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Primary Care Networks (PCNs)

Primary Care Network (PCN) Scheme 

The PCN is a network of General Practitioners (GPs) supported by nurses and care coordinators in providing holistic and coordinated care for patients with chronic conditions such as diabetes, hypertension and hyperlipidaemia. This team-based care approach ensures patients are better cared for in the community.

Primary care forms the foundation of our healthcare system, and the key to enable the three paradigm shifts needed to sustain our healthcare system beyond 2020 - Beyond Hospital to Community, Beyond Quality to Value, and Beyond Healthcare to Health. To effect these shifts, we need to transform our primary care to ensure that good quality and affordable care is accessible and delivered in a sustainable manner in the community.

GPs, like yourself, helm the majority of our primary care market share. Located in close proximity to your patients’ homes, you play an instrumental role in the management of our ageing and increasingly complex chronic patient population.

To support your role in providing a more holistic chronic disease management for your patients, funding and administrative support is now available to you under the PCN scheme.

The PCN Application Call was launched on 1 April 2017. From 1 January 2018 onwards, successfully awarded PCNs (and their GPs) will be able to tap on funding and administrative support to implement team-based care to better monitor and manage their patients’ healthcare needs. The PCN scheme also provides participating GPs a platform for cross-sharing of best practices for patient care.

PCNs 


How does the Primary Care Network (PCN) works? 

First, the patient consults a PCN GP for his or her chronic condition(s). As a PCN GP, you will assess and diagnose the patient’s condition and your clinic may wish to register the patient on the PCN’s Chronic Disease Registry (CDR) if applicable. The patient should also be referred to see a nurse counsellor and the relevant ancillary services such as Diabetic Foot Screening or Diabetic Retinal Photography, if necessary.

The care coordinator at the PCN-HQ level will then work with the respective clinic assistant to schedule the patient for the ancillary service appointment. Upon completion of the ancillary service(s), the doctor will review the test results and follow up with the patient.

The patient’s progress and clinical outcomes will be tracked and monitored to ensure that they follow through with their personalised care plans and treatment. The overall aim is to help patients better manage their chronic conditions and improve their health outcomes.

 PCN infographic v2 
 

 Participate in the PCN Scheme 

 If you are interested to find out more, please contact us at gp@aic.sg and we will arrange with you for a discussion.

For the list of participating clinics under the respective PCNs, click here.

 

1. Benefits
 
1.1 How will the PCN benefit my patients?

Through the PCN, your patients will now be able to access more holistic chronic disease management which includes the provision of ancillary services, such as nurse counselling, diabetic eye and foot screening which might not be readily available in the current GP clinic settings.

The primary care coordinators from the PCN will also help patients coordinate with other healthcare providers when they require other services (e.g. referral to podiatry services). Your patients will have access to nurse counsellors for individualised advice to manage their chronic conditions, including lifestyle and dietary modifications.

There will be closer monitoring of their chronic conditions for earlier intervention and the care coordinators will help to schedule services when appropriate for a more seamless patient experience.

1.2 How will the PCN benefit me as a GP?

Participating GPs would be able to manage patients with chronic conditions in a more holistic manner through the PCN. With additional government funding, the PCN GPs would be better supported to provide team-based chronic care for their patients and monitor their patients’ outcomes more closely. The PCN would also tap on better economies of scale for ancillary services (e.g. diabetic eye & foot screening).

As part of the PCN, participating GPs may also be provided with IT funding and support to increase the clinic productivity and smoothen the operational process. In addition, the PCN-HQ will organise regular meetings for cross sharing of best practices and lectures (i.e. Continuous Medical Education).

2. Models of PCN
 
2.1 What are the types of PCN models?

Under the different types of PCN model, a consistent feature is that PCN leadership role must be helmed by a Family Physician.

The two current models of Primary Care Network (PCN) are as follows:

GP-Driven PCN Model – Driven and coordinated by solo GPs partnering together to form a network. The Administrative leadership role can be helmed by the same PCN leader or by any other GP identified by the group.

GP-RHS/Polyclinics Partnership and GP group PCN Model – Driven by solo GPs in partnership with the Regional Health System (RHS) clusters or led by large GP clinic groups. The Administrative leadership role is helmed by the RHS/large GP group with whom the GPs have partnered with.

Models of PCNs  

3. Ancillary Services and Others
 
3.1 What are the basic ancillary services that you have to offer to your patients upon joining PCN?
  • Diabetic Foot Screening (DFS) 

As part of the holistic chronic disease management, your diabetic patients will be scheduled for periodic foot screening to identify any diabetic-related foot issues that can lead to amputations if not well taken care of. Advice on proper foot care and footwear will also be provided.

