Health Plan
Link is copied

​Background

A key aspect to Healthier SG is a focus on improving or maintaining enrollees’ health, anchored by regular follow up with their chosen family doctor clinic for Health Planning. This means regular, scheduled check-ins with enrollees, so that the GP and his/her care team can assess their overall health condition, conduct necessary health screenings, track results and advise on lifestyle adjustments to help enrollees achieve their health goals.


What is a Health Plan?

The Health Plan aims to empower enrollees to take charge of their health by facilitating health actions that lead to them achieving their health goals, with support from their doctor and their community. Health goals should be discussed using person-centred communication and be meaningful to the enrollee so as to promote patient empowerment and nudge health improvements.

A Health Plan serves as a communication tool between enrollees and their GP, to enable:

  1. Enrollees to better understand their overall state of health,
  2. GPs to ensure that care delivered for disease prevention and chronic condition management is timely and appropriate, and
  3. Development of shared health and lifestyle goals amongst both enrollees and GPs.

Upon enrolment, doctors should initiate a first discussion with enrollees to develop the Health Plan. Details of the Health Plan will flow automatically into the enrollees' HealthHub account, for GPs who are using HealthierSG-compatible Clinic Management Systems (CMSes).

Key points from the digital version of the Health Plan as submitted by the GP will be shared with the Clusters over time, to enable them to support enrollees with more local and relevant activities and support. Enrollees will also be able to show their Health Plan via Health Hub on their phone to other partners to align on their health needs, e.g. Active Ageing Centres (AACs). 

​​
H​ealth Planning includes (but is not limited to) recommended health screenings, vaccinations, and advice on making healthier lifestyle changes, as well as any actions related to management of their chronic ​conditions.

GPs should record key elements of the Health Plan using your clinic management system (CMS) at all Health Plan check-ins (both physical and virtual) as part of good clinical practice. Records are expected to be up-to-date, accurate, clear and complete, taking reference from the template in Table 1. Further details and updates on the guidelines for health screenings, chronic condition management and vaccinations can be found within the relevant Care Protocols.

Table 1: Template on what to cover in a Health Plan visit

Categories ​ Details
History
  • Chief complaint (if any)
  • Medical History, e.g. current acute and/or chronic medical history; chronic medications; drug allergies
  • Family History of medical conditions
  • Health Screening and Vaccination History
  • Lifestyle History, e.g.
    • Important: smoking status; duration and intensity of exercise/physical activity, diet history
    • Optional: quantification of alcohol intake, occupation
Physical Examination
  • Tailor to history and chronic conditions (if relevant) of resident
  • To include measurements of height, weight, waist circumference, and blood pressure.
Diagnosis
  • Update problem list
Treatment Plan
  • Include laboratory and/or radiological investigations, if any, to assist in diagnosis and/or management 
  • Update / schedule for age-appropriate screening and vaccinations
  • Adopt healthy lifestyles (e.g. smoking cessation, increasing physical activity, dietary advice, weight loss targets, etc)
  • Reference to guidelines from relevant protocols
Referrals
  • Document referrals to PCN/ cluster/ community programmes (e.g. HPB, SportSG, PA, etc); and to SOCs/ ED / ECs
  • This segment could be used to auto-trigger referrals to clusters over time
Health goals, activities, and follow-ups
  • Discuss and encourage patients to set health goals and plan activities relating to healthy lifestyles and chronic disease management ​
  • Goals should be specific, measurable, attainable, relevant, and time-based (SMART)
  • Specify date for next check-in ​

​​

​
It is recommended that a patient's first Health Plan is completed within 6 months upon enrolment with a GP. This can be done at the next planned check in with the patient. For new patients, GPs should reach out to schedule appointments with them. This expectation will be conveyed to enrolling residents.  GPs could also conduct Health Plan discussions opportunistically when an existing patient next visits the GP. 


The enrollee and their GP should have regular, scheduled check-ins to assess the resident's overall health condition and progress. For each check-in, GPs should discuss the progress of their health goals and assess if the goals need to be adjusted, or if additional intervention is required.

