Part of NHGP’s overall efforts to empower patients and improve health outcomes.
Singapore, 15 July 2019 – In a bid to advance its efforts to transform primary healthcare, the National Healthcare Group Polyclinics (NHGP) is moving health conversations with its patients upstream to educate, engage and empower them, to help prevent or delay the onset of chronic diseases.
This holistic strategy to improve and sustain good health outcomes has seen the launch of a new care process for NHGP patients, which promotes self-empowerment and self-management. Associate Professor Chong Phui-Nah, Chief Executive Officer of NHGP and Primary Care, shared, “NHGP is committed to being a leading health-promoting organisation, that catalyses the health-promoting ecosystem for patients and the community. The new process of care, together with our existing efforts, maximises such opportunities and is part of NHGP’s overall effort to enhance healthcare delivery and empower patients to have greater ownership of their own health.”
Integrating Health Promotion and Patient Activation into Primary Care
Dr Wee Wei Keong, Director, Health Promotion and Preventive Care Division explained the organisation’s rationale for continuing its journey towards a holistic spectrum of care, “NHGP’s role and strategy in health promotion is analogous to that of a ‘kelong’, where fish enter in shoals, and are ‘caught’. Similarly, we systematically detect health risks among the many patients who visit us. We then educate, empower and engage them for healthy lifestyle changes. The patient becomes activated as a result.”
“Through this process, health risks are made visible to both the patient/family and the care team, thus contextualising relevant health conversations between both parties. This is also further enabled by NHGP’s other health-promoting initiatives, including supportive environments, policies and promotional efforts to nudge our patients towards positive health behaviours,” added Dr Wee. (Refer to Annex A for NHGP’s existing health promotion and preventive care efforts.)
Systematic Contextualised Conversations with Patients
Recognising that risk stratification is vital to identify the right level of care for specific groups of patients, NHGP launched the Tiered-Risk Interventions for Managing Weight (TRIM), at Ang Mo Kio Polyclinic in June 2018, and thereafter at Woodlands Polyclinic in April 2019. TRIM enables NHGP’s care team to activate patients by systematically identifying those with health risks, and then starting contextualised conversations with them as part of their care. These patients are then referred to NHGP’s health promoters in the clinic for health coaching and connected to intervention programmes in NHGP and the community. As of 30 June 2019, almost 4,500 patients have been identified under TRIM, of which close to 40% have been engaged in weight management conversations. Of those engaged, more than 70% either took up the recommended intervention programmes or were coached on health matters.
Targeted Intervention Programmes for Patients
One such recommended intervention programme is Lighter Life, an interactive group programme designed for eligible NHGP patients with chronic conditions such as diabetes and hypertension to achieve weight loss in a healthy way. The programme equips them to confidently self-manage their conditions with strong peer and community support. Over eight sessions spanning six months, these patients are monitored and coached on exercise, eating and behaviour change lifestyle habits by a multi-disciplinary primary care team comprising an NHGP family physician, nurse, dietitian, physiotherapist, clinical psychologist, and health experts. The coaching is also followed up with tele-communication sessions. The programme was first implemented at Ang Mo Kio Polyclinic in October 2018, and has since been made available for patients at Woodlands and Toa Payoh Polyclinics.
In addition to Lighter Life, community programmes such as FitterLife are also offered to patients. NHGP recognises that these health conversations can be continued beyond its patients to the community, and it plays a key role in guiding and helping the community bring together the necessary resources for this community programme. For its efforts, NHGP was recognised at this year’s Asian Hospital Management Awards 2019.
64-year old Madam Saudah Marwan, who has hypertension, hyperlipidaemia and prediabetes, was one such patient who has benefitted from Lighter Life. Since completing the programme, her Body Mass Index and blood pressure readings have improved without any increase in her medication. Sharing her weight management journey, Mdm Saudah said, “Despite being physically active, I still gained weight. My doctor then referred me to Lighter Life. Under the programme, I was able to change my habits and apply what I learnt on healthy eating and safe and sustainable exercises. I’ve also had the valuable opportunity to serve as a peer facilitator for upcoming Lighter Life sessions, and share my experiences with new participants.”
NHGP’s new health promotion initiative goes a long way towards co-creating healthcare models that are relevant and truly person-centred. As Dr Donna Tan, Assistant Director of Clinical Services noted, many of NHGP’s projects are team-based. “Successful collaborations must have a common sense of purpose from not only NHGP’s physicians and healthcare providers, but also from patients, caregivers, non-healthcare partners and the community too. Only then can the benefits and outcomes be truly sustainable, through activating our patients and the community in the long-term.”
