Annual Review Clinic: A Chronic Disease management model of care for schizophrenia and delusional disorder in Singapore
- Author:
Jimmy Lee
;
Catherine Seow
;
Seok-Siew Wong
;
Arumugum Govindasamy
;
Esther Quek
;
Adeline Phang
;
Alex Su
;
Hong-Choon Chua
- Publication Type:Other types
- From:ASEAN Journal of Psychiatry
2013;14(1):1-5
- CountryMalaysia
- Language:English
-
Abstract:
Schizophrenia and delusional disorders are recognised as chronic mental
conditions. During this time, the clinical course may fluctuate and co-morbidities
may set in. Individuals with these conditions often lack insight and have high rates
of default. We report the need to develop a chronic disease model of care to cater to
this unique group of individuals in Singapore. Methods: The Ministry of Health in
Singapore recently funded the Institute of Mental Health to develop a model of
psychiatric care for individuals with schizophrenia and delusional disorders. Crucial
to the success was the development of an information technology (IT) enabled
platform to track and monitor the clinical status of this group of individuals. On a
yearly interval, patients undergo a comprehensive review and needs analysis of their
psychiatric and medical needs in the Annual Review Clinic (ARC). Clinical ratings
and metabolic parameters of every patient were obtained, and every patient was
assigned a case-tracker or case manager to monitor their engagement with the
relevant services. Results: In the first year of operations, ARC reviewed 1525
patients with schizophrenia and delusional disorders. The median GAS score for the
cohort seen was 75 (slight impairment in functioning). The median CGI-S score was
2 (borderline mentally ill). 48.5% of reviewed patients were classified as overweight
and above with BMI ≥ 25. After the needs analysis, 100 patients received referrals to
primary healthcare services for medical conditions that were recently diagnosed or
for which they have defaulted medical treatment. Conclusions: In the first year of
this program, a snapshot of the clinical status of the outpatient population was
obtained and we also identified a high prevalence of obesity among the patients.
Through this program, we can continuously monitor the health status of every
patient and monitor for developing trends so as to plan the necessary interventions.
