The transdisciplinary ICOD team
Yishun Health takes a holistic and integrated care approach to support patients living with chronic illness. This is done through education, community screenings and activities, as well as integrated medical services and support in the community.
Our mission of care is built on a foundation of prevention, education and empowerment to grow a self-managed community that is able to take the steps needed to handle their illnesses well and delay the health complications of chronic disease. This, in turn, reduces the need for hospitalisation.
In addition to the numerous programmes that address obesity and diabetes, this chapter also includes initiatives on eye screening and sports medicine.
INTEGRATED CARE OF OBESITY AND DIABETES (ICOD)
The rates of obesity are rising at an alarming rate, leading to a host of related conditions, known as co-morbidities.
At Yishun Health, a new transdisciplinary initiative was launched in June 2017 to tackle obesity not just as a weight loss issue, but comprehensively managing risk factors such as diabetes. The ICOD programme is a one-stop platform, where weight loss surgery, medical weight management, and diabetes management are offered in conjunction with psychological care, nutrition recommendations, and physiotherapy. Patients are holistically supported and empowered to achieve their goals by a care team comprising physicians and surgeons, psychologists, as well as allied health professionals such as dietitians, physiotherapists and medical social workers.
The team, which is co-located in a single centre, is able to easily consult each other, assess cases, develop care plans, and optimise medications for seamless care coordination. Some patients may benefit from a non-surgical weight loss programme, while others may need weight loss surgery and major dietary changes. And even as medical and physical aspects are tended to, a psychologist is on hand to offer help on other important issues, such as anxiety, depression and low self-esteem.
This pioneering initiative supports Yishun Health’s philosophy of moving beyond episodic treatment of specific diseases and organs to providing comprehensive, long-term care that equips patients with the skills and knowledge to be active participants in their own health.
Bariatric and Metabolic Consultant Surgeons determine whether surgery is an appropriate option in collaboration with patients and the ICOD team. Pre- and post-operation, the patient is supported by the ICOD team to make long-term lifestyle and dietary changes.
Weight Management Consultants look beyond generic advice to customise approaches. It may mean advice ranging from specific lifestyle changes to adjusting medications for pre-existing illnesses to prescribing new drugs for weight loss.
Endocrine Consultants provide endocrinological support for the team; they specialise in managing diabetes and the hormones involved in the disease.
Clinical Psychologists support patients to develop healthful habits while arming them with coping mechanisms to handle anxiety, stress, low self-esteem, and other issues.
Dietitians offer advice on healthy eating, and also educate patients on making better food choices for the long term, thus ensuring that patients get enough nutrition and energy while controlling sugar level and calorie intake.
Physiotherapists develop safe exercise programmes for patients who have problems moving because they are severely overweight. They also runs ‘pre-habilitation’ sessions, which help patients gain strength before bariatric surgery and aid their recovery.
Nurse Managers manage cases and appointments, and coordinate care to ensure care continuity before, during and after surgery. This ensures that patients have access to long-term support even after they have achieved their weight goals.
Medical Social Workers provide psychosocial support to patients and their families. They also conduct financial counselling, assess the home situation, and arrange for the right mix of resources to help the family.
Plastic Surgeons perform body-contouring surgery to improve the patient’s body shape and remove excess skin folds after successful bariatric surgery and weight loss.
OTHER EVENTS AND PROGRAMMES COVERED IN THIS CHAPTER:
The AdMC Diabetes Centre opened in AdMC in July 2017 and offers a convenient location for patients to receive high-quality and streamlined specialist diabetes services. It focuses on the DESMM approach (Diet, Exercise, Support, Monitoring and Medication).
Driving Diabetes Awareness This section describes awareness, screening, prevention and management programmes and events in FY2017 organised by AdMC’s Diabetes Centre in conjunction with community partners and government agencies:
- Annual Diabetes and Metabolism GP Symposium
- World Diabetes Day
- Touch Diabetes 25th Anniversary Celebrations
- Enhancing Integrated Person-Centric Diabetes Care
SMART Community Nursing is Yishun Health’s geographically based Self-Managed Autonomous Regional Teams (SMART), which enhances community nursing in northern Singapore.
One of the SMART nurses in action, giving advice on nutrition and monitoring a patient’s vital signs
Community Nurse Posts offer basic nursing, chronic disease monitoring, personalised health and lifestyle advice/coaching, and early detection of functional limitation through geriatric and functional assessments. They apply the 2S+2C concept to achieve ‘community-up’ instead of ‘hospital-down’ referrals.
Sports Medicine covers the services provided by the KTPH Sports Medicine Centre, from the traditional (acupuncture) to the latest procedures (ultrasound-guided injections of the spine). It also lists the regional and international sports events that the Centre renders medical care.
Community & Home Eye Screening Services (CHESS) was launched in February 2017 by the Ophthalmology & Visual Sciences department and the Population Health & Community Transformation team to improve elderly residents’ access to eye care and identify eye diseases early through screenings and consultations. The CHESS model has reduced specialist referrals to hospitals, increased healthcare accessibility for the elderly and home-bound, and lowered the cost of screening and managing eye conditions.
Macular Amsler Testing App (MATA) replaces the traditional use of paper charts, making the vision test known as the Amsler test (for detecting age-related macular degeneration and diabetic eye disease) more accurate and easy to conduct at home. The app also has useful educational resources for patients in its homepage.