Integrated multi-disciplinary care
• Integrated specialised services (ISS)
The role of allied health professionals was strengthened and expanded to ensure multidisciplinary management. Doctors can refer patients for a set of specific and comprehensive health counselling and education services which will be delivered by ISS personnel matching their area of specialisation (e.g. dietary advice and foot care). These services are made more readily available and patients would no longer need to go to secondary or tertiary facilities to acquire these services.
ISS personnel include pharmacists, dietitians, nutritionists, physiotherapists, occupational therapists and medical social workers
• Cardiovascular care bundle medication therapy adherence counselling
Medication therapy adherence counselling services scope was expanded from diabetes-specific to cardiovascular care which can provide more comprehensive counselling targeting CVD risk.
Continuous improvement of care delivery
• Clinical and prescribing audits
New standard clinical and prescribing audits were introduced for quality monitoring and improvement of T2DM and hypertension care processes in the clinics.
Doctors, nurses, Assistant Medical Officers (AMOs), and Care Coordinators
Improving organisational practices
• Primary triage counter
This was introduced at the entry point of clinics to decongest the registration counter and effectively direct patients to the respective units based on their healthcare needs so that treatment services can be delivered in a timely manner.
Nurses or AMOs
• Secondary triage counter
Enhancement of CVD risk screening, standardised CVD risk stratification using Framingham risk score and tracing of laboratory results were conducted in secondary triage counter prior to doctor consultation, so that all necessary information is readily at hand during consultation.
Nurses or AMOs
• Care Coordinators
A care coordinator’s role was introduced to improve coordination of activities related to T2DM and hypertension care management including tracing appointment or medication refill defaulters and managing referrals, with the aim of reducing appointment and medication defaulter rates. Care coordinators can obtain appointments for patients who needed specialty referrals by liaising with officer in charge at secondary or tertiary facilities and track patients’ movement through referral process. Care coordinators’ tasks also include monitoring performance of T2DM and hypertension management through audits and facilitating team meetings to discuss on audit findings.
Nurses or AMOs
• Family Health Team (FHTs)
Team-based care was introduced to ensure continuity of care. Each FHT consists of at least a doctor, an AMO, a nurse and a - care coordinator. It functions as a unit to provide healthcare services for patients who resides within the team’s assigned geographical zones.
Doctors, nurses, AMOs and Care Coordinators
• NCD care form
The NCD care form was a new standardised documentation tool designed as a checklist of essential information and processes of care to ensure guideline-adherent T2DM and hypertension management practices and CVD risk monitoring for every clinic visit.
• Identification of medication refill defaulter
Patients with medication possession ratio < 80% were identified by pharmacists and a defaulter list would be given to the care coordinators to facilitate medication refill defaulter tracing.