PRIMARY CARE NETWORK (PCN) AS A MODEL OF CARE FOR GP CHRONIC DISEASE MANAGEMENT

ABSTRACT

Objectives: The Primary Care Network (PCN), comprising small private General Practitioner (GP) clinics supported by a mobile team of dedicated nursing and allied health professionals, as well as a chronic disease register (CDR), can be an alternative model for good chronic disease management. GPs in the network manage the mobile team, set common goals for each clinic and self-evaluate. In this paper we share the data and experience of the first year of the pilot PCN in Singapore. Methodology: Process indicators for diabetic patients seen from April 2011 to March 2012 (pre-PCN) and April 2012 to March 2013 were compared. McNemar test was performed. Results: There was statistically significant improvement in process indicators of yearly DRP, DFS and Urine ACR screening for diabetes in the first year post-PCN compared to baseline data. Rates of regular HbA1c and LDL-C testing, as well as smoking blood pressure and weight assessment also showed statistically significant improvement. Conclusion: The PCN has shown promise in improving quality of care for diabetes among small private GP clinics. Key challenges to the success of PCN include good clinician leadership, suitable IT support, and creating a viable business model for GPs.