aha
ISSUE 3: May-June 2019
TOWARDS VALUE-BASED CARE
MCI (P) 101/04/2018
Moving beyond quality to value: supporting our patients’ physical, emotional, functional and social well-being
WHEN MEDICINE IS A TEAM SPORT
12
IN SERVICE TO 16 OTHERS
ACUPUNCTURE FOR PAIN 24
ontents
18
COVER STORY The journey towards value-based care Value-based care delivers the best possible outcomes at the most affordable cost, broadening the way we measure ‘successful’ medical care to consider a person’s physical, emotional, functional and even social well-being.
THE VALUE SERIES 2 |
4
HEALTH HIGHLIGHTS Healthcare news and updates
6
WHAT’S UP Community events, outreach efforts, and more
12 SPOTLIGHT When medicine is a team sport Sports medicine takes a team-based approach to help people stay active and pain-free 16 EVERYDAY HEROES In service to others Medical volunteering is almost a full-time commitment for Dr Tan T’zu-Jen
16
24 5 THINGS ABOUT… Acupuncture for pain Learn how acupuncture is being used to complement the mainstream management of pain 26 LIVE WELL Blossoming through adversity Amputee Mr Tony Ng renewed his commitment to his health, finding joy in crafts and giving back
This is the first of a three-part series that looks at providing value in our care and, more importantly, how this value-based care approach helps us to strategise care delivery and optimise resources in order to improve outcomes for our patients and the community.
PUBLISHER Yishun Health is a network of medical institutions and health facilities in the north of Singapore, under the National Healthcare Group. It comprises Admiralty Medical Centre, Khoo Teck Puat Hospital and Yishun Community Hospital. It also includes community extensions such as Wellness Kampung.
28 28 MAKAN TIME Wholegrain uttapam These savoury South Indian pancakes are packed with wholegrain goodness 30 DAILY DOSE A whole lot of good Why wholegrains are better 31 MIND & HEALTH Spot me Can you find these healthy food items?
T
he challenge of defining value
At a time when the healthcare landscape is balancing between delivering quality care and keeping costs affordable, the idea of value has become even more important. But what exactly is ‘value’? In this three-part series, aha tackles the subject through the lens of value-based care. This issue’s cover story explores what value-based healthcare means at the national level, and also what it means for us at Yishun Health: designing resource-efficient care that considers patients’ wants, preferences and quality of life. This theme continues in other features. Turn to page 12 to understand how the Sports Medicine Centre works as a team to help people stay active in spite of pain or chronic illness. And did you know that acupunture can help with pain management (page 24)? In other stories, we profile ‘super’ volunteer Dr Tan T’zuJen (page 16) and inspiring patient Mr Tony Ng (page 26), share the benefits of wholegrains (page 30), and — for our foodie friends — provide an easy recipe (page 28) for a savoury South Indian treat. Happy reading!
The Editorial Team
EDITORIAL TEAM Hannah Wong Sabrina Ng Sharon Ng Albert Foo
EDITORIAL COMMITTEE
The editorial committee — made up of clinical, nursing, allied health, population health & community transformation, and administrative heads of department — advises aha’s direction. A/Prof Tan Kok Yang Bastari Irwan Chia Kwee Lee Fatimah Moideen Kutty Shirley Heng Teresa Foong
ktph.com.sg/aha aha@ktph.com.sg
PUBLISHING AGENT THINKFARM PTE LTD www.thinkfarm.sg M A N AG I N G D I R E C T O R
Christopher Tay
E D I TO R I A L D I R E C TO R
Chua Kim Beng
C O N T R I B U T I N G E D I TO R
Sheralyn Tay E D I TO R
Dang Hui Ling DESIGNER
Melissa Poon S E N I O R M A N AG E R , C L I E N T R E L AT I O N S H I P
Jessie Kek
C O N T R I B U TO R S
Justin Loh Kelly Loh Lee Lily
aha is the official bi-monthly publication of Khoo Teck Puat Hospital (Co. Reg. No. 200717564H) and is produced by ThinkFarm Pte Ltd. All rights to this publication are reserved and no part may be reproduced without the expressed written consent of the publishers. While every effort has been made to ensure that the information in this newsletter is accurate and up to date, the editorial team will not be responsible for errors due to information received. Opinions expressed are that of the writers and do not necessarily represent the views and opinions of the publishers. Printed by Mainland Press Pte Ltd. MCI (P) 101/04/2018
| 3
ealth Highlights
Empowering
healthy living Following the Budget Announcement in March 2019, the Ministry of Health has rolled out a range of programmes to encourage more Singaporeans to go for important screenings, manage their diabetes, and drive vaccinations for preventable diseases.
Making screening more affordable As of May 2019, CHAS GPs will offer two non-fasting tests for cardiovascular risk screening under the Screen for Life (SFL) programme.
FREE Pioneer Generation: FREE
$2 Merdeka Generation seniors and CHAS Blue/ Orange card holders: $2 (starts 1 November 2019)
4 |
All other Singaporeans: $5
$5
More support for diabetes care To better address diabetes-related foot problems, a new risk-stratified diabetic foot screening, management and escalation framework was launched in polyclinics and public hospitals in April 2019. This will provide healthcare professionals more clinical guidance for performing foot assessments. In addition to this, patients and caregivers can turn to HealthHub (via the app or www.healthhub.sg) for a new set of National Diabetes Reference Materials in four languages by the second half of 2019.
From June 2019, women with a history of gestational diabetes will be able to enjoy SFL subsidies for screening.
Expanding cervical cancer protection From April 2019, female Secondary 1 students in national schools, including madrasahs, can opt in for a free cervical cancer vaccine. The vaccine protects women against the Human Papillomavirus (HPV), a virus that causes cervical cancer.
