Future Primary Care

The FPC programme aims to make primary care the centre of gravity for most health needs, and enable patients to effectively self-manage their chronic diseases in partnership with their primary care providers. 

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Professor Gerald Koh

Head & Clinical Director,

Future Primary Care

Aside from our telehealth initiatives, we are also running several projects to strengthen the primary care sector. These include:

Primary Care Dashboard

The Primary Care Dashboard (PCD) project, which was started in August 2019, aims to design and build a national, near real-time and actionable dashboard to provide clinical insights and recommend improvements for the primary care sector. Both public polyclinics and private General Practitioners (GP) will be able to contribute to, and access, information on the PCD.

The MOHT team will be working closely with a Private Care Network (PCN) on a two-year pilot to study the current state of primary care data collection and develop a minimally-viable PCD. This will allow MOHT to better understand the infrastructure setup, challenges and resources needed to implement a PCD, which will then be used to validate the development of our national efforts.

Concurrently, MOHT will also be working on enablers in the primary care sector, to allow optimal use of the PCD. Firstly, we will support digitalisation plans for the GP sector, which will provide a strong pipeline of data to the PCD. Secondly, we will facilitate Plan-Do-Study-Act (PDSA) training in process improvement for PCN clinics, which will equip them with the skills to use PCD data to improve clinic processes.


General Practitioner Innovation Initiative

In January 2020, MOHT invited GPs to submit innovative proposals to answer the following challenge statement:

“What innovative solutions can help significantly increase the number of chronic patients managed by GP clinics by at least 20% in the next 3 years, with achievement of good disease control, and which are financially sustainable and scalable?”

 

Below, we describe two of the winning projects that MOHT has awarded funding to. 

Project THRUST (Tackling Hypertension Right, Unifying Strengthening Trust)

Project THRUST (Tackling Hypertension Right, Unifying Strengthening Trust) aims to develop a more comprehensive GP care model for hypertensive patients, incorporating tele-monitoring, lifestyle coaching and modification to improve compliance, advance patients’ health and wellness, and increase patient satisfaction. The project will employ a range of technology tools including remote vital sign monitoring devices (such as blood pressure machines, weighing scales and lifestyle trackers) and apps for care coordination, coaching and communication.

Project THRUST is driven by Dr Lee Yik Voon (Lee & Tan Family Clinic and Surgery), supported by MOHT, and involves five GP clinics and their Technology and Care Services Partner, Witz-U, to on-board 500 hypertensive patients to the programme for up to 12 months.  This includes patients with other concomitant chronic disease(s), such as diabetes. Each patient will be monitored and coached on various aspects of his or her behaviour and lifestyle, such as medication, blood pressure monitoring, diet, exercise and mindfulness by a multi-disciplinary team comprising the GP, a health coach/nutritionist, a care coordinator and a mindfulness coach. 

The programme has started recruiting patients. Over the course of the project, patients will be monitored for their BP control, achievement of their lifestyle targets, compliance and satisfaction, and these outcomes will be compared to their baseline. 

 

Project THRUST started in Dec 2020, and plans to eventually partner more than 15 GP clinics. The target is to reach out to more than 3000 patients by the 2nd year.


Chronic Care Transformation in Primary Care Networks (CCT-PCN)

Chronic Care Transformation in Primary Care Networks (CCT-PCN) aims to enhance chronic disease management in GP clinics, by using technology to improve patients’ health. The programme not only empowers patients to take ownership of their health, but also optimises care delivery by care teams.

This project offers a multidisciplinary and innovative solution for the primary care sector to transform chronic disease management and anchor care in the community, potentially reducing the need for huge institutional resources. The project leverages the current Primary Care Network (PCN) scheme, to enhance PCN clinics’ ability and capacity to manage their patients’ chronic diseases.

CCT-PCN focuses on a three-pronged approach: i) develop a user-friendly app for patients’ self-management of their chronic conditions, ii) enhance the current Chronic Diseases Registry for PCNs to provide updated information and evaluate care outcomes based on clinical data collected from various activities and iii) establish a shared IT system for primary and community care partners to manage their patients together.

CCT-PCN is driven by Dr Tham Tat Yean and his team from Frontier Healthcare Holdings, supported by MOHT, and involves multiple partners across both public agencies and private providers. Key stakeholders involved in this project will include MOH, the Agency for Integrated Care, GP member clinics within the PCN, specialist teams at our public hospitals, as well as home care and ancillary service providers.

The project started on 1 December 2020, and will run for three years. Patient

recruitment will start in 2021.

Partners:

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