How Primary Care Teams Work in Singapore to Improve Care for Diabetes and Heart Disease

Lesson 20: Healthcare for Policymakers

Singapore Focuses on Best Practices In Healthcare and Education

If you work in healthcare or if you are interested in our healthcare system, you have undoubtedly heard about patient-centered care, team-based care, medical homes, and primary care healthcare teams that combine doctors, nurses, social workers, and pharmacists that work together to serve patients much better. The medical home idea is a specific type of care team focused on providing coordinated, patient-centered primary care. We also read about team members “practicing at the top of their license” which means that each team member utilizes their full skillset and training to maximize their contribution to the patient care team. The idea is to improve patient outcomes by addressing complex needs with diverse expertise.

The medical home model makes a lot of sense. Patients with chronic diseases like diabetes have many needs. Their blood pressure, blood sugar, and cholesterol should be controlled to certain levels using best practice diet, exercise, and specific medications. They should quit smoking. The should take an aspirin if they have arterial disease or chronic kidney disease. Every year they should have an eye test for diabetic eye damage, a foot exam checking for nephropathy, foot ulcers, and circulation, along with blood and urine tests looking for chronic kidney disease. For any of this to work, there must be a longitudinal trusting relationship. In most practices that load falls entirely on the physician and it does not get done. The doctor only sees the patient for 10 minutes every two to six months. The patient may be more concerned with their back pain or a rash. Those issue may take up the entire visit and these critical issues in diabetes are not addressed. There are many gaps in care.

It makes sense to develop teams to make certain that every patient with a chronic disease gets what they need every time. These teams came into existence to improve clinical and financial outcomes, especially for patients with chronic diseases like diabetes, but in the United States they have not lived up to their potential. We talk all the right talk, but we don’t walk the right walk. Medical homes in our country did not improve health outcomes or save money and there are many reasons for that. “Transforming to a medical home — it’s not fixing one thing,” said Kahn. “It’s really changing everything about how the clinic works. On every single level.” and our medical home projects did not do that. Here are the criteria for medical home recognition.

• Team Based Care and Practice Organization: Practices are evaluated on leadership structure, care team responsibilities, how they engage with patients, families and caregivers.

• Care Management and Support: Practice clinicians use care management protocols to help them identify patients who need closely managed care.

• Know and Manage Patients: Practices must meet standards for data collection, medication reconciliation and evidence-based clinical decision support.

• Care Coordination and Care Transitions: Practices ensure that primary and specialty care clinicians share information and manage patient referrals.

• Patient-Centered Access and Continuity: Practices provide patients with convenient access to clinical advice and continuity of care.

• Performance Measurement and Quality Improvement: Practices have processes for measuring their performance and for quality improvement activities.

These criteria are very vague. It may all look great on paper, but how easy is it for you to get clinical advice? I know the system and it is not easy. Getting certified is mainly a matter of checking boxes. I was in a very large practice that achieved certification while I was there. Nothing changed in the way clinicians interacted with patients before certification or after certification. The medical homes failed because the model was applied to everyone. Half of the patients in a medical practice are healthy. They don’t need intensive management. When you include them in the medical home approach, they dilute the attention that can be directed at patients with multiple, complex chronic conditions. For these teams to work, there must be definition of roles and responsibility with sufficient education and management to make certain that it all functions smoothly. I saw no evidence of that in my very large practice.

The situation is entirely different in Singapore. They dramatically improve their clinical and financial performance because they are more like what our American College of Physicians calls an Advanced Medical Home. “voluntary certification and recognition of primary care and specialty medical practices that provide patient-centered care based on the principles of the Chronic Care Model; use evidence-based guidelines; apply appropriate health information technology; and demonstrate the use of “best practices” to consistently and reliably meet the needs of patients while being accountable for the quality and value of care provided.” These teams focus on the needs of patients with multiple related chronic conditions and the diabetes, hypertension, and cholesterol clinics in Singapore are a proven mature example of that concept.

Singapore has a national system of advanced, one-stop primary care clinics that contain advanced medical home teams to address a related group of high-risk, high-cost chronic conditions. The organization and function of the chronic disease management programs included “identifying the diseases and defining the target population, organizing a multi-disciplinary team led by a clinician champion, defining the core components, treatment protocols and evaluation methods, defining the goals, and measuring and managing the outcomes.” Every member of the team has a specific role. “The Enhanced Family Physician Clinic also known as The Diabetes, Hypertension and Lipid or DHL Clinic contains specific infrastructure built for chronic disease management programs including well-equipped consultation rooms for individual health counseling and education, smoking cessation counseling, a fundus camera for diabetic retinal photography, diet counseling, foot check; each manned by a trained nurse.” Everything does not depend on the doctor. Each team member has specific responsibilities and they are very good at what they do.

The clinical champion is a physician trained in primary care. She leads the team and creates an environment where every team member can make their maximum contribution. She is not responsible for everything that a patient needs as in many of our practices. She is there to deal with more complex patients, decompensations, and those who don’t fit the protocol. That makes the best use of her additional training.

Nurse practitioners and pharmacists trained in ambulatory care manage most patients. Nurse practitioners are trained in team function, care pathways, and protocols. They manage stable patients better than anyone. They mangage them better than physicians. The evidence shows that “The one approach that has proven to be effective (in improving outcomes) is using specially trained nurses or pharmacists, under appropriate supervision, with authority to make medication changes without consulting the physician as long as the changes fell within approved treatment algorithms.” Singapore identifies patients who have poor control of their blood pressure or diabetes or multiple chronic conditions and nurse practitioners address those. When gaps in care are identified, the nurse practitioner has the ability to close the gap without checking with the doctor.

Registered nurses coach patients and establish longitudinal trusting relationships. They identify gaps in care and send those patients to nurse practitioners for closure. They help educate patients to prepare them to manage their disease more effectively. In addition, individual registered nurses specialize in making certain that every patient with diabetes receives best practice counseling on stopping smoking. Another nurse is responsible to be sure that each patient gets a diabetic eye exam. There are standing orders for each nurse to assure that each patient gets each intervention.

These three examples show how our system and the system for chronic disease management is different compared to the one in Singapore. These advanced medical homes in Singapore did not just check off boxes. “Transforming to a medical home — it’s not fixing one thing,” It’s really changing everything about how the clinic works. On every single level.” That is what they did. They changed everything and the members of their teams truly make the maximum contribution that their level of licensure allows. Singapore has proven that you can dramatically improve clinical and financial outcomes if you design your systems to achieve that goal.

How is it that we have not gotten this right and Singapore has? Singapore has designed their system based on best practices. It is patient centered. Our system is not patient centered It is focused on the needs of providers and institutions. As the National Academy of Medicine said 20 years ago: “Between the healthcare that we have, and the healthcare that we could have lies not just a gap, but a chasm.” Singapore has closed that chasm and that benefits every citizen. They are saving 15% of gross domestic product on healthcare costs. They have shown us the way and making progress down that path must be a national priority.