Symposium 4

Dr Hu Pei Lin
Consultant Family Physician, Marine Parade Polyclinic
SingHealth Polyclinics

Dr Hu Pei Lin joined SingHealth Polyclinics in 2012. She attained the Masters of Medicine (Family Medicine) in 2013 and the Fellowship of the College of Family Physicians Singapore in 2016. She is currently a Consultant Family Physician and the clinic director of SingHealth Polyclinics – Marine Parade. She is also an Adjunct Assistant Professor for DUKE-NUS Medical School. Together with the clinic team, Dr Hu has continued to reinforce the strong ties between Marine Parade Polyclinic and the other care providers in the Marine Parade community.

Session:

Continuum & Community, 7 October 2022, 1415 - 1615hrs
PACE-It: The Primary Care Based Integrated Community Care team

Amongst patients with multi-morbidity, there is a segment of patients with complex needs. These patients often have poorer outcomes as a result of the interaction of many factors at the personal level and their interactions with the community and the healthcare system. Routine care alone does not meet the needs of the complex patient. Challenges result in fragmented care and a lack of person centeredness that in turn leads to lower quality of life, poor care experience and poor health outcomes. PACE-It is a new model of care that brings together stakeholders currently providing care in the community and bridges the health-social divide. The stakeholders are: i) Primary Care – Marine Parade Polyclinic ii) RHS community nursing iii) RHS care co-ordinator and iv) Community social care provider – GoodLife!. The care model builds on the Innovative Care for Chronic Condition Framework and includes elements described in literature such as person-centred care, holistic assessment, self management , integration of services and collaboration.

PACE-It is a complex intervention on comprising of

a) Integrated Primary Care Based Community Care Team

b) technology enhanced care co-ordination supported by a mobile platform

This study initially started as a RCT aimed at evaluating the PACE-It intervention versus usual care in improving the glycemic control, quality of life and activation of patients living with Diabetes and complex needs. It has since evolved into a service programme with a widened inclusion criteria that benefits more patients and families.

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