FREE
SFL will also extend subsidies to women for a new, more accurate, HPV screening test.
| 5
hat’s Up
Winning Big at the Asian Elderly Care Awards T
he Population Health and Community Transformation teams at Yishun Health and Woodlands Health Campus won five awards at the inaugural 2019 Asian Elderly Care Awards (AECA), which recognises best practices and excellence in healthcare providers towards the physical, emotional, economic, social and spiritual wellbeing of the elderly. enjoying a nutritious bowl of soup prepared by the residents.
community, an ecosystem of care has been nurtured through leveraging group activities, community resources, the individual and collective strengths of people, and stealth health. Services such as Wellness Kampungs and Community Nursing Posts, as well as programmes such as Share a Pot® and CHOPE, decentralise healthcare to a low-cost, high-access network of community nodes.
Together, We Build
Mini Medical School Outstanding Innovations in Health Education, Excellence Award Yishun Health’s Mini Medical School (MMS) is a ground-up initiative that makes medical education accessible to the community through a series of informative and easy-to-understand lectures. Its goal is to raise health literacy and self-efficacy so that people can be active participants in managing their own health. Over five years, 14 runs have been held, with more than 4,111 attendees and 1,919 participants and graduates.
Most Creative Community Partnerships, Gold Award Intergenerational programmes such as Tri-Generational HomeCare @ Northwest (TriGen) and Community of Hope (CHOPE) build compassionate communities through engaging and educating university and secondary school students. They are paired with seniors to offer befriending, health and psychosocial support. The experiential learning and mentorships build empathy among students, who then design creative activities to meet seniors’ needs.
Share a Pot® Excellence in Brand Building and Marketing, Gold Award Share a Pot® promotes communal eating and exercise to address frailty and social isolation in the senior community. The programme gets seniors out of their homes to interact socially and exercise together before
6 |
Healthy Self-Managed Communities in Northern Singapore Best in Healthy and Active Ageing Services, Gold Award To build a healthy self-managed
Community Nursing in the North of Singapore Excellence in Day-Care / Home Care or Stay-in Services, Gold Award Community nurses visit seniors in their homes after their discharge from the hospital to assess their clinical, psychosocial, and environmental needs. Via individualised care plans, rapport building, close collaborations with community partners, and building up self-management capabilities of seniors themselves, the programme aims to help seniors stay well in the community.
Going for Gold!
M
ore than 400 people gathered at Yio Chu Kang Sports Hall on 23 March 2019 to join in the fun at the first Goldlympics. The community sports event for seniors was jointly organised by Yishun Health, ActiveSG Masters Club, and Team Nila, and spearheaded by the Population Health and Community Transformation (PHCT) team from Yishun Health. More than 100 competitors, aged 50 and above, from Wellness Kampungs and community partners participated in games such as chair volleyball, beanie dash, and human tic-tac-toe. They not only had fun, but showcased their strength, vitality and sportsmanship. The Goldlympics supports active ageing, a healthy lifestyle, and family togetherness through an inclusive platform.
These seniors proved that age is just a number as they showed off their competitive spirit during the Goldlympics games!
| 7
hat’s Up
A Partnership for a More Active and Healthy Population Y
ishun Health and Sport Singapore (SportSG) signed a Memorandum of Understanding (MOU) on 11 March 2019 at Admiralty Medical Centre (AdMC) to establish a new collaboration to bring healthy living to the residents in the North. Under this MOU, SportSG and AdMC will roll out a national social movement for health and wellness called Active Health. Active Health is aimed at empowering and motivating individuals to take ownership of their health, and to build strong social bonds and support through shared experiences. The programme will leverage AdMC’s role as a one-stop medical centre and a source of community health outreach activities to strengthen various initiatives that educate and empower the community.
Under the MOU, SportSG will partner AdMC to roll out a national social movement for health and wellness called Active Health
A Yummy Win for Our Chefs T
Chef Jason (left) and Chef Terry’s healthy yet delicious creation: Oriental Stuffed Chicken Thigh
8 |
wo of KTPH’s chefs came in second at the Share & Cook competition organised by the Agency for Integrated Care (AIC) on 28 February 2019. Sous Chef Terry Wan and Chef De Partie Jason Khor, from KTPH Food Services, received their second spot out of a pool of 26 competing teams from other healthcare organisations. Using a combioven, they created a healthy, flavourful dish with minimal seasoning designed to be appealing to seniors. The dish, Oriental Stuffed Chicken Thigh, was a complete and balanced meal.
Highlighting the Work of MSWs M
edical Social Workers (MSWs) from Yishun Health launched an exhibition on 5 March 2019 to showcase the work they do with patients in the hospital and out in the community. Held in conjunction with Social Work Day 2019, the week-long exhibition was aimed at raising awareness of the roles and work of MSWs. It was also a platform to share real patient stories and experiences.
Mr Toh Ah Seng, 71, posing with his exhibit, which shares how his quality of life has improved tremendously with the help of our MSWs
Yishun Health’s MSWs are all smiles at an exhibition of their work
(Left): Chef Ali and Dietitian Ryan Ong demonstrated how wholegrain uttapam is prepared (Above): A member of the public receiving advice from Dietitian Magan Ho
Make Wednesdays Wholegrain W
e’ve all heard of Meatless Mondays, so why not increase the wellness factor and introduce Wholegrain Wednesdays? To educate staff and visitors about the benefits of wholegrains (turn to page 30 to learn more), Yishun
Health’s Nutrition & Dietetics launched the Wholegrain Wednesdays initiative on Dietitian’s Day 2019 (13 March). Apart from introducing more wholegrain-based food at Foodfare@ KTPH and patient menus, an event was held with interactive games,
quizzes and a tasting session for local delights prepared with wholegrains by the KTPH and YCH Food Services teams. There was also a cooking demonstration for wholegrain uttapam (find the recipe on page 28), and claypot chicken with brown rice. | 9
hat’s Up For a holistic understanding of kidney health and its related diseases, there were also educational posters on topics such as how diabetes is related to kidney failure
Rallying Around Renal Disease T
o mark World Kidney Day, which falls on 14 March, the Yishun Health Renal Medicine team organised an exhibition at Kampung Admiralty Plaza. Themed ‘Kidney Health — For Everyone Everywhere’, the team set up educational posters and interactive booths to highlight the functions of the kidneys, raise awareness of kidney disease, and educate people on kidney health. As kidney health is related to diabetes, the exhibition also included useful educational material from the Diabetes Centre and Nutrition & Dietetics teams. Apart from raising awareness and education, there was a
health screening programme and a promotion of CHAMP, Yishun Health’s health coaching and lifestyle management initiative.
