Primary Care model

About

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.                                                                                                

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.                                                              

Benefits

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.                                                                                                                                      

• 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 seminars (i.e. Continuous Medical Education).                                                                                          

Models of PCN

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 PCN leader is helmed by a Family Physician, while 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 PCN leader is helmed by a Family Physician, while the Administrative leadership role is helmed by the RHS/large GP group with whom the GPs have partnered with.                                                                                                                                             

Ancillary Services and Others

Enrolment of PCN and PCN-Chronic Disease Management

Resource

Participate in this scheme