Check-ins and updates to the enrollees's Health Plan can be done opportunistically, where appropriate, during an acute or chronic visit; otherwise, the GP should contact the enrollee to schedule a follow up check-in.

  • For well enrollees, defined as enrollees with no CDMP conditions, an annual check-in should be performed. The first check-in should be done in-person to establish rapport and relationship with the patient. Subsequent check-ins can be done via phone or video consult, although we would recommend an in-person consult minimally once every 3 years as long as the enrollee remains generally well. ​

  • For chronic enrollees with at least 1 CDMP condition, at least 2 chronic consults should be conducted annually and the Health Plan should be updated during these visits. If phone or video consults are conducted, it should be clinically appropriate with at least one in-person consult conducted annually. These phone, video and in-person consults are claimable under CHAS/ CDMP, subject to prevailing claims requirements. 

GPs are encouraged to tap on their PCN care team, such as nurses or care coordinators, to work with the enrollee to actualise their treatment plans and meet their health goals in the Health Plan.

​


A key aspect of Health Plan is goal-setting with an enrollee to encourage ownership and action by the enrollee. To facilitate the process, we have developed a simple set of shared goals for the first phase of Healthier SG .​ These can be submitted using the template on health goals which can be found in GPs' Healthier-SG compatible Clinic Management System or the Primary Care Digital Services (PCDS). The goals will be reflected in patients' Health Hub account automatically . The list of goals will be reviewed and adjusted as we move on to other conditions under Healthier SG and as we take in resident and GP feedback. ​

Aside from the shared goals and activities, there will also be a free text box for GPs to document their comments/notes for sharing with their enrollees. Such comments/notes will be reflected in the enrollee's Health Hub account.

Depending on the enrollee's condition, GPs will need to provide the necessary care components as outlined in the respective Care Protocols – please refer to these protocols for the list of data to be submitted to MOH. We are working to reflect these data in your patients' Health Hub accounts for them to keep track of their health status. ​​

​

The Health Plan is intended to augment care planning that GPs already routinely provide for their patients today, and support patients in improving their health. The key enhancement is that the Health Plan allows documentation of health goals and key actions that are mutually agreed by GPs and enrollees, and to make these available to the patients in the Health Hub (HH) app. More goals and actions will be added over time.​

​

GPs are strongly encouraged to conduct a check-in with patients who have transferred care to them, to address any possible outstanding health concerns. GPs will be able to access patients' previous Health Plans through their CMS or PCDS, and other information through NEHR.

Government reimbursement for the first Health Plan discussion is not applicable to enrollees who have already had their first Healthier SG consultation with a previous doctor. The service fees covering annual check-ins and on-going care for the enrollees will still apply, subject to the prevailing terms and conditions (e.g., whether the required information was submitted).​

​

Seniors that need assistance to follow up with their Health Plan can visit their AAC and show AAC staff their Health Plan for help with working towards their shared goals and activities.

AACs serve as key nodes for seniors as the go-to points for their community health, lifestyle activities and social needs. AACs currently provide the “ABC" suite of services, which include Active Ageing activities, Befriending and Buddying, as well as Information and Care Referrals. To support Healthier SG, AACs will also deliver “2Cs": Community Connector for lifestyle and social interventions and Community-based vital signs monitoring. The 2Cs support seniors who need further assistance with achieving their activities and goals within their Health Plan. More information on AACs can be found here if a GP would like to contact an AAC to discuss support for their patients.

​

GPs will be paid a fixed fee upon completion of the first Health Plan discussion, i.e. after the first Health Plan is submitted. This fee for the Health Plan discussion can only be claimed once for each enrollee. GPs who make a claim for the first Health Plan discussion should not charge a consultation fee for this visit. Similarly, no fee should be charged for subsequent Health Plan check-ins conducted each calendar year. GPs will receive a payment for this check-in from the Government via the annual service fee, as long as the required information was submitted. ​