‘Water’-way to be Clean and Green Y
ishun Health commemorated the 2019 World Water Day on 17 March. The annual event drives both water conservation and environmental awareness through a yearly litter-picking session at Yishun Pond. To drive the clean and green message, there was a performance by children from Little Skool House by the Lake on water conservation tips. Guests and audience members, including Guest of Honour Er Dr Lee Bee Wah, Adviser to Nee Soon GRC GROs and MP for Nee Soon GRC, also recited a pledge to commit themselves to protect the environment. 10 |
A community commitment to water conservation on World Water Day
The event, organised by the Renal Medicine team, attracted over 200 people
Getting to Know Gut Health O
ver 300 people turned up for the Gastrointestinal Public Forum held at the KTPH Auditorium on 30 March 2019. The session was aimed at educating people about gastrointestinal and colorectal cancer. It included topics such as how to prevent the disease, recognise symptoms, and what treatment options are available. Cancer survivors also shared their experience of recovery. To showcase how to eat better to lower the risk of cancer, a live cooking demonstration was held. Apart from these, there were interactive educational booths on the importance of healthy foods and how a colonoscopy procedure works. The forum, which was split into two sessions (English and Mandarin), was organised by the General Surgery Department.
Educational posters and demonstrations helped to reinforce the message of prevention
Running in Support of Cancer Survivors O
n 2 March 2019, Yishun Health joined 7,000 participants in Relay For Life, a 15-hour relay run. The Yishun Health contingent was led by A/Prof Tan Kok Yang, Head and Senior Consultant, General Surgery, and was supported by members from his department and the institution. Organised by the Singapore Cancer Society (SCS), Relay For Life, which started in 2017, raises funds for SCS programmes and services. The relay also signifies solidarity with patients, families, survivors and caregivers in their cancer journey. Over 30 staff dedicated their time and energy to represent the Yishun Health contingent at the relay.
Over 30 staff took steps to symbolically journey with cancer survivors in the 15-hour relay
| 11
potlight
When medicine is a team
12 |
sport
In an era of multidisciplinary medicine, one specialty where this principle is particularly apparent is sports medicine.
W
ant to beat your personal best at your next marathon, or perform at peak strength for a regional tournament? Maybe there’s a nagging pain that’s preventing you from doing your daily walk or taking part in daily activities? Sports doctors such as Dr Teoh Chin Sim make it their goal to help people be as active as they want to be for as long as they want to. Dr Teoh, a Senior Consultant and Director of the Sports Medicine Centre (SMC) at KTPH, explains that Sports Medicine is a branch of medicine that deals with the treatment and prevention of injuries related to sports or other activities, exercise prescription, and functional movements. The centre sees a wide spectrum of patients across age groups, from professional and recreational athletes to students and National Servicemen, and from blue-collar workers to professionals and retirees. “Our goal is to encourage and support people to remain active throughout the age continuum, educating them on how to prevent and manage injuries,” she explains. This can mean treating both chronic as well as acute issues.
SPORTS MEDICINE FOR EVERYONE
The Sports Medicine team: (LEFT TO RIGHT) Dr Ong Joo Haw, Dr Shauna Sim, Dr Teoh Chin Sim, Dr Teh Kong Chuan and Dr Dinesh Sirisena
“The demand for Sports Medicine is rising,” Dr Teoh states. More and more people are adopting an active lifestyle. A large proportion of the newly active are not people in their 20s, but those in their 40s and even 50s. “This is a positive trend, but this group of people may require additional support to achieve their goals, particularly if they had previously led a sedentary lifestyle, have an existing chronic illness, or suffer from an age-related issue,” she advises. The department also treats people on the other end of the spectrum: professional or serious athletes of all ages. | 13
potlight But Sports Medicine is not just for athletes. “We tackle real-world problems,” emphasises Dr Dinesh Sirisena, Consultant. From taxi uncles with stiff necks to technicians suffering from wrist pain, SMC solves everyday problems that interfere with their daily function. “Apart from treating people who are sporty, it is also about treating uncles and aunties who want to go to the market, take walks, or do their work,” he says. Dr Teh Kong Chuan, Senior Consultant, reveals, “I see patients who are in secondary school to those in their 70s. A significant number of them are national servicemen, as well as recreational sports persons.”
GIVING PATIENTS OPTIONS “To address the diversity of patients as well as the range of conditions, the
SMC has, over the years, grown its range of services,” Dr Teoh shares. This includes acupuncture (turn to page 24 to find out more about this), extracorporeal shockwave therapy, and ultrasound-guided procedures. Shockwave therapy, for instance, is a non-invasive treatment used to ease inflammation and speed up recovery of injured muscles, tendons and other soft tissues. Pressure waves are transmitted to the affected areas to stimulate the body’s natural healing response and relieve pain. The SMC also offers a number of unique ultrasound-guided injections. Dr Ong Joo Haw, Consultant, explains that ultrasound imaging allows doctors to clearly visualise musculoskeletal structures. “We can then guide an injection more precisely into the intended region,” he describes.
Apart from treating people who are sporty, it is also about treating uncles and aunties who want to go to the market, take walks, or do their work. DR DINESH SIRISENA CONSULTANT SPORTS MEDICINE CENTRE KTPH
Dr Teoh Chin Sim, Head of Sports Medicine Centre, providing extracorporeal shockwave therapy treatment
14 |
In the past, such procedures would require a separate appointment and may include the use of more exposure-prone imaging modalities, such as X-ray or CT. In contrast, this ultrasound-guidance can be done in the clinic, with considerable accuracy, in a timelier fashion and at minimal risk to the patient. Examples of ultrasoundguided injections include high-volume tendon stripping by identifying the precise areas between tendons and tendon sheaths, and platelet-richplasma and prolotherapy injections for tendon and ligament injuries. Another benefit of ultrasound-guided injections is that “it allows us to offer more alternatives to patients”.
