Eastern Health Alliance integrated care programmes will widen reach to benefit more people in eastern

The Health Management Unit, Community Health Centre, and the Eastern Community Health Outreach have shown encouraging results since their inception; expansion plans reflect EH Alliance's key role as regional health system for eastern Singapore

Friday, 18 November 2011 – The Eastern Health Alliance (EH Alliance), the regional health system for eastern Singapore, announced that its integrated care programmes – the Health Management Unit (HMU1), Community Health Centre (CHC) and Eastern Community Health Outreach (ECHO) – have shown encouraging results since their inception, and will be expanded to benefit more people and address more types of chronic health conditions. Launched in January 2011, these programmes address crucial needs in the preventive, primary and sub-acute areas of the healthcare system. The EH Alliance regards the gradual extension of these integrated care programmes in eastern Singapore as part of its key responsibility to develop the regional health system.

"These integrated care programmes are part of the EH Alliance's collective innovation to optimise healthcare delivery in order to enable people in eastern Singapore to live healthily for as long as they can in the community," explained Mr T. K. Udairam, CEO of EH Alliance and Changi General (CGH). "The encouraging results we have received from the data thus far show that we are on the right track, and we need to keep listening to feedback and work closely to innovate with our partners."

Health Management Unit: Walking with patients in their recovery, one call at a time The HMU comprises a team of dedicated, trained nurses who deliver proactive, personalised follow-up care with patients on their medical conditions through the phone. Nurses monitor patients between medical visits and guide them to manage their medical condition, providing coordination. Patients can call the HMU nurses as needed.

First launched for diabetic patients, the programme has shown encouraging results. Patients with poorly controlled showed a reduction in their HbA1C, blood pressure and lipid control compared to those who were not in the programme (see Annex 1). In addition, the hospital re- admission rate for patients on the programme was reduced by 28%, compared to 9% for those on standard therapy (see Annex 2).

Since November 2011, the programme has been extended to diabetic patients discharged from St. Andrew's Community Hospital. The programme will be extended to patients with COPD (chronic obstructive pulmonary disease) and heart failure from December 2011 to early 2012.

"We are changing the model of chronic disease management by working with our patients and empowering them to look after their condition well in the community," stressed Prof Fock Kwong Ming, Assistant CEO of EH Alliance. "The HMU was conceived with the concept that patients with long-term diseases live with their conditions in the community for their whole lives. There is a need to engage patients and equip them to cope and even manage their health in spite of their disease."

There are currently 1,800 patients on the HMU diabetes programme. With the new extensions, the HMU aims to reach out to at least 4,800 patients by end 2012.

Community Health Centre: Supporting GPs in chronic disease management The CHC complements the clinical care by General Practitioners (GPs) by providing allied health and nursing services in the management of chronic diseases in the community. It is helmed by nurses with broad clinical experience in caring for patients with chronic conditions. This is aligned with the Ministry of Health’s desire to have GPs play a bigger role in caring for those with long- term health conditions.

The first CHC in Singapore has received thumbs-up from referring GPs. Located in the heartland of Tampines, it began operations in August 2010 after detailed consultations with and feedback from GPs in the east. To date, some 179 GPs – of which 63% are within a 5km radius of the facility – have referred their diabetic patients for eye screening, foot screening and counselling services. The CHC has served more than 1,100 patients in its first year.

Data showed that one in five diabetic patients who went for eye screenings required further evaluation due to abnormalities, and one in 10 diabetic patients who went for foot screenings had medium to high risk of developing foot complication, which required early follow-up and treatment by respective GPs.

"Since day one, we have consulted closely with GPs about what they wanted in the CHC; their feedback has been critical to the CHC's success," said CHC Programme Director, Dr Derek Tse. "We believe the CHCs provide a valuable support service for our GPs to assist in managing patients with chronic conditions in the community."

The CHC team is currently looking to set up a second site in eastern Singapore to serve more GPs and their patients.

Eastern Community Health Outreach: Guiding the community to healthy living ECHO is a community-based health screening and coaching programme for the early detection and prevention of chronic diseases. Offered in partnership with grassroots organisations, the programme provides health screenings and health coaching workshops, targeting healthy residents aged 35 years and above. Since its pilot in Changi Simei constituency, ECHO has enrolled 536 residents.

Health screening data from the first year of ECHO's launch showed that 45% of the participants – almost half – had abnormal results. They were found to have one or more chronic diseases such as diabetes, high blood pressure and cholesterol, which were not known to them before the health screening. Those participants have since been referred to GPs and appropriate healthcare providers for further consultation.

Dr Ben Ng, Programme Director for ECHO said: "This data is of concern to us and reinforces our commitment to reach out to more residents with the ECHO programme. We strongly believe that with adjustments to their lifestyle and with early detection, these chronic diseases can be prevented or delayed."

1 The ECHO programme will be extended to residents in Tampines constituency in early 2012.

Annex 1: These patients show a reduction in their HbA1C, blood pressure and lipid control compared to diabetes patients not in the HMU programme.

DMU patients Patients receiving standard therapy

Before After Before After HbA1c 8.08% 7.98% 7.89% 8.09% Blood Pressure 134.7mmHg 130.3mmHg 134.4mmHg 138.1mmHg LDL Cholesterol 2.67mmol/L 2.59mmol/L 2.75mmol/L 2.72mmol/L

Annex 2: Fewer HMU patients were admitted to hospital compared to patients receiving standard treatment. Hospital admission was reduced by 28% for HMU patients while those on standard therapy only saw hospital admission fall by 9.5%. Total admission episodes also decreased by 24.4% for HMU patients and only 7.06% for those on standard therapy.

Patients receiving standard DMU Patients (n=543) therapy (n=372)

6 months 6 months % 6 months 6 months % before after change before after change No. of patients 150 108 -28.0 63 57 -9.5 with admission Total Admission 201 152 -24.4 85 79 -7.06 episodes

1 The HMU was previously known as the Disease Management Unit (DMU) when it was launched.

About the Eastern Health Alliance The Eastern Health Alliance is the regional health system for eastern Singapore. It is a partnership of health service providers dedicated to delivering, through their combined expertise, the right quality care at the right time for each patient. The Eastern Health Alliance coordinates an integrated range of healthcare services, from disease prevention, treatment, through to ongoing care. For more information, please visit www.easternhealth.sg.