Taking reference from the CCM and framework for patient-centred access to healthcare and considering the interview findings, the patients’ journey in managing MCCs generally involves 3 key areas, namely, accessing care, receiving appropriate care and self-managing (43, 44) (Figure 1). First, patients need to access healthcare and other essential services without experiencing financial hardship, and able to physically access the services that they need. Second, it is crucial for patients to receive appropriate care at the polyclinic. Last, patients have to be able to self-manage with minimal monitoring by healthcare professionals in the community.
Findings through interviews with healthcare providers and users were merged under each theme, with a clear distinction between the facilitators and barriers. The 4 themes, specifically accessing affordable care, the ability to reach and utilise services, receiving safe and quality care, and self-managing in the community, as well as the corresponding 17 sub-themes indicated below each theme, were elaborated as follows.
Figure 1: Journey of patients with MCCs & derived themes
Theme 1: Accessing Affordable Care
a. Facilitators
i. Affordable charges & presence of “helping hands”
Physicians indicated that the most common chronic conditions that are managed in polyclinics include diabetes, hypertension and hyperlipidemia. All patients in this study reported being diagnosed with at least one of these conditions. A total of 10 patients mentioned that they chose to manage chronic conditions in the polyclinics due to subsidised and affordable charges. Other reasons quoted for visiting polyclinics include close proximity to their homes and relationships with healthcare providers. Most patients tapped into MediSave to pay for the charges (47). Providers shared that patients requiring financial and other support could be referred to financial counsellors or medical social workers situated in polyclinics to facilitate the process of subsidies and other applications.
i. Financial challenges specific to the MediSave withdrawal limit, higher non-standard drug charges & support schemes
Several patients reported the inadequacy of the MediSave scheme to cover outpatient visits, particularly with higher charges for certain medications. Physicians shared that although unsubsidised non-standard medications might be beneficial for patients with chronic diseases, they would not be able to prescribe them to patients with financial constraints. For existing patients who were prescribed non-standard medications but subsequently encountered financial challenges, physicians expressed that they would reduce the dosage or replace non-standard medications with other drugs, with consideration of the clinical implications. A patient commented that he would follow his neighbour to purchase medication from a neighbouring country if needed to cope with high medication costs.
Although patients could apply for financial assistance through polyclinics, Dr Candy emphasised that some might not be eligible:
“They (patients) don’t meet the criteria to get the subsidy but yet…they really feel that they can’t cope (with) the charges, but there is nothing (that) you can do because the criteria have already been set.”
Dr Amanda also questioned the necessity for all needy patients to be assessed based on eligibility criteria:
“I don't see why people who need a walking stick must prove that they need it. Is there a need to prove that they are already 80 years old?... Must we fill up some forms for them to qualify for (purchase of) wheelchair?”
Dr Amanda further suggested for flexibility to be exercised on a case-by-case basis and added that healthcare providers would rather pay for the patients’ expenses when needed.
Half of the caregiver and patient participants reported not knowing where they could seek help, with a few sharing that they would discuss their situations with their family members. While one of the patients, Mary, applied for a Foreign Domestic Worker grant about one month ago to hire a helper to take care of her elderly mother with chronic conditions, she stressed on the need to reduce processing turnaround time to ensure the provision of timely support:
“It shouldn't take so long. By the time you (the government) approved the grant, my mother might no longer be around…I think the service can be a little faster.”
Theme 2: Ability to Reach and Utilise Services
i. Perceived accessibility to comprehensive services
Physicians reported that patients could access consultation, diagnostic and pharmacy services to manage MCCs in a single polyclinic. As services such as physiotherapy and podiatry are not available at certain polyclinics due to space and resource constraints, some patients may need to travel to a different polyclinic to access these services. However, all patients reported that with the availability of buses and trains, they did not encounter any challenges traveling to polyclinics. Physicians explained that patients’ frequency of visits to polyclinics depends on their ability to control their diseases instead of the number of conditions and could range from 2 to 4 times a year. Patients can schedule subsequent appointments during each visit in the polyclinics and receive SMS reminders about these appointments.
i. Impractical for polyclinics to cover all patients
Some participants reported challenges facing bedridden patients and wheelchair users in trying to access polyclinic services.
Physicians further cautioned that patients might “fall through the cracks” if they did not schedule any follow-up appointments or defaulted on their appointments, for instance, due to work commitments. Dr Peter explained:
“Most of them will say it is (due to) work…they forget…still have their medications... if they are not here, I can't help them anyway.”
While polyclinics can follow up with patients enrolled under specific care teams or programmes, physicians generally felt that it would be challenging to reach out to all other patients.
ii. Challenges of elderly navigating the polyclinic system
A few participants highlighted the difficulties encountered by some elderly in their consultation journeys. These include the challenges of them using self-registration and payment kiosks, communicating with polyclinic staff who do not speak dialects, and missing stations. Ang, who is an elderly patient, mentioned the following:
“It is very troublesome now, we (elderly) don’t know how to read and use the kiosks…If my daughter did not go with me, I will not know how to press (the kiosks). In the past, when we buy medicine, we pay by cash, now we (will) need to place cash in the machine.”
iii. Long waiting time
Half of the patient and caregiver participants reported long consultation waiting time of up to 3 hours despite having scheduled appointments. Several patients thus stressed waiting time in the polyclinics as a key area for improvement. Two patients mentioned that the demand for polyclinic services had increased with new housing developments around the polyclinics and because of patients who continue to seek treatment at the polyclinics even after relocating to other areas. For instance, a patient shared that due to personal preference and familiarity, he has continued to visit Queenstown Polyclinic, which is located in the West, despite moving to the East.