TEAM EFFORT Offering alternatives and treatment options to patients is part of the job, shares Dr Shauna Sim, Resident Physician. “We work with active people, many of whom find it frustrating to rest for extended periods of time,” she says. “We do our best to support and educate patients on how they can moderate their activities and find alternatives so they can remain healthy.” A former national waterpolo player, Dr Sim found herself drawn to this specialty partly because she benefited from it in the past as a sportsperson. Dr Teh, who has been practising sports medicine since joining the Sports Medicine and Research Centre of Singapore Sports Council (now Sport Singapore) in 1977, adds, “I enjoy helping patients with their sports injuries, to help them recover as soon as possible so that they can return to their sports and physical activities. I also encourage patients to keep fit with regular exercise.” The SMC is staffed by active people: Dr Teoh is an avid runner, Dr Teh walks daily, Dr Ong is a powerlifter, and Dr Dinesh cycles and
plays golf; many of their colleagues in the Centre are equally active. It all lends to a collaborative spirit at the Centre, one that Dr Ong likens to a team sport, with the patient playing an active role in his or her own recovery. “We take care of the patient as a whole. We diagnose and treat as a team, working with radiologists, physiotherapists, podiatrists, surgeons, acupuncturists and dietitians to come up with a plan to help individuals achieve their goals.” Dr Dinesh adds, “As active people ourselves, the team has experienced sport injuries before and understand it from a personal perspective. This means we can relate to patients better and offer some reassurance and empathy.” Dr Sim feels this underscores the meaning of what they do each day, saying, “I believe that sport and exercise are beneficial to people. I find it very meaningful to be able to come up with a plan to get people back to their chosen activities.”
OUTREACH AND ENGAGEMENT The team also finds it meaningful to give back to the community through
their work. This takes the form of medical coverage for sports events and growing sports medicine know-how. For instance, SMC — together with the Orthopaedics Department — has run for the past three years the highly successful Sports Medicine Masterclass Series for General Practitioners (GPs), educating them on various sports and muscoskeletal conditions. In addition to expanding knowledge, it provides GPs with an opportunity to improve their skills in early rehabilitation, acupuncture, and the recognition and diagnosis of conditions. Another area of skill-sharing is through the Alexandra Academy for Clinical and Emergency Sonography (AACES), where medical professionals are given an introduction and early training in the use of ultrasound for musculoskeletal medicine. “It is all part of our outreach and engagement efforts, sharing the love for both medicine and sport,” reveals Dr Ong. “When you are surrounded by people who share the same interest, work doesn’t feel like work.” It motivates him and his colleagues to do better as sportspeople, as doctors, and as human beings.
| 15
veryday Heroes
In service to others Medical volunteering is at a whole other level for Dr Tan T’zu-Jen. He spends nine months a year at a 25-bed rural hospital on the Thailand-Myanmar border, using his surgical skills in service to refugees and other displaced communities.
W
hile some doctors start the day to the sound of computer whirs, phone rings, and the chime of the clinic’s queue number system, the sounds Dr Tan hears are the crowing of roosters, howling of village dogs, and screeching of quarrelling cats. This is the enlivening backdrop against which Dr Tan volunteers nine months out of a year at the Kwai River Christian Hospital. Located in the mountainous northwestern region of Kanchanaburi province in Thailand, it is the only fully staffed surgical facility capable of performing emergency obstetrics and general surgery within a radius of 230km. The staff, comprising two doctors and 10 nurses, provide essential and emergency treatment to people on the Thailand-Myanmar border — the rural poor, refugees, displaced peoples, and anyone else — regardless of their ability to pay. Although small, the hospital sees about 12,000 outpatient visits, and performs more than 300 surgical procedures each year. When he is not here, Dr Tan is a Senior Consultant in the Department of General Surgery, KTPH.
THE PATH TOWARDS SERVICE Dr Tan reflects that it was during his training years that he began to see how his professional interests,
16 |
Dr Tan, together with A/Prof Edwin Seet (Head, Department of Anaesthesia, KTPH) and Dr Tan Ruobin, in surgery at the Kwai River Christian Hospital
personal passions, and abilities could come together to improve medical and surgical care in the developing world. This led him to take part in the occasional medical mission as a medical student and young doctor, with this commitment growing over the years. Dr Tan and his family began to use his annual leave to visit humanitarian hospitals and projects around the region. This gave him valuable insight into the needs, opportunities and dynamics of different medical teams. These trips were also useful in gauging the capacity for change management and the skill sets required at various sites in developing countries.
In 2015, he learnt that the Kwai River Christian Hospital was in need of a replacement as the doctor who had been covering the work there was returning to his home country. “Seeing the good work they were doing with the rural poor, refugees and displaced peoples, as well as the organisational culture, we decided to explore how we could help,” Dr Tan shares. “Over the years, this has involved getting training and informal teaching from other surgeons, anaesthetists, internal medicine physicians, paediatricians, radiologists, obstetricians, gynaecologists, and tropical medicine specialists.”
With the strong support of KTPH and its Department of Surgery, as well as generous donations from friends, family and his church, Dr Tan embarked on his self-funded volunteer work. The funds have gone toward providing assistance to the neediest patients and the purchase of essential equipment, he explains. “We have also had surgeons, nursing and operations staff from KTPH come to visit, provide technical assistance, practical training, and carry in donations of expired but usable supplies.”
