and are confident that the family physician can manage their condition", she said.


As for Mr Chua, he has been alternating between visiting the hospital and clinic for several years since the programme began.


"NUH has its own lab, and I am able to get the results within a day. For Frontier, I've to go there twice as I get the results after two days," he said.


However, in view of the physical distancing required now, he was happy to visit the GP in March, and said that he will be very careful when he visits the hospital this month.


"I've anxiety, I don't want to get the coronavirus," he said.


Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.



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