Supported by the Kewalram Chanrai & Enpee Group Research Fund in Diabetes and Astra Zeneca, the Year of Care (YOC) programme provides ‘Care and Support Planning’ (CSP) for patients with diabetes at the National University Hospital. The programme empowers patients with support from clinicians and results in improved control over the disease.

The programme at NUH is modelled on the YOC programme in the UK, which was developed to address the unique needs of people living with chronic illnesses such as diabetes. A major challenge for individuals with diabetes is maintaining effective self-management of their condition. The YOC model is based on principles of engaging and activating people to be partners in their own healthcare, by changing the focus from the healthcare professional (HCP) to the patient. Patients are sent their results before the consultation and encouraged to think about items for discussion with their HCP. During CSP consultations, patient and HCP discuss the patient’s goals and develop a care plan together. The UK Royal College of General Practitioners (RCGP) has endorsed collaborative CSP as an effective approach to increase patient activation, health literacy and self-management whilst improving some patient outcomes and HCPs’ job satisfaction.

Since its inception in 2017, the NUH YOC programme has made several important advances. A key aspect initiated early in the YOC programme is the education of both HCPs and patients. The UK YOC team came to Singapore in July 2017 to train a group of 30 HCPs in conducting CSP consultations and motivational interviewing techniques. The team came back in August 2018 to conduct a ‘train the trainers’ workshop for a smaller group of HCPs, who are now training others in person-centred care. Educational videos have also been developed to inform HCPs and the public about person-centred care, and about how to get the most out of the results letter sent to participants prior to their CSP consultations. The pilot programme has been successfully implemented, with the help of 2 clinical coordinators who were hired to recruit participants, take informed consent and coordinate consultations. To date, 215 people living with diabetes have been enrolled in the programme, with more than 200 having completed at least 1 CSP consultation and over 160 having completed 2 or more CSP consultations.

The pilot has been evaluated to assess the fidelity of implementation and the level of acceptance by participants, and to identify barriers to implementation and areas for improvement. Qualitative, in-depth interviews were conducted with 30 patients and 9 HCPs who have been involved in CSP consultations. Both patients and HCPs provided favourable feedback and reported positive outcomes from the programme. For example, patients reported feeling empowered to ask questions and discuss their care with their doctors and motivated to be more involved in their own care. HCPs reported being more aware of the importance of listening to their patients and discovering motivations and care goals.

Furthermore, thanks in part to the smooth implementation of the pilot programme, the YOC model has expanded beyond NUH to 2 polyclinics under National University Polyclinics in 2019. This initiative, called Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D), has been separately funded by the Ministry of Health. The PACE-D programme aims to transform primary care of people living with diabetes, leading to better self-management of the condition.

As a testament to its success, PACE-D was a recipient of the NUHS Education Collaboration Award in 2021, which recognised teams that have impacted patient experience through collaborations in education efforts.

Finally, the YOC model has also been adopted at the metabolic clinic, Alexandra Hospital, in late 2021. Their programme, PAtient-centred CarE (PACE@AH), includes obese patients with metabolic syndrome (not limited to diabetes mellitus), as well as patients with obstructive sleep apnea, non-alcoholic fatty liver disease and gout.

Partners and Collaborators

• Dr Yew Tong Wei, NUS Yong Loo Lin School of Medicine and NUH Department of Endocrinology
• Prof Mohan Dutta, NUS Communications and New Media

Staff

• Elaine Tang, NUH Department of Endocrinology
• Ian Russell, NUH Department of Endocrinology

This study, which started in 2019, will explore the perspective of patients who have experienced collaborative ‘Care and Support Planning’ (CSP) consultations under the PACE-D model of care at National University Polyclinics (NUP). PACE-D, or Patient Activation through Community Empowerment/Engagement for Diabetes Management, is a programme funded by the Ministry of Health directly to NUP, and draws on the experience of NUH doctors who have been running the similar Year of Care programme in NUH since 2017.

