[AVBC 2025] COMBED: COMmunity-BasEd Diabetes Mellitus (DM) management of CGH DM patients with HbA1c...
Care Continuum
Appropriate & Value-based Care Conference
SingHealth
19 November 2025
The aim is to improve the HbA1c levels of CGH DM patients through community activation. The intervention shows promise for improving patient care by reducing HbA1c levels through community support and medical supervision.
Year Submitted: 2025
Published Date: 19 November 2025
Tags: Care Continuum, Preventive Care, Community Health, Primary Care
About this Content
Aims
The aim is to improve the HbA1c levels of CGH DM patients through community activation.
Background
Effective diabetes mellitus (DM) management extends beyond medications. Without a primary DM care provider, patients miss crucial holistic care like DM screenings and lifestyle guidance, risking deteriorating glycated haemoglobin (HbA1c) and DM-related complications.
Methods
The COMBED pilot proactively tele-recruits target patients to Community Nurses (CN) for monthly home visits focusing on needs assessment and patient empowerment through personalized goal settings. CN provides diabetes education, including vital signs self-monitoring and connects patients to Well-being Coordinators (WBC) for psychosocial support.
Results
Patients receiving community visits showed a greater average HbA1c reduction of 1.6% vs 0.8% for patients without community visits, suggesting the positive impact of community visits on HbA1c. Highest HbA1c reductions are seen when community visits are complemented with either visits to primary care physicians or to SOC specialists managing patients DM.
Conclusion
The intervention shows promise for improving patient care by reducing HbA1c levels through community support and medical supervision.
Lessons Learnt
Positive HbA1c outcomes in patients with community intervention suggest the potential for expanding community interventions through SOC specialist collaboration.
Keywords
HealthierSG, Health and Social Integration, Community Nursing, Community Activation, Wellbeing Coordinator
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Changi General Hospital, SingHealth |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Medical, Healthcare Administration, Nursing |
Applicable Specialty or Discipline | Endocrinology |
Project Lead(s) | Tan Chee Wei |
Project Member(s) | Atikah Ahmad |
Connect with this contributor!
Edris Atikah Binte Ahmad - atikah.ahmad@singhealth.com.sg