Table 1 Adaptations of CCM to SingHealth Polyclinics
From: Asthma care based on Chronic Care Model in an aging Asian community
Key pillars of the Chronic Care Model | Adaptations |
|---|---|
System re-design | Health Monitoring Stations (HMS) are set up at each polyclinic, in which trained Allied Healthcare Workers (AHW) use the Asthma Control Test (ACT) to triage patients with asthma. The ACT scores for patients with asthma constitute a key clinical performance indicator for each polyclinic. The indicator is collated monthly by the institution Quality Management department and presented to the director of each polyclinic during senior management meeting as one of the measures for clinical performance |
Clinical information system | The ACT scores from the HMS are entered into the electronic medical records (EMRs) for review by the physicians and nurses. The ACT scores are accessible to physicians and nurses at their service points. The data depicts the status of the current visit as well as those of previous visits; they are presented as data points or in the form of trend chart to reflect longitudinal asthma control status |
Decision support | Clinicians such as physicians and nurses gain an overview of the asthma control of each patient from the asthma dashboard in the EMR. The dashboard is automated as the first interface when clinicians access the EMRs of patients with diagnosis of asthma. Clinical data such as the ACT score, PEFR measurements, smoking status, and asthma action plan on the dashboard facilitate decision support for the physicians to review the treatment plan |
Proactive practice team | Patients identified by AHWs with acute asthma symptoms and/or low ACT scores on arrival at the polyclinic or at the HMS will be immediately directed to the trained nurses at the polyclinics for assessment before patients are further reviewed by physicians. Every registered nurse will be rostered to undertake specific training module, including lung auscultation technique, based on a protocol-based rescue therapy regimen |
Proactive practice team | Multidisciplinary team of primary healthcare professionals from all the polyclinics, meets quarterly to review the care processes, shares best practices and makes recommendation to improve care services to patients with asthma. Minutes are taken at these collaborative meetings for dissemination to other staff |
Self-management support | Each patient (or caregiver of paediatric patients) is provided with a personalised written asthma action plan, which is updated at each visit. The action plan is a self-management platform for the multidisciplinary team to educate and remind patients of their adherence to their medications according to their asthma control status and to self-initiate rescue therapy at the advent of impending asthma exacerbation. Oral prednisolone is prescribed for adult patients as stand-by medication for use in acute exacerbations |
