​Last updated on 19 December 2023

Healthier SG aims to improve and maintain enrollees' health, through regular Health Planning with their chosen family doctor. This means regular, scheduled Health Plan check-ins with enrollees, 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 enrollees achieve their health goals.

The Health Plan aims to empower enrollees to take charge of their health by facilitating health actions that lead to the achievement of their health goals, with support from their GP and community. Health goals should be discussed using person-centred communication and be meaningful to the enrollee so as to promote patient empowerment and nudge health improvements.

A Health Plan serves as a communication tool between enrollees and their GP, to enable:

  1. Enrollees to better understand their overall state of health.
  2. GPs to ensure that care delivered for disease prevention and chronic condition management is timely and appropriate.
  3. Development of shared health and lifestyle goals amongst both enrollees and GPs.

Upon enrolment, GPs should initiate a first discussion with enrollees to develop the Health Plan. Details of the Health Plan will flow automatically into the enrollees' 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, enabling them to support enrollees with more local and relevant activities and support. Enrollees will also be able to show their Health Plan via HealthHub on their phone to other partners, e.g. Active Ageing Centres to sync up on their health needs. ​

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 their Healthier SG-compatible 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

Categories  Details
  • Medical ​History, e.g. current acute and/or chronic medical history, chronic medications, drug allergies
  • Family History of medical conditions
  • Health Screening and Vaccination History
  • Lifestyle History, e.g.:
    • Important: smoking status, duration and intensity of exercise/physical activity, diet history
    • Optional: quantification of alcohol intake, occupation
Physical Examination
  • Tailor to history and chronic conditions (if relevant) of enrollee
  • Include measurements of height, weight, waist circumference, and blood pressure
  • Update problem list
Treatment Plan
  • Include laboratory and/or radiological investigations, if any, to assist in diagnosis and/or management 
  • Update/schedule for age-appropriate screening and vaccinations
  • Adopt healthy lifestyles (e.g. smoking cessation, increasing physical activity, dietary advice, weight loss targets, etc)
  • Reference to guidelines from relevant protocols
  • Document referrals to PCN/cluster/Active Ageing Centres, community programmes (e.g. HPB, SportSG, People's Association, etc); and to Specialist Outpatient Clinics/Emergency Departments
  • This segment could be used to auto-trigger referrals to clusters over time
Health goals, activities, and follow-ups
  • Discuss and encourage enrollees to set health goals and plan activities relating to healthy lifestyles and chronic disease management . More information about suitable lifestyle activities can be found here​.
  • Goals should be specific, measurable, attainable, relevant, and time-based (SMART)
  • Specify date (month/year) for the next Health Plan check-in

It is recommended that an enrollee'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 who enrolled to the clinic via Healthhub, GPs should reach out to schedule appointments with them.  GPs can also conduct Health Plan discussions opportunistically when the patient next visits the GP. ​

The enrollee and their GP should have regular, scheduled check-ins to assess the enrollee'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 enrollee's Health Plan can be done opportunistically, where appropriate, during an acute or chronic visit; otherwise, the GP should contact the enrollee to schedule a follow up check-in.

  1. For well enrollees, defined as enrollees with no Chronic Disease Management Programme (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 enrollee. 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 enrollee remains generally well.

  2. For chronic enrollees 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. The first check-in should be in-person.  Thereafter, 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 Primary Care Network (PCN) care team, such as nurses or care coordinators, to work with the enrollee to actualise their treatment plans and meet their health goals in the Health Plan.

A key aspect of the Health Plan is goal-setting with an enrollee to encourage ownership and action by the enrollee. 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 CMS or the Primary Care Digital Services (PCDS) portal. The goals will be reflected in the enrollees' HealthHub automatically . The list of goals will be reviewed and adjusted as Healthier SG includes other conditions over time and in consideration of enrollee 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 enrollees. Such comments/notes will be reflected in the enrollee's HealthHub.

Depending on the enrollee'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 enrollees' HealthHub 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 enrollees, and to make these available to the enrollees in the HealthHub app. More goals and actions will be added over time.

GPs are strongly encouraged to conduct a check-in with enrollees who have transferred care to them, to address any possible outstanding health concerns. GPs will be able to access enrollees' 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 enrollees who have already had their first Healthier SG consultation with a previous GP. The service fees covering annual check-ins and on-going care for the enrollees 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 “2Ss": Social Connector for social and lifestyle interventions, and Community Screening. The 2Ss support seniors who need further assistance following through with their Health Plan. As Social Connectors, AACs will assist seniors in registering for active ageing programmes as needed to achieve their social and lifestyle goals in their Health Plan. AACs will also serve as nodes for Community Screening.  Specifically, they will assist seniors in monitoring and recording their vital signs as prescribed in their Health Plan.

Enrollees can find a recommended AAC and 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 respective PCN headquarters and request to be updated when their enrollee is contacted by an AAC.​​

GPs will be paid a fixed fee upon completion and submission of the first Health Plan discussion. This fee for the Health Plan discussion can only be claimed once for each enrollee. GPs who make a claim for the first Health Plan discussion should not charge a consultation fee for this visit. However, if the enrollee seeks other treatment during the same visit, the clinic should inform the patient of the charges upfront and charge the patient separately at the clinic's prevailing rates.

Similarly, no fee should be charged for subsequent Health Plan check-ins conducted each calendar year. Upon completion of these annual check-ins, as well as other stipulated care milestones, Healthier SG GPs will received the fixed payments under the Annual Service Fee.  Other than the annual check-ins, Healthier SG GPs can continue to charge for enrollees' regular visits on a fee-for-service basis and MOH subsidies (CHAS, SFL and VCDSS) will continue to apply, alongside the additional subsidies under Healthier SG Enrolment Benefits.

More details can be found in the Healthier SG Enrolment Programme Agreement and in the list of Healthier SG Frequently Asked Questions​.