Dr Jason Cheah Chief Projects Officer National Healthcare Group, Singapore

1. DISEASE MANAGEMENT: SINGAPORE STYLE Dr Jason Cheah Chief Projects Officer National Healthcare Group, Singapore

2. THE COMPARTMENTALISED “ILLNESS” CARE Pre-illness Illness Post-illness • Vaccination • Public Health Education • School Health • Workplace Health Promotion • Clinics, hospitals • Home Care Services • Nursing Homes

3. THE “HOSPITAL-WITHOUT-WALLS” Pre-illness Illness Post-illness • Health Recovery • Skills-for-life • Homecare support • Follow-up support • Health Maintenance • Vaccination • Public Health Education • Health Screening • Workplace Health promotion • Illness Care • Cost effective, efficient • care • - systems processes • - clinical pathways

4. Brief on Singapore Healthcare System • Dual care delivery system – public and private • Co-payments and use of Medical Savings Scheme • Hospital services utlise largest portion of NHE • Funding for public hospital services by DRG (in-patient and day surgery) and per attendance basis (specialist outpatient clinics) • Establishment of two public sector clusters to foster vertical integration of clinical services

5. Megatrends • Demographic transition – ageing population, decreasing total fertility rates • Epidemiological transition – changing disease profiles to chronic diseases (diabetes mellitus – 9%, hypertension – 27% of adults) • Demand for cost-effective healthcare services • Decreased information asymmetry and increased consumer choices • Technology changes

6. National Healthcare Group Inpatient facilities: - 1 Tertiary Hospital – National University Hospital (NUH) - 2 Regional General Hospitals – Tan Tock Seng Hospital (TTSH) & Alexandra Hospital (AH) - 1 Specialty Hospital _ Woodbridge Hospital (WH) • Outpatient facilities: • 2 National Centres – National Neuroscience Institute (NNI) & National Skin Centre (NSC) • 9 Polyclinics – located at various housing estates in Singapore

7. Vision Adding Years of Healthy Life to the People of Singapore

8. Mission We will improve health and reduce illness through patient-centered quality healthcare that is accessible, seamless, comprehensive, appropriate and cost-effective in an environment of continuous learning and relevant research

9. Fragmentation of Healthcare System Healthcare Spectrum Higher Costs Lower Costs Self-directed Primary Tertiary Secondary Long Term Family Practitioners Allied health professionals Specialists Hospitals Outpatient Clinics Preventive Strategies Hospitals Centers of Excellence Institutions Nursing Homes Home Care

10. Clinical Integration Objectives • To coordinate the entire continuum of primary, secondary and tertiary healthcare services. Clinical integration extends both horizontally and vertically.

11. Clinical Integration Achieving clinical integration requires: • Clinical leadership • Availability of expertise • Availability of resources • Supportive management

12. Definition of Disease Management (DM) A clinical management process of care that spans the continuum of care from primary prevention to ongoing long-term maintenance for individuals with chronic health conditions or diagnoses. It identifies individuals with chronic diseases, assesses their health status, develops a program of care and collects data to evaluate the effectiveness of the process. It intervenes proactively with treatment and education so that the individual with a chronic disease can maintain optimal function with the most cost-effective and outcome-effective health care expenditure.

13. Primary Objectives of DM • Encourage disease prevention and maintenance of good health • Promote correct diagnosis and treatment planning • Maximize clinical effectiveness of interventions • Eliminate ineffective or unnecessary care and interventions • Eliminate duplication of effort and activity • Utilize only cost-effective diagnostics and requirements • Maximize the efficiency of healthcare delivery while maintaining appropriate standards of quality • Continually improve outcomes of the care delivery process • Emphasizes an evidence-based approach

14. Requirements of a successful DM program • Holistic/Team approach with healthcare professionals working together in a cooperative and coordinated approach • Understanding the course of the disease/practice guidelines • Targeting patients likely to benefit from intervention • Takes into consideration the total cost across the entire continuum of care • Appropriate information to the development & evaluation of “best practice” for particular diseases • Focusing on prevention and resolution • Increasing patient compliance through education • Providing full care continuity • Audit must be integral part of medical practice • Establishing integrated data management for outcome measurement • Patient/Family involvement is critical

