Mr Edwin Tong
Minister for Culture, Community and Youth, Second Minister for Law, and Adviser to Marine Parade GRC GROs
Mr Cheng Wai Keung
Professor Ivy Ng
Group CEO, SingHealth
Dr David Ng
CEO, SingHealth Polyclinics
Ms Junie Foo
Chief Executive Officer, Methodist Welfare Services
Distinguished guests, ladies and gentlemen
1. I am happy to join you today for the official opening of Eunos Polyclinic. This is our 23rd polyclinic, and part of our continued efforts to strengthen primary care capacity.
2.. Let me first express my deepest gratitude to all our healthcare professionals at Eunos Polyclinic for being part of the battle against COVID-19. The Polyclinic started ramping up for opening during the Delta infection wave late last year. So, it was plunged into the deep end. It has not been an easy journey, but you have risen to the challenge, and I thank the staff of Eunos Polyclinic for your important contributions.
Methodist Welfare Services Senior Care Centre
3. We have also been co-locating polyclinics with our health-related services. Today I would like to recognise the good neighbour of Eunos Polyclinic, which is the Senior Care Centre operated by the Methodist Welfare Services (MWS).
4. MWS has over 40 years of community service in Singapore, and currently serves more than 8,000 beneficiaries through their 21 centres. This is MWS’ first Senior Care Centre, and I am confident that the two institutions will synergise their work to serve our residents better.
5. Through MWS, the Polyclinic can now better encourage active ageing by organising appropriate health and wellness activities, such as health talks and healthy cooking demonstrations for our seniors.
Team-Based Care in Chronic Disease Management
6. With the COVID-19 situation stabilised, our polyclinics have been focusing on non-pandemic workload. We are working upstream to better manage the rise and increasing complexity of chronic disease management.
7. This is why the future of healthcare is in primary care. Today, let me talk about an important aspect of primary care, which is delivering care through multi-disciplinary teams.
8. Our polyclinics, including Eunos Polyclinic, have harnessed the strength of teamwork.
9. A team-based care system is based on two beliefs. First, by tapping on the expertise and competencies of different professionals, we can deliver better outcomes for the people we serve. Second, by assigning a dedicated team to a patient as far as possible, we build a strong relationship between the team and the patient, and that is fundamental to better care for the patient.
10. A typical team has up to three family physicians, whose core responsibility is to adopt a relationship-based approach in good chronic disease management. With good relationship, comes trust; with trust, comes the patient’s willingness to heed the advice of the doctor. Then patients can be empowered to self-monitor and self-care. Indeed, a big part of better health outcomes stems from each of us being responsible for our own health, and learn how to do so with the help of our doctors.
11. There will also typically be a registered nurse trained in chronic disease management who is the care manager, whose duty is to provide chronic disease counselling, teach patients self-management skills and manage stable chronic conditions in collaboration with the doctor.
12. Another member acts as the care coordinator, who will provide pre-consultation screening of the patient, to find out if he has underlying chronic diseases, taken his relevant vaccinations, and state of mental health and frailty.
13. There may also be a care coach, who will look into social aspects of health. The coach may have to tap into external support to address issues within the family, or help the patient adjust their lifestyles. Other resources available to the team include allied health professionals and hospital specialists. The care team must know that the entire healthcare system is supporting their work to care for patients.
Model of Care
14. With a team-based approach, the model of care changes. So a typical journey of a patient may look like this.
15. First, when a patient with chronic illness visits the polyclinic, he will measure his blood pressure, height and weight using the self-help machines at the polyclinic.
16. Then, the polyclinic will assess their medical complexity and other social needs. Depending on his control, the patient could be reviewed by a nurse clinician if stable and well controlled. If it is a more complex case, he will be immediately attended by a doctor.
17. As the team reviewed the complex case, it may prescribe tests such as diabetic eye and foot screenings, which they are now empowered to order. The nurse counsellor will provide individualised health education to optimise blood sugar control and check that follow-up appointments are booked.
18. After the patient leaves the clinic, a telecare nurse may contact him before his next visit to the polyclinic. The nurse will review the patient’s lifestyle habits, suggest adjustments, and remind him to take his medications.
19. This is one example. Others may have difference experiences, depending on their conditions. Through the team-based approach, polyclinics try to deliver care that is as customised as possible, according to patients’ care needs.
20. I believe private family doctors also see value in a team-based approach. Many are now part of Primary Care Networks, where they can tap on each other’s support. I understand that many private family doctors are also visiting our polyclinics, to draw reference from best practices in team-based care.
Support from the Community
21. It is important to recognise that in team-based care, there needs to be an extended team beyond the polyclinic. Because everyone of us spends much more time in our home, workplace and community than at a healthcare facility. So good healthcare requires the support of the community.
22. To better assist patients with complex medical and social care needs, SingHealth Polyclinics piloted the Primary Care Based Integrated Community Care Teams programme at Marine Parade Polyclinic.
23. In this programme, SingHealth Polyclinics care teams collaborated with partners from across the health and social sectors, including SingHealth Community Nursing, Changi General Hospital Neighbours for Active Living, and Montfort Care GoodLife!. These partners played distinct roles in the management of the patient’s medical and social wellbeing, in the community.
24. In the initial pilot, despite the majority of patients having at least three chronic conditions, more than 80% of these patients benefited from better blood sugar control six months after enrolling in the programme. More than two-thirds of patients demonstrated an improvement in their knowledge, skills, and confidence in managing their own health and well-being.
25. Indeed, other studies showed that over three years, patients cared for by polyclinic teams showed significant positive clinical outcomes, compared to other patients. This includes better diabetes control, fewer specialist outpatient clinic visits, fewer visits to emergency departments, and fewer hospital admissions.
26. With the support of team, patients also generally take better care of themselves. Interestingly, when surveyed, many patients cared for by teams reflected that some of their social and family issues that affected their health have been addressed. Somehow, as the conditions of patients improved, they also took steps and efforts to resolve some of their social and family issues. Better team care begets better self-care, and vice versa.
27. Given the success of the pilot programme, SingHealth Polyclinics will progressively extend the programme to its remaining eight SingHealth Polyclinics, including Eunos Polyclinic.
28. I would like to congratulate SingHealth Polyclinics on the official opening of Eunos Polyclinic and thank all the staff for your commitment to serve the residents here.
29. Other than the unveiling of a spanking new facility, what is equally important is the emergence of new models of care that will benefit our patients, raise the morale and heighten the mission and purpose of healthcare workers, and bring about a healthier population.