Theme 3: Receiving Safe and Quality Care
a. Facilitators
i. Quality assurance and improvement efforts
Physicians reported that in order to have the skillsets to deliver safe and quality care, they are required to attend regular Continuing Medical Education and training sessions conducted either by specialists or physician champions. Furthermore, a physician mentioned that by tracking common clinical indicators across polyclinics, physicians could identify potential gaps and initiate quality improvement (QI) projects. A few physicians were of the opinion that the polyclinics had created a facilitating environment for physicians to propose and drive QI projects.
ii. Collaboration among multidisciplinary teams
Close to half of the patients interviewed were visiting nurses instead of physicians regularly to review their conditions and were generally supportive of this approach. Mary said that:
“Yes, it is a nurse instead of the doctor who does the explanation. The nurse is really good…She has more time to explain the details to us.”
Physicians could also refer patients with multiple medications to clinical pharmacists to assist with medication reconciliation. A few physicians illustrated the crucial roles played by non-doctors in understanding and addressing the needs of patients, including those who require more assistance in making changes.
Through the interviews, physicians described multiple care delivery models in the polyclinics, of which the teamlet model was the most discussed. Physicians explained that there are plans to expand the teamlet model and empanel more patients through this model to comprehensively address healthcare needs. Five physicians interviewed were involved in this model, which comprises a team of 2 doctors, care manager and care coordinator. While doctors review patients’ laboratory results and assess conditions, trained nurses, who assume the roles of care managers, conduct counselling sessions to educate and empower patients to control and manage their conditions. The counselling sessions could cover education on chronic diseases, training on insulin injection for diabetes patients, taking and tracking of blood pressure and blood sugar readings, as well as guidelines on lifestyle practices. In addition, care coordinators who are lay-persons support by keeping track of the screening tests that patients are due for, as well as assist in appointment scheduling and tracking. With fixed care teams managing specific patient groups, physicians elaborated that provider-patient relationships could be well established. In addition, Dr Christine shared the following:
“If there are any difficult patients, we can always discuss within the team on how to manage.”
b. Barriers
i. Challenges of physicians adhering to clinical and other guidelines
Although physicians could refer to clinical practice and other guidelines to understand the latest care standard and targets, a physician mentioned that it would be difficult to refer to such guidelines, particularly during consultation sessions. She felt that it would lower patients’ confidence if physicians paused to check guidelines during the consultation process. Another physician also raised the need for the timely updating of guidelines to ensure alignment between national and international guidelines to avoid confusion.
ii. Perceived inadequate consultation duration
Most physicians reported the issue of high patient load as a key barrier to providing appropriate levels of care to their patients. Physicians also needed to manage patient waiting time, which has been tracked as an operational key performance indicator (KPI). Physicians mentioned that they could only spend an average of 10 minutes with each patient diagnosed with chronic conditions. Many felt that this amount of time was inadequate, particularly for patients with MCCs who were referred from hospitals. To manage patients discharged from hospitals, physicians explained that they needed time to review the discharge summary and access different IT systems to view clinical notes and lists of medications.
Physicians shared that the duration of consultations for some patients might be reduced due to several reasons. These include the presence of patients perceived as “highly demanding” or “overly empowered,” with a long list of questions and requests. There were also instances of IT system break-down and slowness, further inducing time pressure and stress among physicians. It was reported that inadequate consultation durations might create the possibility for error and result in physicians neglecting critical areas, which would be detrimental to patient care. As Dr Amanda said:
“You cannot rush a chronic patient's consult (session). If they (the polyclinics) just pile patients to the queue…you are bound to make mistakes.”
iii. Lack of care continuity
Some patients visit both hospitals and polyclinics concurrently, but physicians reported several challenges in providing coordinated care. First, while physicians can view the clinical notes of patients visiting or referred from hospitals using the same electronic medical record (EMR) system, they are unable to view the detailed notes of other patients. Second, it was reported that most primary care physicians (PCPs) and specialists mainly communicated through hardcopy memos passed through patients’ hands. PCPs highlighted the challenges of contacting specialists involved in co-managing patients in a timely manner, with less than half mentioning that they could liaise with specialists through emails or phone calls. With the presence of these constraints, it could be challenging for polyclinics to coordinate care for patients who use healthcare services across primary and hospital settings, as Dr Jenny recalled:
“My patient was double-dosing himself with the medication stocked by the specialist, but we continued to give it because we didn't know that patient was seeing a specialist and his medicine was changed.”
iv. Difficulties of polyclinics managing complex patients
Moreover, physicians reported various challenges of managing certain patient groups, including hospital-referred patients. Frail elderly with MCCs, individuals with poorly controlled conditions, bed-bound patients, and others with rare diseases or complex conditions such as end-stage kidney failure were flagged. Physicians specifically highlighted the lack of expertise, infrastructure and resources, as well as the unavailability of specific medications and services such as occupational therapy for post-stroke patients. For instance, Dr John explained:
“The main challenging part would probably be the medications because we are not trained to give some medications… and the ministry will have to provide us with the resources… to see the patient safely.”
