Team-based care for chronic illnesses shows results: Study

Mr Leon Chester Stewart, 48, was diagnosed with diabetes in 2012. He managed his weight better with help from the teamlet care model developed by the National Healthcare Group polyclinics. He is seen here with teamlet members - Dr Tricia Chang (seate
Mr Leon Chester Stewart, 48, was diagnosed with diabetes in 2012. He managed his weight better with help from the teamlet care model developed by the National Healthcare Group polyclinics. He is seen here with teamlet members - Dr Tricia Chang (seated) and Ms Evonne Oh.ST PHOTO: KELVIN CHNG

NHG polyclinics' model involves dedicated group looking after patients on regular basis

Mr Leon Chester Stewart tipped the scales at 100kg.

Doctors warned the diabetes patient about the possible health implications of his weight, but he paid no heed to them. Then, from December last year, he shed 15kg in five months. It was due to a new "teamlet" care model developed by the National Healthcare Group (NHG) polyclinics.

The care model involves having a dedicated team of family physicians, nurses and other healthcare providers in the polyclinic look after patients with chronic conditions on a regular basis.

A recent study by the NHG polyclinics showed that it has had a positive impact on patients' health. There was a reduction in avoidable emergency department and hospital admissions, improvements in the uptake of preventive health screenings and improvements in patients' clinical outcomes.

Mr Stewart, 48, who was diagnosed with diabetes in 2012, said: "The team got to know me as a person, and what I've been through. That made a big difference at the relational level."

He said that it was the level of openness in his relationship with his doctors that got him to "wake up" and do something about his weight. Mr Stewart, who is a youth pastor at a church in Kovan, sold his motorcycle and took up cycling as his main mode of transport. It also served as a form of exercise.

The teamlet care model was first implemented in Toa Payoh Polyclinic in 2015, and subsequently rolled out in the other five polyclinics under the NHG in Ang Mo Kio, Woodlands, Yishun, Geylang and Hougang. The latter two were not involved in the study, which was conducted from July 1, 2015, to Dec 31, 2016. It involved about 20,000 patients - half were enrolled in teamlets, while the other half were a control group. Patients had a mix of different chronic conditions, though those in the control group were selected based on similarities to the teamlet group in ethnicity, age group, gender and the severity of their conditions.

The NHG polyclinics have over 200,000 patients with chronic conditions. As of last month, there were 25 teamlets with some 100,000 enrolled patients.

Dr Sabrina Wong, assistant director of clinical services at the NHG polyclinics, said: “Our intention is to develop a relationship with patients to empower them to look after their health better - it's about providing holistic care for their overall health, and it goes beyond just caring for their chronic conditions.”

As of last month, there were 25 teamlets with some 100,000 enrolled patients. The aim is to enrol the remaining patients, and their family members who may be at risk, by the middle of next year.


Correction note: Dr Sabrina Wong's quote has been edited for clarity.

A version of this article appeared in the print edition of The Straits Times on August 18, 2018, with the headline 'Team-based care for chronic illnesses shows results: Study'. Print Edition | Subscribe