THE ART OF RURAL MEDICINE Working in a jungle hospital has its obvious challenges. Apart from the resource-poor setting, there is a sense of isolation, as Dr Tan does not have colleagues to consult on tough cases. “The delicate balance is in trying to responsibly broaden and develop skill sets in areas outside one’s specialty,” he says. It has meant lots of reading up and self-training to cover the breadth of tropical medicine and surgical cases. At the same time, he also works to build up local capabilities in diagnostics, procedural techniques, best practices, technology transfer, and equipment upgrades. “One area of much anxiety during my first few months was in providing anaesthesia, and performing cases outside of general surgery,” he recalls. In one particularly memorable case, a refugee with a condition known as placenta previa turned up at the emergency room one night, bleeding profusely. Placenta previa is a highly dangerous condition requiring immediate surgical attention. It occurs when the placenta lies too low in the uterus, and partially or completely covers the birth canal, resulting in the placenta tearing away. “The patient was a first-time mother, and
I had no first-hand experience with placenta previa at this point,” Dr Tan reveals. “As I prepared for the spinal anaesthetic and the Caesarean operation to follow, I wondered who was more nervous! Thankfully, the operation went smoothly for both mother and child.”
The delicate balance is in trying to responsibly broaden and develop skill sets in areas outside one’s specialty. DR TAN T’ZU-JEN SENIOR CONSULTANT DEPARTMENT OF GENERAL SURGERY KTPH The occasional medical challenge aside, there is also the unique experience of living in the hospital compound. For Dr Tan, his wife and three daughters (11-year-old twins and a 13-year old), this is truly kampong life. Part of the fun that communal living provides, he notes, is that he can tell when each of his neighbours is coming home or going out. As for his family, they have adjusted well to village life and home schooling. Living close to the hospital has its benefits, he adds. “It makes it easy to swing by to take care of emergencies or check on patients at any time.”
A BETTER APPRECIATION For three months a year, Dr Tan is stationed in KTPH. The experience cements not just his passion for this chosen profession, but also deepens his appreciation of the healthcare system here.
Dr Tan and his family in Huay Malai village
Trained by and working alongside well-respected surgeons in KTPH such as A/Prof Kenneth Mak and Dr Anton Cheng in his younger days, he values each stint back at the hospital where he has built much of his career. Veteran mentors aside, Dr Tan attributes much of his own learning and development to skilful and supportive colleagues. “A lot of my understanding of the practical aspects of change management and team building were learned here. It is a great opportunity for me to be updated on best practices of what we can do better for our patients.” Returning to these roots reinforces the reasons why he pursued medicine in the first place, and his decision to dedicate this phase of his life to humanitarian work. How would he encourage others to do the same? Start by exploring one’s own interests and passions, he advises, then make an effort to learn about the work being done in these areas. Visit the teams on the ground, make use of opportunities to develop skill sets and experiences that can bring value, and be humble and flexible in how you serve. “While there are many ways that one can serve, one just needs to make the first move. After all, the journey of a thousand miles begins with a single step,” he encourages.
| 17
Cover Story
The Journey Towards
Value-Based Care
18 |
THE VALUE SERIES PART 1 OF 3
T
Value-based care is our way of delivering the best possible outcomes at the most affordable cost. But what is value, how do we define what it means in health and healthcare, and how do we create more value for our patients and the community through the work we do? Can value be measured?
he concept of value-based care has become a topic of interest in recent years, given challenges such as our ageing population, rising public expectations, and increasing costs. In Singapore, the Ministry of Health (MOH) has included value-based care as one of its three strategic shifts. First announced in 2017, these shifts aim to transform healthcare in Singapore so that we can sustainably meet the longterm care needs of Singaporeans. The first shift, ‘Beyond Healthcare to Health’, aims to build a healthy population through lifestyle efforts and choices, as well as create healthsustaining communities. The goal is to reduce preventable illness and lifestyle diseases from happening in the first place. The second, ‘Beyond Hospital to Community’, looks at right-siting care so that people can receive appropriate care in the community or at home rather than only in hospitals. The approach includes more community-based care and services to help people stay well and avoid hospital admissions. ‘Beyond Quality to Value’ is the third shift. According to MOH, this refers to retaining or increasing the quality of care while ensuring value for money, using finite resources such as time and medical equipment more effectively to attain desired outcomes while driving productivity and efficiency in care processes. One way MOH has chosen to enable value at the national level is through the creation of the Agency for Care Effectiveness (ACE), which researches and recommends treatments and technologies that provide the best value for money. ACE will enable doctors to make more informed, cost-effective choices when offering treatments to patients.
| 19
Cover Story Move beyond Hospital to COMMUNITY To enable Singaporeans to receive appropriate care in the community and closer to home
To give every Singaporean best value, while keeping our system sustainable
THREE KEY SHIFTS TO BETTER HEALTH
Move beyond Healthcare to HEALTH To help and support Singaporeans to lead healthier lives
This three-pronged strategic shift in Singapore’s approach to health and healthcare delivery points towards a greater maturity of the system, says Dr Angeline Seah, Head and Senior Consultant, Geriatric Medicine, KTPH. “Where we previously looked at cost, quality of life years, and burning issues such as reducing bed crunch and polyclinic queues, we have reached a different stage,” she notes. In particular, the spotlight on providing value in our care takes a step back to consider the larger and longer-term perspective of value from the level of a national healthcare delivery system and, at the same time, taking into account the needs of individual and family.
20 |
A CLOSER LOOK AT ‘VALUE’ These shifts have led Yishun Health to look more deeply at what we can do as a health system to support these goals. For example, many steps have been taken to enhance our current service models, as well as roll out new community-based services and shared care partnerships in accordance with Yishun Health’s Unified Clinical Care Model concept. Chief Financial Officer Mr Roger Leong points out that value to Yishun Health is not just about allocating the amount of resources that is proportional for a given outcome — it is “about adding value through the work we do as
Move beyond Quality to VALUE
We add value by delivering the best possible outcomes for our patients at the most affordable cost, while also considering their physical, emotional, functional and social well-being. MR ROGER LEONG CHIEF FINANCIAL OFFICER YISHUN HEALTH a healthcare organisation”. This means delivering the best possible outcomes for our patients at the most affordable cost, while also considering their physical, emotional, functional and even social well-being.