  • Diabetic Retinal Photography (DRP) 

The PCN coordinator will also help to coordinate periodic DRP screening for diabetic patients through service providers such as Community Health Centres (CHCs) to enable early detection of any diabetic-related eye conditions. This will ensure early interventions which will reduce the risk of complications that can lead to blindness.

  • Nurse Counselling & Education (NC) 

Your patients will be able to learn more about their chronic condition(s) from the nurse counsellors. The nurse counsellors will provide them with personalised advice on positive lifestyle changes and empower them to self-manage their condition(s).

3.2 What are the optional initiatives that my clinics can participate in as part of being in a PCN?

The PCN-HQ will need to discuss with its GPs on whether to participate in any of the optional initiatives made available to the PCNs.

• PCN Mental Health Initiative 

The PCN Mental Health Initiative aims to achieve the following:

  • Holistic management of patients’ physical and mental health conditions in the primary care setting;
  • Increase accessibility of mental health services within primary care:
    • Increase early identification of signs and symptoms of mental health issues
    • To support early diagnosis and treatment of mental health issues
     
  • Co-management through team-based approach involving medical and allied health services.
 
4. Enrolment of PCN and PCN-Chronic Disease Management
 
4.1 Will I be able to continue my existing practices or do I have to agree with what the GP Lead tells me to do?

Each PCN clinic will remain as an independent business entity, which means the day-to-day business-related decisions (e.g. consultation fees, operating hours) will still be determined by the individual clinic.

In terms of chronic disease management, the PCN GP Lead will work closely with all the PCN GP clinics on the clinical aspects of patient care (e.g. sharing of best practices, cross-learning), while the PCN-HQ will coordinate the operationalising of the PCN Chronic Disease Registry and the ancillary services for chronic disease management.

4.2 What are the criteria to join a PCN?

As a pre-requisite, your clinic should participate in all of the following MOH core schemes to join the PCN-GP community:

  • Community Health Assist Scheme (CHAS);
  • Chronic Disease Management Programme (CDMP);
  • Public Health Preparedness Clinic (PHPC); and
  • Screen for Life (SFL).

You may wish to approach AIC for more information on the enrolment process.

4.3 What are the criteria for chronic patients to be enrolled into the Chronic Disease Registry?

The patient should be either Singaporean Citizen or Singapore Permanent Resident at the time of enrolment, as well as clocked at least one chronic follow-up visit in the last 6 months. He/she can only be enrolled on the subsequent visit if the next visit is within 6 months of the last visit.

4.4 Do I need to obtain patient’s consent prior to patient’s enrolment into the Chronic Disease Registry?

AIC will be providing a consent form template to aid you in obtaining patient’s consent.

5. Resources
 
5.1 Ministry of Health’s Press Release


• 2017

Date 

Title 

Attachment 

29 March 2017

Developing Primary Care Networks for Better Care in the Community

MOH Press Release for Developing Primary Care Networks for Better Care in the Community 
5.2 Media Coverage

• 2017

Date 

Title (Source)

09 March 2017


(The Straits Times) 

Parliament: GPs encouraged to join primary care networks to better care for people with chronic ailments

Click here to access the article 

 

09 March 2017


(Ministry of Health) 

Speech by Minister of State for Health, Dr Lam Pin Min, at the MOH Committee of Supply Debate 2017

Click here to access the article 

 

10 March 2017

(Ministry of Health) 

More GPs to get on primary care scheme

Click here to access the article 

 

29 March 2017

(Channel News Asia) 

GPs can apply to Join Primary Care Networks scheme from April

Click here to access the article 

 

02 September 2017


(Channel News Asia) 

Primary Care Network scheme to coordinate long-term care of patients with chronic disease (video)

Click here to access the article 

 

5.3 Articles / Paper

• 2017

Date 

Title 

Attachment 

SMA News – October 2017 Issue

AIC Says: Team Up for Better Chronic Disease Management (Page 30) 

AIC Says: Team Up for Better Chronic Disease Management 

• 2015

Date 

Title 

Attachment 

01 July 2015

Primary Care Network (PCN) As a Model of Care For GP Chronic Disease Management by Dr Linus Kee Loon Chua, Dr Chin Kwang Chong, A/Prof Wee Hwee-Lin, Dr Tham Tat Yean 

Primary Care Network (PCN) As a Model of Care For GP Chronic Disease Management 
5.4 PCN Resources

Descriptions 

Attachment 

Listing of Primary Care Networks GP Clinics

  

Listing of Primary Care Networks GP Clinics  
 


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