88-year-old Madam Ang Hwea Kee had a doctor for most of her chronic conditions — a cardiologist, rheumatologist, ophthalmologist and respiratory physician. In one year, she had 13 specialist appointments and took about 16 different types of medicines. She and her family had trouble keeping track of the appointments and the progress of each condition. As a result, she was admitted twice to the hospital, staying a total of 13 days.
Her cardiologist then referred her to the Frontier Family Medicine Clinic (Frontier FMC) in Clementi to manage her heart condition. The FMC was set up in 2013 as part of an initiative by the Frontier Healthcare Group and National University Health System to better manage patients with stable and complex chronic conditions. Eventually, most of Madam Ang’s medical conditions came under the family physician’s care with close support from the hospital’s specialists.
As part of the partnership, the family physicans have access to the patients’ medical records at the National University Hospital. With access to Madam Ang’s medical records, Dr Koh Thuan Wee and the primary care team case manager were able to keep her out of the hospital several times when she had fluid in her lungs due to her weak heart. “There were other times when she developed a chest infection and consulted me first. I was able to treat her before the infection worsened,” said Dr Koh.
He added that a seamless exchange of patients' medical information between the GP and the specialists is crucial: “If GPs don’t have full view of a patient’s medical history, they are more likely to send them to the Accident and Emergency (A&E) department for further management when they deteriorate.”
The high quality, personalised care that doctors like Dr Koh can provide helps them build a strong rapport with patients and caregivers. “It is not only about treating the patients’ medical conditions but also understanding their social background and needs,” explained Dr Koh. For example, knowing Madam Ang’s daughter had Tuesdays off from work helped the care team organise Madam Ang’s medical appointments accordingly.
While this integrated team-based care model is still being refined — to justify the extra resources needed to manage patients, it is best suited for patients with multiple medical conditions and high-risk patients — physicians are seeing benefits.
Said Dr Koh: “The overall improvement in patients' and caregivers' satisfaction by having a regular family physician, a primary care team to manage all their medical needs, with the hospital specialists’ support, is undeniable. This warrants a further look at how we should continually innovate the way we deliver care."
Says Ms Pauline Lim, Madam Ang’s daughter: “Dr Koh’s patience and warmth towards my mum is beyond words. When mum’s condition isn’t good, he would email me or get his staff to text me or call my mum. The rest of the team have also been very kind, they would try to accommodate my time. I’m really very grateful to them. I have definitely made the right choice in asking NUH to let my mum come under the care of the family medicine clinic back in 2013.”