15. Skills & Tools in DM process Skills/Tools Process Medical database – information on clinical and cost-effectiveness of all interventions Disease Review evidence Clinical expertise eg peer review groups, patient advocates O U T C O M E S Define good practice guidelines (evidence-based) Clinical management tool eg patient follow-up reminders to aid collection of relevant data Data collection Outcomes database – store, retrieve, analyze outcomes Data analysis Clinical expertise Review outcomes data

16. Elements of Disease Management at the Mayo Clinic

17. Conceptual Model of the Healthcare Providers who may be involved in DM plan Secondary & Tertiary Care Basic Primary Care Extended Primary Care Social Services Self- directed care Long-Term Care -Community Nurses -Counselors -Physiotherapists -Occupational therapists -Specialists Centers of excellence -Other service providers -Institutional Care -Nursing Home -Home Care -Housing -Employment -Income Support -Family Practitioners -Practice Nurses -Pharmacists -Laboratory Service Providers Public Health Personnel

18. Developing a DM Plan • 1.Identify an appropriate disease / case type and team • 2.Determine current clinical practice • 3.Perform an economic analysis in terms of disease burden • 4. Identify key patient segments and target treatment groups • 5.Identify critical (failure) points • 6.Create a disease management plan (with key stakeholders) • 7. Disseminate and reinforce the plan

19. Systems-Thinking Model: The Disease Management Process 1. Build a Shared Vision PLANNING 2. Establish a Shared Reality 3. Understand & Share Key Benefits 4. Identify Barriers to Change 8. Learn & Continuously Improve 5. Develop Strategic Options DESIGN 6. Identify Leverage Options IMPLEMENTATION 7. Determine how to measure results

20. Continuum of Care Disease Prevention Health Promotion Maintenance/Recovery Disease Awareness/Symptom Recognition Reintegration/ Rehabilitation Diagnosis Outcomes Measurement Compliance – Self Management Therapy

21. Data Sources for Developing Disease Models Validate Data Sources Epidemiology Claims data Expert panels Economic and quality of life studies Clinical trials for drugs, devices, diagnostics Published literature Primary market research Project impact of disease-specific process changes and utilization and cost control measurements Disease models, disease maps, standards of care Basis for capitation and risk sharing

22. Core Components Processes of Outcomes Measurement • 1. Define data requirements • Determine what sorts of outcomes need to be measured • Determine what measurement tools should be used • Obtain the data • Define data collection protocol • Implement data collection protocol • 3. Manage the data • Create database • Enter data into database • Assure quality of data • Analyze the data • Analyze data quality and completeness • Determine method for scoring responses to outcome indicator • Perform risk adjustment • Perform outcome analysis • Report results • Prepare written summary of results • - Present results to key customers

23. Disease Management in NHG • We have formed 8 teams that will focus on: • - Congestive Heart Failure / Acute Myocardial Infarction • - Asthma / COAD • - Stroke • - Diabetes Mellitus • - Hypertension / Hyperlipidaemia • - Specific cancers (eg breast, lung) • Development of clinical databases / disease registries • Primary healthcare enhanced care programmes

24. Disease Management – operational considerations • Preliminary data – epidemiology and patient profiles, DRG data, financial data, etc • Multidisciplinary workgroups to draft plans – develop shared care evidence-based protocols or pathways, case management practices and use of care coordination tools (eg telephone reminders, web-based interactive reminders) • Focus on prevention and self management – establishment of a vascular disease risk factor prevention workgroup and using IT tools to promote patient adherence and self monitoring • Standardising clinical pathways between institutions • Post discharge follow up and linkages with the community • Continuing care between the family physician, case manager and hospital specialist

25. Disease Management – unresolved issues • Funding for such programmes in an output-based, non-capitated environment • Incentives for patients to do better for themselves • Operational running costs for disease registries • Incorporating quality of life measures into real and practical indicators which give providers a better understanding of the impact of interventions on health status

26. Critical Success Factors • Select key clinician champions as leaders • Provide adequate resources and case managers to support the programme • Appropriate funding incentives to be built into the system (eg capitation in the USA) • Using information technology to harness clinical information sharing and seamlessness at the back-end of care delivery • Team-based approach • Disease registries

27. Useful Contacts • Disease Management Association of America (DMAA) – www.dmaa.org • National Healthcare Group – www.nhg.com.sg • HCFA website • Managed care websites

28. Thank you Jason_Cheah@nhg.com.sg See you at Asia’s First Disease Management Conference 25-26 May 2001 Sheraton Towers Hotel, Singapore