DISEASE
MANAGEMENT:
SINGAPORE STYLE
Dr Jason Cheah
Chief Projects Officer
National Healthcare Group, Singapore
THE COMPARTMENTALISED “ILLNESS” CARE
Pre-illness
Illness
• Vaccination
• Clinics, hospitals
• Public Health Education
• School Health
• Workplace Health Promotion
Post-illness
• Home Care Services
• Nursing Homes
THE “HOSPITAL-WITHOUT-WALLS”
Pre-illness
Health Maintenance
• Vaccination
• Public Health Education
• Health Screening
• Workplace Health promotion
Illness
Illness Care
• Cost effective, efficient
care
- systems processes
- clinical pathways
Post-illness
Health Recovery
• Skills-for-life
• Homecare support
• Follow-up support
Brief on Singapore Healthcare
System
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•
•
•
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
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
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
Vision
Adding Years of Healthy Life to the
People of Singapore
Mission
We will improve health and reduce
illness through patient-centered quality
healthcare that is accessible, seamless,
comprehensive, appropriate and costeffective in an environment of continuous
learning and relevant research
Fragmentation of Healthcare System
Lower Costs
Self-directed
Preventive
Strategies
Healthcare Spectrum
Primary
Family
Practitioners
Allied health
professionals
Higher Costs
Secondary
Tertiary
Long Term
Specialists
Hospitals
Outpatient
Clinics
Hospitals
Centers of
Excellence
Institutions
Nursing Homes
Home Care
Clinical Integration
Objectives
• To coordinate the entire continuum of
primary, secondary and tertiary
healthcare services.
Clinical integration extends both
horizontally and vertically.
Clinical Integration
Achieving clinical integration requires:
•
•
•
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Clinical leadership
Availability of expertise
Availability of resources
Supportive management
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.
Primary Objectives of DM
o


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
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
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
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
Skills & Tools in DM process
Skills/Tools
Medical database – information
on clinical and cost-effectiveness
of all interventions
Clinical expertise
eg peer review groups,
patient advocates
Clinical management tool
eg patient follow-up reminders
to aid collection of relevant data
Outcomes database –
store, retrieve,
analyze outcomes
Clinical expertise
Process
Disease
Review evidence
O
Define good practice
U
guidelines (evidence-based) T
Data collection
Data analysis
Review outcomes data
C
O
M
E
S
Elements of Disease Management at the Mayo Clinic
Primary care practice guidelines
Information Systems
Continuous quality management
Resource management techniques
Information management
Specialty care management
Hospital management
Emergency room management
Pharmacy management
Diagnostic utilization management
Case management
Patient education
Primary care teams
Triage system/telephone systems
Benefit design
Conceptual Model of the Healthcare Providers who may
be involved in DM plan
Selfdirected
care
Public
Health
Personnel
Basic
Primary
Care
Extended
Primary
Care
-Community
-Family
Nurses
Practitioners
-Counselors
-Practice
-Physiotherapists
Nurses
-Occupational
-Pharmacists
therapists
-Laboratory
Service Providers
Secondary
& Tertiary
Care
-Specialists
Centers of
excellence
-Other
service
providers
Long-Term
Care
-Institutional
Care
-Nursing
Home
-Home Care
Social
Services
-Housing
-Employment
-Income
Support
Developing a DM Plan
1. 1.
Identify an appropriate disease / case type and team
2. 2.
Determine current clinical practice
3. 3.
Perform an economic analysis in terms of disease burden
4. 4.
Identify key patient segments and target treatment groups
5. 5.
Identify critical (failure) points
6. 6.
Create a disease management plan (with key
stakeholders)
7.
Disseminate and reinforce the plan
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
5. Develop Strategic Options
DESIGN
6. Identify Leverage Options
IMPLEMENTATION
7. Determine how to measure results
8. Learn &
Continuously
Improve
Continuum of Care
Maintenance/Recovery
Health Promotion
Disease
Prevention
Disease
Awareness/Sympto
m Recognition
Reintegration/
Rehabilitation
Diagnosis
Outcomes
Measurement
Compliance –
Self Management
Therapy
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
Disease models,
disease maps,
standards of care
Project impact
of diseasespecific process
changes and
utilization and
cost control
measurements
Published literature
Primary market research
Basis for capitation and
risk sharing
Core Components Processes of Outcomes Measurement
-
Define data requirements
Determine what sorts of outcomes need to be measured
Determine what measurement tools should be used
2.
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Obtain the data
Define data collection protocol
Implement data collection protocol
3.
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Manage the data
Create database
Enter data into database
Assure quality of data
4.
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Analyze the data
Analyze data quality and completeness
Determine method for scoring responses to outcome indicator
Perform risk adjustment
Perform outcome analysis
5.
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Report results
Prepare written summary of results
Present results to key customers
1.
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
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
Disease Management – unresolved
issues
• Funding for such programmes in an output-based, noncapitated 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
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 backend of care delivery
• Team-based approach
• Disease registries
Useful Contacts
• Disease Management Association of
America (DMAA) – www.dmaa.org
• National Healthcare Group –
www.nhg.com.sg
• HCFA website
• Managed care websites
Thank you
Jason_Cheah@nhg.com.sg
See you at Asia’s First Disease
Management Conference
25-26 May 2001 Sheraton Towers
Hotel, Singapore