THE VALUE SERIES PART 1 OF 3
Dr Ng Yeuk Fan, Head of Corporate Development, Yishun Health, has been working with clinical teams over the last two years to define just what these outcomes are. To him, ‘Beyond Quality to Value’ is a significant evolution. “It is a more sophisticated measure of what healthcare, health and healthy living really means,” he says. “For many years, healthcare institutions have been measuring success using outcome indicators such as workload numbers and door-to-needle time, but from the patient’s perspective, these are not true outcomes.” The majority of what we measure today are process or output measures. ‘Beyond Quality to Value’ is therefore a much more holistic look at measuring the outcomes that matter to the people
we serve, as well as measuring our cost to achieve those outcomes.
VALUE-BASED CARE, THE YISHUN HEALTH WAY In fact, the accepted definition of value is exactly that: outcomes that matter to people, divided by the cost of delivering it. “This understanding and definition of value sets the direction for value-based care in Yishun Health. It has the power to help us direct health system resources towards the attainment of outcomes that are important to people,” explains Dr Ng, who also heads the Yishun Health Value Office. In this value equation, outcomes are represented by four types of outcome metrics: clinical, functional,
experience and cost to patient. In the hospital, clinical outcomes have long been the mainstay for assessing quality of care. This looks at measurements such as mortality rate, complication rate, and the incidence of side effects. However, from the patients’ perspective, what they want is a safe and uneventful treatment, among other outcomes important to them. And this is where the other outcome metrics come in. Take functional outcomes, for example. If a patient, despite an uneventful hip replacement procedure, no longer takes his daily walks to the market because of pain, lack of physical stamina, or fear of falling, we need to ask if we have missed something important. “We may be able to measure excellent wound
Held since 2001, our latest Quality Convention took place in April. It aptly touched on adding value to quality, including how value can be added to a patient’s journey in the acute hospital, community hospital, and in the community
| 21
Cover Story underpins Yishun Health’s culture of value-based care
EMPATHY for our patients, their families, and our community OUTCOME Clinical Functional Experience Cost to patient
COST
How much does it cost us to deliver the above?
We need to understand what people want before, during and after their care, and provide appropriate care to reach that goal. DR NG YEUK FAN HEAD, CORPORATE DEVELOPMENT YISHUN HEALTH
22 |
healing and a good range of motion, but if the patient becomes reliant on a wheelchair permanently, have we truly restored function?” Dr Ng asks. Functional outcomes is therefore an important metric that is on par with — if not more important than — its clinical counterpart. It comprises measuring outcomes such as quality of life and the ability to perform the activities of everyday living. “It is about understanding what people want before, during and after their care, and providing appropriate care to reach that goal,” says Dr Ng. The third outcome metric in the value equation is experience. Is there a perception of benefit? Is there a perception of quality? Did the patient feel that his or her needs were met? Even better, were these expectations surpassed? As Roger observes: patients or residents can tell if healthcare providers make the effort to understand their needs and feelings. “If they can feel our empathy for them as people, as fellow human beings, our actions will invariably add value to their lives. This
will then ‘naturally’ show up when we measure outcomes,” he affirms. The last outcome is cost to patients. This can be direct costs, such as how much it costs the patient in financial terms. But cost to patients can also be indirect, such as waiting time and the number of days one is away from work.
THE EMPATHY FACTOR Measurements aside, one of the most important factors in enabling a culture of value-based care is empathy, adds Dr Ng. “This science is underpinned by empathy towards patients and caregivers, and also towards each other.” Yishun Health’s Chairman of the Medical Board, A/Prof Pek Wee Yang, sums up the research around empathy with this analogy: “You know the patient’s name, but do you know the name of his cat?” Citing a body of research, he points out that listening, empathy and genuine care towards patients, together with good medical care, have been shown to improve clinical outcomes. In fact,
THE VALUE SERIES PART 1 OF 3
high levels of empathy also reduce burnout in staff, enabling a positive reinforcing cycle where high levels of purpose and rapport with others strengthen care delivery teams as well as improve outcomes that really matter to patients. Dr Seah points out that acts of empathy such as listening and observing can help healthcare providers to understand the true needs of patients, especially when they are unable or unwilling to articulate these without assistance. “There are times we need to probe and create that tension by holding conversations to understand deepseated motivations,” she urges. She was involved in a focus study of about 30 patients aged around 60, who said they would decline dialysis if they ever needed it. “As doctors, we could not understand this initially,” she muses. Through interviews and home visits, it became clear that these patients felt that their life journey was complete since their children and grandchildren
THE MEASUREMENT OF VALUE
Can value be measured? The short answer is ‘yes’. “We are building organisational capabilities to quantify outcomes and costs systematically. This will enable us to eventually generate an ‘optimal care index’ for the organisation,” Dr Ng explains. While judicious measurement is important, the goal is not in the quantification of value in and of itself; rather, it is to provide our care teams with useful feedback in the form of outcomes that matter to patients and the costs it takes to attain them, so that every care team can continuously improve on the value they provide. were grown. The conferment of additional years with poor quality of life meant little to them. This insight into what the patients valued about their care helped the doctors to design treatment approaches around what was important to the former. This same empathy and understanding can make each interaction therapeutic and every treatment relevant.
want and value, while also being judicious with resources. But this cannot be done without patients bearing some responsibility, too. The same empathy and understanding can guide treatment in other ways. By building rapport and trust between doctors and patients, there is a safe space that allows patients to understand what medicine can and cannot do. This relationship can be used to affirm decisions, WE’RE IN THIS promote greater responsibility and participation in care, motivate TOGETHER Ultimately, the goal for valueaction and more — while also being based care is to design care that is respectful of a patient’s experience conscientious of what our patients and autonomy. There should be a shared sense of ownership in reaching the desired outcomes, notes Ms Shirley Heng, Chief Nurse, Yishun Health, where healthcare teams as well as patients are active and equally involved in care plans. “Value-based care may only be fully realised when we combine holistic measurement with the strong partnership of patients who feel empowered to be the main actors of Dr Ng Yeuk Fan and his Value Office team work closely with clinical teams to define outcomes that matter to our patients, thus setting the direction for value-based care in Yishun Health their care.”
| 23
Things About...
