Primary Care Network (PCN) as a model of care for GP chronic care management

Abstract

Objectives:The primary care scene in Singapore is undergoing a major transformation. The Primary Care Network (PCN), comprising small private general practitioner (GP) clinics supported by a mobile team of dedicated nursing and allied health professionals, can be an alternative model for good chronic disease (CD) management. GPs in the network manage the shared resources (eg. mobile team), set common goals for each clinic and self-evaluate. Methodology: We report the preliminary findings from pilot implementation of PCN by Frontier Healthcare Group among 10 GP clinics. Results: Benchmarking of clinical care among private GP clinics was established through setting up a CD registry and measurement of clinical indicators. With better tracking of patients and enhanced accessibility of chronic care services, improvement in process and clinical indicators were evident. For example, in one clinic, compliance rate to diabetes eye screening (DRP) and diabetes foot screening (DFS) increased dramatically within 5 months after joining PCN (DRP: 0.03% vs 32.4%: DFS: 0% vs 32.4%). Conclusion:The PCN has shown promise to improve chronic care, which is crucial in delaying complications onset and reducing downstream costs. Key challenges to success of PCN include changing the funding model to support operations and incentivise GP leadership.