Applicant: ​Bright Vision Hospital (implementation site at Sengkang Community Hospital)
Programme Name:BVH Integrated Primary Care for At Risk Elderly (iPCARE 2.0)
Programme Background: ​

In Singapore’s current healthcare system, General Practitioners (GPs) usually encounter multiple challenges caring for patients with complex needs and inevitably lands up referring them to public or tertiary institutions (e.g. polyclinics, specialist outpatient clinics) where there are abundant resources. Moreover, these patients or their caregivers find it difficult to navigate and coordinate their care services across different healthcare settings.

From 2017 to 2020, iPCARE has been established as a proof-of-concept, supporting an alternative model of integrating primary and community care services. It showed that:

• Patients with complex needs were willing to be seen by their GP for medical care, with other care needs1 coordinated by the iPCARE team and supported by resources from the nearby community hospital;
  
• GPs were willing to accept such patients, and were receptive towards the iPCARE team providing support to both GPs and patients outside of the GPs’ scope of work or working hours.
  

iPCARE 2.0 aims to further explore how to improve the integration between primary and community care; and evaluate the costs and barriers of anchoring such patients with the GPs (instead of acute hospitals and specialist outpatient clinics) and in the community by answering the following questions:

• What are the patient archetypes that GPs are reluctant to manage today?
  
• What are the services and resources that the GPs would require to better manage these patient archetypes?
  
• What is the overall cost of such a service bundle?
  

The lessons learned from iPCARE 2.0 could also potentially help to develop the next phase of Primary Care Networks (PCN) so more GPs and patients could benefit from it.

Clinic-based and home-based care e.g. nursing, allied health and social care services provided by a community hospital’s outpatient clinic, major home and social providers.

Applicant: ​Buddhist Compassion Relief Tzu Chi Foundation (Singapore)
Programme Name:Conservative (Non-Dialysis) Management of Patients with End Stage Renal Disease
Programme Background: ​

Singapore ranks the 4th highest in the number of end stage kidney failure globally. On average, 5 people are diagnosed with end stage kidney disease every day, based on the Singapore Renal Registry 2018, and this number is expected to increase, with an aging population and with increasing prevalence of diseases like diabetes. Besides dialysis and transplant, conservative care is another modality to care for the patients with end stage kidney disease.

Comprehensive Conservative Management (CM) is an active management without dialysis. These includes a shared decision-making process, interventions to delay kidney disease progression and minimise the adverse events and complications, management of symptoms related to end stage kidney failure without dialysis, and psychological, social and family support. The elderly patients with multiple health conditions, are frail or have declining health where the risks for dialysis are high - CM is an alternative treatment to support these patients in order to maintain their quality of life and to support their love ones.

For this pilot programme, Tzu Chi (TC) plans to:

1. increase ESRD patients’ awareness of CM so they can make informed decisions on care options;
2. partner Sengkang General Hospital (SKH) to identify ESRD patients who would not benefit from dialysis and refer them to the CM programme;
3. upskill its Home Nursing and Home Medical teams to provide continuity of care for these patients who opt for CM (e.g. renal failure symptoms, e.g. swelling, anaemia, etc.);
4. discuss Advance Care Planning (ACP) with patients; and
5. transit CM patients to its Home Palliative team if prognosis is 12 months or less (or refer to hospice if patients’ condition could not be managed at their home).

The pilot would help to inform policy, support the scale up of CM capabilities in other community care providers, and evolve the support for home care patients.