Integration of Acute, Primary and Community Care for the Management of Diabetes Mellitus
Care Continuum
Care Process & Redesign
National Healthcare Group Quality Improvement
National Healthcare Group
24 December 2025
Integration of Acute, Primary and Community Care for the Management of Diabetes Mellitus. The interventions show promise for improving patient care by increasing referrals and actualised appointments with the DM care network.
Year Submitted: 2025
Published Date: 24 December 2025
Tags: Care Process ＆ Redesign, Cost Saving, Workflow Redesign, Quality Improvement, Productivity, Care Continuum, Primary Care, Acute Care, Intermediate and Long Term Care ＆ Community Care, Chronic Care
About this Content
Aims
Integration of Acute, Primary and Community Care for the Management of Diabetes Mellitus
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 standardised DM admission rate is 2.1 times of OECD average. However, only 30% of DM patients have regular follow-up to prevent and reduce complications.
Methods
Plan-Do-Study-Act (PDSA) cycles allow rapid feedback and testing of changes. Understanding the patients story will help with engagement and change management. Designing an effective and efficient counselling script to best engage patients. Leveraging upon EPIC to drive sustainability and change.
Results
Increased percentage of patients referred to DM care network from 16% to 55%. Increased percentage of patients referred to and actualised appointment with DM care network from 35% to 57.8%.
Conclusion
The interventions show promise for improving patient care by increasing referrals and actualised appointments with the DM care network.
Lessons Learnt
No increased rate of unplanned 72 hours or 30 days ED re-attendances or re-admissions and no increase in ED P2 consult wait time.
Keywords
Diabetes, Glycaemic Control, Emergency Department, Endocrinology, Cost Avoidance
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | National Healthcare Group Polyclinics, NTUC Health Family Medicine Clinic |
Platform(s) | National Healthcare Group Quality Improvement |
Healthcare Professional Group(s) | Medical |
Applicable Specialty or Discipline | Endocrinology |
Project Lead(s) | John Chua Mingzhou |
Project Member(s) | Chiu Li Qi |
Connect with this contributor!
Group Quality - nhggroup.QRM@nhghealth.com.sg