5 Things About
Acupuncture for pain Acupuncture, one aspect of traditional Chinese medicine (TCM), involves the stimulation of specific points in the body, typically with the use of needles. Increasingly, acupuncture is being used to complement the treatment of various ailments, including musculo-skeletal issues and pain management. Here’s why! In consultation with Ms Melissa Ong and Ms Amanda Chua, Acupuncturists, Sports Medicine Centre, KTPH & Admiralty Medical Centre
24 |
1
ACUPUNCTURE CAN BE USEFUL IN RESOLVING CHRONIC PAIN
The TCM perspective is about good flow and balance. Pain, be it acute or chronic, is due to weakened body defences and exposure to external pathogenic factors, such as cold and dampness. These cause stagnation in the flow of energy and blood in the body, resulting in pain. Pain can also be due to poor nourishment of tissues, bones and muscles.
2
THE TCM PRINCIPLES BEHIND ACUPUNCTURE VIEW CHRONIC PAIN DIFFERENTLY
themselves more refreshed, less tense, and are able to sleep better at night, allowing their body to repair itself during sleep.
In mainstream Western medicine, chronic pain is due to ongoing inflammation of joints and surrounding tissues, or to sensitising of pain, resulting in more pain with less provocation. All these send nerve signals to the brain. In TCM, diet, emotions, environment and lifestyle all play a role in a person’s well-being. An imbalance of these factors can result in slower recovery from pain.
4
3
ACUPUNCTURE HAS ITS PLACE AS A TREATMENT METHOD, PARTICULARLY IN PAIN MANAGEMENT TCM involves a wide variety of treatment methods, ranging from herbs and massages to needles and cupping. These may help to reduce pain and swelling, as well as improve circulation to affected areas. While the evidence from clinical trials and research has been mixed, some studies have shown that acupuncture has an effect on the nervous, endocrine, circulatory and immune systems. For instance, it can activate parts of the cortex, modulate endorphin levels, and improve blood circulation. Evidence has also shown that acupuncture complements existing therapies, such as physiotherapy and medication, well. For a portion of patients, acupuncture also helps with relaxation. They find
ACUPUNCTURE IS INCREASINGLY BEING ACCEPTED BY PUBLIC HOSPITALS More and more clinicians have observed the positive impact that acupuncture brings to their patients. This awareness has driven a higher level of acceptance as clinicians seek more options for patients. There is also increasing global research into alternative methods, including acupuncture, that has put the mechanism and efficacy of acupuncture in a manner understood by doctors.
5
YISHUN HEALTH’S ACUPUNCTURISTS WORK CLOSELY WITH VARIOUS CLINICAL SPECIALTIES, INCLUDING THE SPORTS MEDICINE CENTRE TCM physicians trained in acupuncture are governed by a regulatory board in Singapore, which ensures all practising physicians maintain a certain professional and ethical standard. Yishun Health has two TCM physicians who, apart from seeing patients for various ailments, work with sports physicians and sports physiotherapists to treat pain as part of a holistic treatment programme that includes an accurate tissue and functional diagnosis.
| 25
ive Well
Blossoming through adversity Although diabetes complications led to the loss of his lower leg, Mr Tony Ng strives to rebound from the loss with a new commitment to his health. Beyond getting fit and eating better, he channels his energy and creativity into giving back through colourful works of craft.
W
ith a slight sheen of sweat on his brow and a look of concentration on his face, Mr Ng finishes the last few repetitions on the lats pull-down machine. He then moves on to the next series of exercises. As with most exercises, his workouts are aimed at overall conditioning and improving his cardiovascular fitness. But unlike regular gym-goers, Mr Ng does his twice-weekly sessions at Admiralty Medical Centre (AdMC) under the watchful supervision of his physiotherapist. These exercises also have another important goal apart from weight management and general fitness — to help him get fit enough for a prosthesis.
26 |
Just a few months ago, the 52-year-old had to have part of his lower right leg amputated due to a diabetes-related infection. A chronic non-healing wound had been bothering him since July 2018 and, by October, two toes had to be removed. All this was the culmination of years of neglect, Mr Ng admits. Diagnosed at 28, he never paid much attention to diet or lifestyle modifications. In fact, he used to guzzle sugary soft drinks daily and “had not exercised for 13 years”. His long hours as an electronic appliance salesperson meant long hours and irregular meal times. When he did eat, he would do so to the point of throwing up. Part of this was due to the stress of being the sole
breadwinner, he explains. His wife, who is handicapped due to polio, is a stay-at-home mum. The pressure of providing for her and his daughter led to bouts of binge eating. Over the years, these habits took a toll on his health. For quite a while, he put off his surgery for the sake of his daughter, as he did not want to undergo an invasive procedure that may adversely affect her studies. It was only in October 2018 — after his daughter had graduated from her nursing studies — that he went ahead with the amputation.
REDEMPTION AND RENEWAL These challenges with his health sparked a mindset change in Mr Ng. Over the last 10 months, he has made a slew of changes to improve his lifestyle and activity. Regular exercise has been a large part of this. Since July 2018, he has been hitting the gym at AdMC regularly, partly to prepare himself for surgery and partly to get fit. When he’s not working out at the gym, he does home-based workouts using dumbbells and resistance bands. Since then, he has lost about 7kg. “I will get my six-pack soon!” he jokes. His whole family has also made a stronger commitment to eating better. Apart from swapping to brown from white rice, they also pay attention to portion control. “I now eat just one bowl of rice,” he says cupping his hand to illustrate. Dishes, too, are lighter: steamed, boiled, or fried with less oil. “We eat more vegetable and fruit,” he adds. His daughter even replaced their random collection of plates and bowls with a new matching set that are smaller in size. These changes are making a positive impact. “When I control my portions and eat better, I feel that my wound heals faster,” Mr Ng enthuses. The regular exercise sessions have also given him more energy.
