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.