Chronic Care

Our polyclinics attend to a high proportion of patients with long-term diseases such as diabetes, high blood pressure, high cholesterol, stroke, heart disease and asthma. 

We have on our teams not only doctors and nurses but also allied health professionals such as dietitians, medical social workers, psychologists, physiotherapists and podiatrists to help you manage your condition, and improve your quality of life. 

 Patients with more complex chronic conditions may also be referred to be managed at our Family Physician (FP) Clinics. Here a Family Physician will work together with the rest of the team of nurses and allied health professionals to closely co-manage each case, to ensure that these patients receive appropriate and quality care within the community. 

 

 About Teamlet Care

Patients with chronic conditions can now be managed by a regular healthcare team, called a Teamlet. A Teamlet comprises two Family Physicians, a Care Manager who is a registered nurse and a Care Coordinator who is a layperson trained in preventive health management. The Teamlet coordinates care with other healthcare professionals such as Pharmacists, Allied Health professionals and hospital specialists as well as community partners to ensure Teamlet patients receive care that is customised to their medical, emotional and social needs. Only patients with one or more chronic conditions who require regular follow-up care at NHGP would be enrolled into Teamlets. There is no additional cost for being enrolled into a Teamlet. 

 The diagram below describes the composition and roles of each member in a Teamlet and how the Teamlet coordinates care with healthcare professionals within and outside the polyclinics to address your healthcare needs.  

 Teamlet Model Diagram
 

Benefits of Teamlet Care 

 

If you are enrolled into a Teamlet, you will receive personalised, continuous care for your chronic condition(s) based on your medical, emotional and social needs. Access to a dedicated Teamlet fosters a strong relationship and trust between you and your healthcare team. Hence you will feel more at ease discussing and making joint medical decisions on your chronic condition(s) with a permanent Teamlet.  

Our evaluation of patients enrolled into Teamlets and a similar comparative group of non-Teamlet patients over a period of twelve to twenty-four months has shown that Teamlet patients were more likely to have better control of their diabetes, more likely to go for preventive health screening and less likely to visit the Emergency Department for diabetes and hypertension-related problems.  

 

Ang Mo Kio 
Geylang 
Hougang 
Toa Payoh 
Woodlands 
Yishun