As part of the national Healthier SG initiative, patients of SingHealth Polyclinics have a care team of professionals called My Care Team to oversee and accompany them on each step of their journey towards better health and healing.

For patients with multiple medical conditions, a routine visit to the doctor can uncover health issues beyond the scope of a single consultation. My Care Team (MCT) is a multidisciplinary healthcare team that oversees a patient's healthcare journey and provides integrated care to help the patient achieve his or her health goals.

Joining hands for holistic healthcare

From its inception as a pilot programme at Eunos and Punggol Polyclinics in July 2022, the strength of the MCT initiative lies in the formation of multidisciplinary care teams in the polyclinic setting. Each team consists of four doctors, two Care Managers or nurses, and two trained ancillary staff known as Health Pals.

These teams care for patients enrolled in Healthier SG with whom they develop personalised care plans for better health outcomes.

In this assembly of healthcare expertise, doctors take the lead in addressing patients’ medical needs, while Care Managers conduct clinical assessments, provide health counselling and recommendation, and coordinate with community partners to address patients’ social needs. Rounding up the care experience are the Health Pals, who go beyond appointment scheduling to provide recommendation on preventive care and close the care gaps by making such appointments for them as well.

“With each member having distinct but complementary roles and responsibilities, the MCT initiative also supports the national Healthier SG’s vision of ‘one resident, one doctor’ or ‘one team’,” said Dr Ng Lok Pui, Director of Regional Clinical Services (East), and the Programme Lead for MCT.

This strategic alignment within the MCT supports the national shift in healthcare delivery to preventive care upstream. “With an ageing population and the increasing complexity of our patients’ care needs, it can be challenging to deliver comprehensive care, especially in the busy polyclinic context,” explained Dr Ng. “With MCT, after managing all the complex chronic problems during the consultation, doctors then entrust the care to their Care Managers and Health Pals who will continue conversations with patient on preventive care.”

Connections beyond check-ups

MCT also seeks to build enduring, longterm relationships and foster trust between patients and their care team.

“Relationship building is critical to meet the intent of empowering and engaging patients to take charge of their health, which is the cornerstone to the national initiative of Healthier SG,” said Dr Ng. “Recommendations of preventive care such as vaccinations and cancer screenings are healthcare information that are available to all patients. The key lies in empowering and activating our patients to take action. Our MCT members engage patients through their relationships, provide recommendations, address concerns, and close the last mile by coordinating such appointments for them.”

The mindsets that patients have when it comes to caring for their own health varies. While some patients may agree to treatments that resolve their issues directly, they may be sceptical or uncomfortable with taking further steps on their own towards preventive care. Care Managers and Health Pals, in particular, bridge this gap by connecting with patients and encouraging steps towards preventive care.

Ms Nur Zanaria Binte Zulkifli, Senior Patient Service Associate and a Health Pal at Marine Parade Polyclinic, recounted an encounter with a diabetic patient in her 50s who was diligent with her appointments but had reservations about screenings and vaccinations. After hearing the patient’s concerns, Ms Nur Zanaria advised her on the importance of vaccinations in preventing infections and improving immunity, and explained the procedures in fuller detail to allay her concerns. “As her concerns and doubts were clarified, she thanked me for helping her to understand these procedures as she felt truly cared for,” recalled Ms Nur Zanaria. “It was encouraging that I was able to directly contribute to the patient’s health.”

MCT fosters stronger bonds not only between the team members and their patients, but also among the members themselves. Under this collaborative approach to better healthcare, a strong relationship and harmonious coordination between MCT members is emphasised so as to serve patients better. “My colleagues and I feel more involved in the care journey of our patients,” said Ms Nur Zanaria. “Prior to being Health Pals, we were separated from the concept of caring for patients as our role was mostly about appointment bookings. Now, instead of having to refer patients to nurses and doctors for everything medical-related, we can advise better on certain aspects using the medical knowledge that we have been given access to. We have now become stronger partners to doctors and nurses.”

As of December 2023, SingHealth Polyclinics has enrolled approximately 80,000 patients. Nevertheless, Dr Ng pointed out that both Healthier SG and MCT are still in their infancy stage, and it would be optimal for more to be enrolled in Healthier SG and thus MCT. “Enrolled patients can be looked after by a regular team of healthcare providers journeying with them in pursuit of their health, where care can not only be delivered by doctors but also by other trained MCT members,” she said.

Mr Ho is one patient who appreciates the integrated care offered by MCT. “The enrolment process was very fast. My doctor and I discussed and agreed on a set of health goals, which enables me to better manage my diet and lifestyle,” shared Mr Ho, who also highlighted the enhanced communication and stronger rapport he enjoys with his assigned care team. “The Health Pals from my MCT also remind me of my required vaccinations and make sure I am always up-to-date with them,” he added.

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