Physicians reported that some patients may choose not to manage their conditions in hospitals due to certain considerations, such as cost, the challenge of traveling to the hospital, and disagreement with hospital care plans. Although it may not be optimal for such patients to visit polyclinics, physicians reported that they would continue to manage them and discuss their cases with multidisciplinary teams or consult specialists when needed. Physicians would also refer patients in deteriorating condition to hospitals.
Theme 4: Self-managing in the Community
a. Facilitators
i. Patient education and empowerment
Some physicians explained that they would request for more information from new patients in order to better address those patients’ potential challenges in coping with chronic disease management. These details, which include medical history, family background, daily routines and risk factors, would help physicians assist patients in setting targets such as exercise hours. All patients and caregivers reported that healthcare professionals had provided them with dietary and exercise guidelines and that they were able to understand the information.
Some patients reported that healthcare providers had guided them to self-monitor their blood pressure and blood sugar levels and capture the readings regularly on a form to be discussed with providers at upcoming consultation sessions. A few patients mentioned that the providers had also informed them about symptoms to take note of and that they had been advised to seek early treatment when those readings were out of the standard range.
ii. Patients with understanding on conditions and making some forms of lifestyle modifications
Most healthcare users were able to articulate patients’ conditions. Patients reported that when unwell, they would visit their polyclinics and GP clinics to seek treatment. To obtain further information on their conditions, the majority mentioned that they would either check with healthcare professionals or discuss with their family members. Most patients emphasised making some form of lifestyle change, mainly through reducing food and sugar intake and engaging in physical activities. Six patients reported participating in community programmes such as running, cycling and yoga.
b. Barriers
i. Infeasible for polyclinics to track patients’ progress closely
Physicians reported that they were checking laboratory results and clinical indicators to infer whether patients were making any lifestyle changes and would refer patients to other providers, such as nurses and dieticians, to reinforce the guidelines when needed. However, Dr Peter explained that due to resource limitations, polyclinics were not able to customise detailed plans for individual patients or monitor the progress closely. He mentioned the following problem:
“There is no service to assess what kind of exercise (patients) are suitable for. Nobody to prescribe the exact exercises (that) they need, nobody to monitor their progress.”
ii. Low adoption of technology by patients
Although patients and caregivers could check their screening test results prior to consultation sessions through HealthHub (48), an online application, only one person reported doing so. Key reasons for not using the application include the details being available only in English and in a small font size, not being able to interpret the results, as well as preference for healthcare providers to explain the results to avoid anxiety.
While polyclinics offer telecare services, through which patients could measure and submit their blood pressure and blood glucose readings online for nurses to monitor and provide necessary advice, participants reported that this might only benefit patients with IT knowledge. For instance, Leong held the view that:
“I think the government spends a lot of money on technological services. I think that is good. But the problem is, some people (who) know how to use it will benefit from it. But those who don’t will be at a disadvantage.”
iii. Multiple factors influencing patients’ self-management and decisions to make lifestyle changes
Although patients could take greater ownership of their health by self-monitoring their conditions, a physician noted that some might not be able to afford devices such as blood pressure monitor and blood glucose monitor, and consumables. Physicians and healthcare users emphasised that patients would also need to be able to interpret the readings and recall the standard guidelines, including dietary control. In addition, most patients mentioned that they had at some point forgotten to take their medication and would simply continue with the next dose of medication. A few physicians also reported that patients’ work nature was a key contributor to missing medications.
Patients’ lifestyle behaviour were reportedly affected by various factors. First, five healthcare users mentioned that patients and family members would search for information online. However, one physician cautioned that the information might be unreliable, and she had tried to clarify the details with patients. Second, the environment around patients’ homes and workplaces, as well as the nature of their work, could affect their food choices and decisions to make lifestyle changes. For example, dietary choices could be dependent on the availability of affordable healthy food options near homes and workplaces. In addition, Ah Hock, a taxi driver, felt that his work nature was a key reason for not being able to exercise regularly.
“Because we (drivers) have to cover our rental and petrol before talking about earning, so sometimes struggle for certain hours… when I come back, I’m tired already.”
Third, even though patients could be aware of the benefits of physical activities, they might not be able to exercise due to physical constraints, as explained by Patrick:
“The only thing that affects me is that my leg hurts…Exercising is good, but it may affect my leg. I don’t know who to ask about it? Not sure what’s the problem.”
Lastly, patients’ and caregivers’ beliefs, for example, in terms of perceived benefits and adverse outcomes of making lifestyle changes, might influence their decision to do so. Linda, a caregiver to her mother-in-law who was above 70 years old, said:
“She (patient) started smoking since she was young. There’s a saying that, old people if they suddenly stop smoking, they will go faster.”