[AVBC 2025] Integration of Acute, Primary and Community Care for the Management of Diabetes Mellitus
Care Continuum
Care Process & Redesign
Appropriate & Value-based Care Conference
National Healthcare Group
6 November 2025
To increase the percentage of Emergency Department (ED) discharged patients with non-optimal glycaemic control referred to. The interventions have led to improved referral and appointment actualization rates, indicating a positive impact on patient.
Year Submitted: 2025
Published Date: 06 November 2025
Tags: Care Process ＆ Redesign, Workflow Redesign, Quality Improvement, Productivity, Cost Saving, Care Continuum, Primary Care, Preventive Care, Community Health, Acute Care, Chronic Care
About this Content
Aims
To increase the percentage of Emergency Department (ED) discharged patients with non-optimal glycaemic control referred to the DM care network and actualizing the appointment over a sustained period.
Background
The projected prevalence of DM in the population above 60 years old is 40% by 2050, leading to heavy disease burden and healthcare cost. Singapore's age-sex standardized DM admission rate is 2.1 times the OECD average, and only 30% of DM patients have regular follow-ups to prevent and reduce complications.
Methods
Interventions include ED-to-Endocrinology same-day referrals, collaboration with Endocrinology and General Practitioners to establish protocols, and fixed date appointments with polyclinics and GPs via Right-Siting Officers.
Results
Increased percentage of patients referred to DM care network from 16% to 55% and increased percentage of patients referred to and actualized appointments with DM care network from 35% to 57.8%.
Conclusion
The interventions have led to improved referral and appointment actualization rates, indicating a positive impact on patient management.
Lessons Learnt
Plan-Do-Study-Act (PDSA) cycles allow rapid feedback and testing of changes. Understanding the patient's story helps with engagement and change management. Designing effective counseling scripts and leveraging EPIC drive sustainability and change.
Keywords
Diabetes, Emergency Department, Glycaemic Control, Care Network
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Medical |
Applicable Specialty or Discipline | Endocrinology |
Project Lead(s) | John Chua Mingzhou |
Project Member(s) | NA |
Connect with this contributor!
John Chua Mingzhou - mingzhou_john_chua@ttsh.com.sg