Last updated on 25 April 2023
A key aspect to Healthier SG is a focus on improving or maintaining enrolees' health, anchored by regular follow up with their chosen family doctor clinic for Health Planning. This means regular, scheduled check-ins with enrolees, so that the GP and his/her care team can assess their overall health condition, conduct necessary health screenings, track results and advise on lifestyle adjustments to help enrolees achieve their health goals.
The Health Plan aims to empower enrolees to take charge of their health by facilitating health actions that lead to residents achieving their health goals, with support from their doctor and their community. Health goals should be discussed using person-centred communication and be meaningful to the enrolee so as to promote patient empowerment and nudge health improvements.
A Health Plan serves as a communication tool between enrolees and their GP, to enable:
Upon enrolment, doctors should initiate a first discussion with enrolees to develop the Health Plan. Details of the Health Plan will flow automatically into the enrolees' HealthHub, for GPs who are using Healthier SG-compatible Clinic Management Systems (CMSes).
Key points from the digital version of the Health Plan as submitted by the GP will be shared with the Clusters over time, to enable them to support enrolees with more local and relevant activities and support. Enrolees will also be able to show their Health Plan via HealthHub on their phone to other partners to sync up on their health needs, e.g. Active Ageing Centres (AACs).
Health Planning includes (but is not limited to) recommended health screenings, vaccinations, and advice on making healthier lifestyle changes, as well as any actions related to management of their chronic conditions.
GPs should record key elements of the Health Plan using your clinic management system (CMS) at all Health Plan check-ins (both physical and virtual) as part of good clinical practice. Records are expected to be up-to-date, accurate, clear and complete, taking reference from the template in Table 1. Further details and updates on the guidelines for health screenings, chronic condition management and vaccinations can be found within the relevant Care Protocols.
Table 1: Template on what to cover in a Health Plan visit
It is recommended that an enrolee's first Health Plan is completed within 6 months upon enrolment with a GP. This can be done at the next planned check in with a patient. For new patients, GPs should reach out to schedule appointments with them. This expectation will be conveyed to enrolling residents. GPs could also conduct Health Plan discussions opportunistically when an existing patient next visits the GP.
The enrolee and their GP should have regular, scheduled check-ins to assess the enrolee's overall health condition and progress. For each check-in, GPs should discuss the progress of their health goals and assess if the goals need to be adjusted, or if additional intervention is required.
Check-ins and updates to the enrolee's Health Plan can be done opportunistically, where appropriate, during an acute or chronic visit; otherwise, the GP should contact the enrolee to schedule a follow up check-in.
For well enrolees, defined as enrolees with no CDMP conditions, an annual check-in should be performed. The first check-in should be done in-person to establish rapport and relationship with the patient. Subsequent check-ins can be done via phone or video consult, although an in-person consult should be performed minimally once every 3 years as long as the enrolee remains generally well.
For chronic enrolees with at least 1 CDMP condition, at least 2 chronic consults should be conducted annually and the Health Plan should be updated during these visits. For purpose of the annual service fee, these visits should be at least 3 months apart. If phone or video consults are conducted, it should be clinically appropriate with at least one in-person consult conducted annually. These phone, video and in-person consults are claimable under CHAS/ CDMP, subject to prevailing claims requirements.
GPs are encouraged to tap on their PCN care team, such as nurses or care coordinators, to work with the enrolee to actualise their treatment plans and meet their health goals in the Health Plan.
A key aspect of Health Plan is goal-setting with an enrolee to encourage ownership and action by the enrolee. To facilitate the process, a simple set of shared goals has been developed for the first phase of Healthier SG . These can be submitted using the template on health goals which can be found in GPs' Healthier SG-compatible Clinic Management System (CMS) or the Primary Care Digital Services (PCDS) portal. The goals will be reflected in patients' HealthHub account automatically . The list of goals will be reviewed and adjusted as Healthier SG includes other conditions over time and in consideration of resident and GP feedback.
Aside from the shared goals and activities, there will also be a free text box for GPs to document their comments/notes for sharing with their enrolees. Such comments/notes will be reflected in the enrolee's HealthHub account.
Depending on the enrolee's condition, GPs will need to provide the necessary care components as outlined in the respective Care Protocols – please refer to these protocols for the list of data to be submitted to MOH. MOH is working to reflect these data in enrolees' HealthHub accounts for them to keep track of their health status.
The Health Plan is intended to augment care planning that GPs already routinely provide for their patients today, and support patients in improving their health. The key enhancement is that the Health Plan allows documentation of health goals and key actions that are mutually agreed by GPs and enrolees, and to make these available to the patients in the HealthHub app. More goals and actions will be added over time.
GPs are strongly encouraged to conduct a check-in with patients who have transferred care to them, to address any possible outstanding health concerns. GPs will be able to access patients' previous Health Plans through their CMS or PCDS, and other information through NEHR.
Government reimbursement for the first Health Plan discussion is not applicable to enrolees who have already had their first Healthier SG consultation with a previous doctor. The service fees covering annual check-ins and on-going care for the enrolees will still apply, subject to the prevailing terms and conditions (e.g. whether the required information was submitted).
AACs serve as key nodes for seniors as the go-to points for their community health, lifestyle activities and social needs. AACs currently provide the “ABC" suite of services, which include Active Ageing activities, Befriending and Buddying, as well as Information and Care Referrals. To support Healthier SG, AACs will also deliver “2Cs": Community Connector for lifestyle and social interventions and Community-based vital signs monitoring. The 2Cs support seniors who need further assistance with following through their Health Plan. As Community Connector, AACs will assist and empower seniors to participate in active ageing programmes as appropriate through guiding or helping seniors to register for programmes as needed to achieve their social and lifestyle goals in their Health Plan. AACs will also deliver Community-based Vital Signs Monitoring by assisting and empowering seniors to monitor and record their vital signs as prescribed in their Health Plan.
If your patient would like to visit an AAC, they can find a recommended AAC and obtain more information on AACs here. For seniors that need further assistance with finding an AAC, GPs can put up a referral to an AAC through their PCN HQ and request to be updated when patient is contacted by an AAC.
GPs will be paid a fixed fee upon completion of the first Health Plan discussion, i.e. after the first Health Plan is submitted. This fee for the Health Plan discussion can only be claimed once for each enrolee. GPs who make a claim for the first Health Plan discussion should not charge a consultation fee for this visit. Similarly, no fee should be charged for subsequent Health Plan check-ins conducted each calendar year. GPs will receive a payment for this check-in from the Government via the annual service fee, as long as the required information was submitted. More details can be found in the Healthier SG Enrolment Programme Agreement.