Primary Care Networks and Starfield’s 4Cs: A Case for Enhanced Chronic Disease Management
1.1. Singapore’s Primary Care Landscape
1.2. Starfield’s “4Cs” of Primary Care
2.1. Study Design
2.3. Recruitment and Data Collection of the OriginalSstudy
2.4. Ethics Approval
2.5. Data Analysis
“I am able to offer a one-stop service for my diabetic patients. So, when they come here [PCN GP Clinic], they will have their DRP, DFS done and they come for consultation with the doctor and even for nurse counselling. It is all done at that one stop [PCN GP Clinic]. So, the patients actually like it and there is very little reason for them to want to go elsewhere.”(R48)
“At the moment, I think they [MOH] are exploring different means of enhancing primary care, by having the spirometry, the Holter test which I have not used. […] for patients that need all these, initially, we will send to the hospital because we can’t do it. Now if the PCN provides these capabilities at the primary care level, we can do all these. We don’t have to refer them. Now if it is available and the PCN can do it […] I will contact my PCN to arrange for you [the patient], then that raises our capability.”(R39)
“We charge a very nominal pricing [for ancillary services] for PCN […] a PG [Pioneer Generation, elderly] patient will pay $10 flat for any of these three services whether it’s eye, foot or nurse counselling. It is just $10.”(R36)
“Our nurse counselling is $1. So, my patients cannot say no, right? In fact, for example, eye check [DRP], foot check [DFS], are all priced at maybe half to one third of the polyclinic fees. In fact, that is the truth. My patient looked at the polyclinics and said that polyclinics are more expensive than us.”(R17)
“[…] some of them could be seeing us for common illnesses and we will ask them have you had your eye screened before? Then if they say never, I say why don’t you have it done here? So that is where it gives us a chance to have a conversation starter with them.”(R48)
“Some of them [patients] are agreeable [to seek treatment from private GPs] because they can come after office hours.”(R30)
“We [GPs and PCN nurses] have a little bit more time to explain to them [patients] how it can be very affordable even at the clinic, if not they [patients] will always think that polyclinics are always cheaper. But it is not true you know. But we do not have time to explain to them. So, we have all these nurse counsellors [PCN nurses] where they have a bit more time to interact with the patients [explain the benefits of receiving services from PCN] when they do the diabetic retinal photography and when they do the nurse counselling then they [patients] begin to understand.”(R48)
“The PCCs will follow up with the patients on their appointments, they will book their appointments and then bring the provider [ancillary service provider] to provide their service in our clinic.”(R46)
“No, there is no common one [EMR], because we are different, different clinics coming from different backgrounds and so on […] so we have to try and get some commonality [same EMR] so that we can draw the information […], so there is a standard.”(R19)
“About five of them, initially out of the 30 [GP practices] were on paper and pen, but they are now in flight to convert to some form of electronic medical system.”(R36)
“[…] CDR reminds especially the private doctors when your clinic so busy, a lot of times we will overlook, or we will you know forget certain things. So, this, in a way, is a constant reminder to make sure that this has been done for the patient.”(R26)
“Everyone, every clinic, every single clinic in the PCN should be eligible for the Care Plus Fee, if there are patients who satisfy the criteria required. I think three visits per year or two or three visits per year with the necessary blood investigations [amongst other requirements] being done for them to be eligible for the Care Plus Fee.”(R18)
“It [Care Plus Fee] is basically a process indicator and regularity of follow-up […] that was a carrot [financial incentive] to tell the GPs don’t be afraid to see complex patients […] to recognise the increased time that you [GPs] are spending with complex patients.”(R36)
“The CHAS subsidies help, but it is for simple chronic illness. For simple cases, it may be comparable to the polyclinic. But when it comes to more medications, it makes it very difficult, even with the CHAS subsidy.”(GP R48)
“If you are talking about chronic patients here, then the distribution between private and public chronic patients are highly steered towards the government side [polyclinics] because polyclinics are offering such a high subsidy that it makes no sense for patients to follow up with private [GPs]. Most of the patients that follow up with private [GPs] are simple chronic patients, meaning that they are probably on one or two chronic medications […] So that means out-of-pocket [costs] will not be so high per year. But what happens when the disease starts to deteriorate or what happens when people start to age, and they need more and more medications to control their chronic diseases? Their out-of-pocket [costs] in primary care in private sector is going to get higher and higher until a point where all these patients are driven back to the polyclinics.”(R26)
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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Foo, C.D.; Surendran, S.; Jimenez, G.; Ansah, J.P.; Matchar, D.B.; Koh, G.C.H. Primary Care Networks and Starfield’s 4Cs: A Case for Enhanced Chronic Disease Management. Int. J. Environ. Res. Public Health 2021, 18, 2926. https://doi.org/10.3390/ijerph18062926
Foo CD, Surendran S, Jimenez G, Ansah JP, Matchar DB, Koh GCH. Primary Care Networks and Starfield’s 4Cs: A Case for Enhanced Chronic Disease Management. International Journal of Environmental Research and Public Health. 2021; 18(6):2926. https://doi.org/10.3390/ijerph18062926Chicago/Turabian Style
Foo, Chuan De, Shilpa Surendran, Geronimo Jimenez, John Pastor Ansah, David Bruce Matchar, and Gerald Choon Huat Koh. 2021. "Primary Care Networks and Starfield’s 4Cs: A Case for Enhanced Chronic Disease Management" International Journal of Environmental Research and Public Health 18, no. 6: 2926. https://doi.org/10.3390/ijerph18062926