PACE-D is a primary care health services delivery intervention which, like Year of Care, is designed to facilitate patient engagement and ownership of diabetes care in collaboration with their physician. PACE-D will measure and analyse quantitative data about patients’ health and the programme, while this CDPM project will evaluate the quality of the patients’ experiences. It will lead to a better understanding of the factors that encourage or motivate patients to become engaged in their own diabetes care and to adopt a healthy lifestyle, as well as those which cause barriers. These factors may be personal, interpersonal or sociocultural, or depend on determinants such as access to information or community resources and the consultation with the doctor.

Fifty-two patients enrolled in PACE-D have been sampled across gender, age group and sociocultural demographics. Eligible patients participated in audio-recorded in-depth interviews. In preparation for patient interviews, researchers have developed specific interviewing tools and trained designated interviewers.

This research will inform the process of CSP implementation in polyclinics in the short term and influence local outpatient care settings beyond polyclinics in the medium term, hopefully across Singapore. In the long term, it may impact regional populations in East and Southeast Asia.

Partners and Collaborators

• Prof Doris Young Yee Ling (Visiting), Family Medicine, NUS Yong Loo Lin School of Medicine
• Dr Victor Loh, Family Medicine, NUS Yong Loo Lin School of Medicine
• Dr Kavita Venkataraman, NUS Saw Swee Hock School of Public Health
• Dr Tan Wee Hian, Pioneer NUP (Principal Investigator for PACE-D)
• Dr Yew Tong Wei, NUS Yong Loo Lin School of Medicine and NUH Department of Endocrinology

Staff

• Monica Ashwini Lazarus, Family Medicine, NUS Yong Loo Lin School of Medicine

Working collaboratively with clinicians in National University Polyclinics (NUP), this study will enhance understanding of the challenges that arise in their provision of person-centred support to people living with diabetes. It will develop ideas about what can be considered a ‘good’ handling of these challenges, and about how clinicians can be supported to understand and work well through issues.

The study will focus on clinicians who have been trained to provide, and are actively providing, ‘Care and Support Planning’ (CSP) consultations under the PACE-D programme. PACE-D, or Patient Activation through Community Empowerment/Engagement for Diabetes Management, is a programme funded by the Ministry of Health directly to NUP, and draws on the experience of NUH doctors who have been running the similar Year of Care programme in NUH since 2017. PACE-D, like Year of Care, is designed to facilitate patient engagement and ownership of diabetes care in collaboration with their physician. While the PACE-D programme will measure and analyse quantitative data about patients’ health and the programme, this CDPM project will evaluate the quality of the clinicians’ experiences.

                                             Source: National University Polyclinics

There are many aspects to ‘good’ professional practice in the care of people with diabetes and different perspectives on what should be considered ‘successful’. It can be difficult for a clinician to balance their own conflicting interests, e.g. supporting people to manage their diabetes well whilst also supporting people to live well with their diabetes. This balance can be both informed and challenged when a clinician adopts a person-centred approach in their consultations and when they attend carefully to what matters from their patient’s perspective and help that patient set goals accordingly.

The study will involve qualitative interviews with the clinicians involved in PACE-D and observation of team meetings of those clinicians. Data analysis will focus on identifying challenges in clinicians’ talk about their work and their experiences with PACE-D study, as well as exploring how clinicians worked through the issues or considered working through them in practice, and how they evaluated what they did. Key ideas will be discussed among the research team and developed with the broader group of clinicians. Findings will help directly inform future PACE-D CSP diabetes consultations. In addition, it is anticipated that the findings may influence clinical practice more broadly in Singapore and elsewhere.

Partners and Collaborators

• Prof Vikki Entwistle, Health Services Research Unit, University of Aberdeen
• Dr Victor Loh, Family Medicine, NUS Yong Loo Lin School of Medicine
• Dr Tan Wee Hian, NUP Pioneer polyclinic (The Principal Investigator for PACE-D)
• Dr Yew Tong Wei, NUS Yong Loo Lin School of Medicine and NUH Department of Endocrinology