A COLOURFUL WAY TO HEAL These physical and lifestyle changes have been coupled with enhancing his emotional health. During his three-week hospital stay in KTPH,
time to spare, he spends his days taking care of himself and giving back to the community. For instance, he recently signed up for magic and balloon art lessons at his neighbourhood community centre. Every Friday, he volunteers at St Luke’s Community Hospital, making balloon animals for patients. “I have been given so much, I wanted to give back,” he explains simply.
HIS OWN CHEERLEADING SQUAD Mr Ng working out under the supervision of senior physiotherapist Jazimin Haron
Mr Ng kept his mind on more positive things, channelling his energy into the art of origami. “I have always liked handicraft. While I was in the hospital, it helped to keep my hands busy and my mind focused on other things,” he shares. In fact, apart from origami, he has taken up a range of other crafts, including knitting and making festive decorations. After being transferred to St Luke’s Community Hospital for his rehabilitation and recuperation, Mr Ng continued working on his various crafts, transforming his bed area and the entrance to the ward with Christmas trees, wreaths, multicoloured roses, and other floral and festive décor. “Once I start crafting, I can forget about all my worries and concerns,” he affirms. Now that he is back home, Mr Ng is continuing with his crafts, sometimes gifting his handiwork to nurses as a gesture of thanks. These days, as he is unemployed and has
He credits the Yishun Health team for rallying around him all these years. A patient since the Alexandra Hospital days, Mr Ng has developed a close relationship with his healthcare team, who have journeyed with him for some 13 years. Apart from his physiotherapy sessions, Mr Ng also sees his doctor, podiatrist and other members of his diabetes management team at AdMC. “It is very convenient for me to come here as it is close to the MRT station,” says the Bukit Batok resident, who travels independently on his motorised wheelchair. It was his medical social worker who helped him to apply for funding for the device, which has made a big difference in enabling his mobility. Beyond this, the team also ensures Mr Ng is well settled back home. For example, to assess the home for fall risks and improve safety and accessibility for both himself and his wife, an occupational therapist visited the home to make recommendations. He greatly appreciates all the support that he has received from his healthcare team. “I feel they are my friends cheering me on!”
| 27
akan Time
Turn to
page 30 TO LEARN MORE ABOUT WHOLEGRAINS!
28 |
Wholegrain uttapam
cut & keep
This savoury, fluffy pancake is a light and healthy South Indian breakfast that can be customised with your favourite vegetables and other toppings. Recipe contributed by Chef Ali Saikh Arsed, Food Services, KTPH, in consultation with Nutrition and Dietetics, KTPH
INGREDIENTS Serves 7 (14 pieces) • • • • • • • • •
250g brown rice powder 150g atta flour 5g salt 1.1L water 15ml soyabean oil 100g oats 100g onion, chopped 100g tomato, chopped 50g coriander leaf, chopped
METHOD 1. In a large bowl, combine the brown rice flour, atta flour, salt and water. Mix the batter well. 2. Drizzle a little oil onto a frying pan. When the oil is hot, pour in about a tablespoon of batter. 3. Sprinkle the batter with some of the chopped onion, tomato and coriander leaves. Top with some oats and gently press the fillings into the batter. 4. Cook the batter for about 2 to 3 minutes until the bottom of the uttapam is a light golden brown. 5. Flip the uttapam gently and cook for 1 more minute or until it is completely cooked. 6. Repeat steps 2 to 5 for the rest of the remaining ingredients.
NUTRITIONAL INFORMATION (1 SERVING) Energy
269kcal
Carbohydrates
48g
Protein
7g
Fat
5g
. Saturated
1g
. Polyunsaturated
2g
. Monounsaturated
1g
Cholesterol
0mg
Fibre
6g
Sodium
272mg
| 29
aily Dose
A Whole Lot of Good
We know wholegrains are better for us. But do you know why exactly? Apart from fibre, wholegrains pack a lot more nutrition than their refined versions.
Bran
Endosperm Germ Husk
In consultation with Ms Magan Ho, Dietitian, Nutrition & Dietietics, KTPH
M
ade up of parts such as the husk, bran, endosperm and germ, wholegrains are packed with nutrients. The bran and germ alone comprise about 25% of a grain’s protein and contain many key minerals and vitamins. Wholegrains contain fibre, B vitamins (thiamine, riboflavin, niacin and folate), vitamin E and phytic acid, as well as minerals such as iron, magnesium and selenium. These nutrients aid in maintaining the integrity of blood vessels, slowing down digestion, regulating insulin, and supporting a healthy gut.
EAT YOUR SHARE The Health Promotion Board recommends two to three servings per day, with each serving around 50g. Look out for the ‘Higher in WholeGrains’ Healthier Choice Symbol when grocery shopping. If you have been eating refined grains for a long time, you may need time to get use to the texture of wholegrains. In this case, start by adding half portion of wholegrains to your meals. For example, you could replace half the amount of white rice with brown/red/black rice, or swap
A VARIETY OF CHOICES Wholegrains consist of cereals, minor cereals and pseudocereals. • Cereals These include wheat, rice and corn
• Minor Cereals These include oat, barley and millet
• Pseudocereals These include quinoa and buckwheat 30 |
a slice of white bread for a slice of wholegrain/multigrain bread when making a sandwich.
WHOLEGRAINS AND FOOD SENSITIVITIES & INTOLERANCES Certain wholegrains can be consumed by people with food sensitivities and intolerances. Those with coeliac disease should avoid wholegrains that contain gluten, a type of plant protein, as it can cause gut inflammation. Wheat, barley, rye and spelt contain gluten, while rice, quinoa, millet, oats, buckwheat and corn are gluten-free. People with irritable bowel syndrome (IBS) should avoid wholegrains that have FODMAP: Fermentable Oligo-, Di-, Monosaccharides And Polyols. These short-chain carbohydrates are poorly absorbed by the small intestine. A low-FODMAP diet can alleviate IBS symptoms. FODMAPfree wholegrains include oats, quinoa, brown rice, wholemeal bread, buckwheat, corn and millet.
ind & Health
SPOT me
For each nutritious and healthy food item listed at the bottom, find and circle it in the picture below:
| 31
