For years, Mr Adam Salim, 63, used to skip his doctor's appointments and take his medication only every other day to make it last longer.

And that could have cost the diabetic a leg if not for a vigilant doctor-nurse team which found out that Mr Adam could not afford the fees. By the time they realised what was happening, six months had passed since his last doctor's visit.

They then referred him to a financial counsellor who helped him apply for subsidies through Medifund.

Today, the retiree religiously attends his three-monthly check-ups at Ang Mo Kio Polyclinic, and his diabetes is under control. His fees are completely covered by Medifund.

Mr Adam, who was self-conscious about his finances, said he felt comfortable enough with the team to share his financial difficulties as he sees them at every visit. He stopped working 10 years ago because of his health.

In 2014, National Healthcare Group Polyclinics started matching patients with chronic diseases to the same team at every visit, and the model was rolled out to all nine branches in April this year.

Called the Teamlet Care Model, patients are assigned to a team comprising two doctors, a care manager who is a nurse, and a care coordinator who schedules appointments.

There are about 5,000 to 6,000 patients currently enrolled under the care model.

The team wants to build trust with patients with chronic diseases, who have to make regular trips to the doctor to collect their medication. Previously, the patient would see a different doctor at every visit.

SingHealth Polyclinics, which also has nine branches, piloted a similar care model in Bedok Polyclinic in January last year. It will be fully implemented by the end of this month.

There are plans to roll out the care model progressively at other polyclinics.

Dr Tricia Chang, a family physician and Mr Adam's doctor since 2015, said the model helps build trust between doctors and patients.

"Patients are more motivated, and we feel that we can empower them more and that they are more willing to take charge of their health... It is very important in chronic disease management because it is a long-term thing," she said.

"They don't feel embarrassed and will tell us when they have a problem, which is what we want."

Madam Zaiton Salleh, 56, Mr Adam's wife, said she used to have to keep chasing him to go for his doctor's appointments.

"Now he goes even when I can't accompany him. It's a good change."