Health Plan

Healthier SG aims to improve and maintain enrollees' health, through regular Health Planning with their chosen family doctor. This means regular, scheduled Health Plan 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 the achievement of their health goals, with support from their GP and 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:

Enrollees to better understand their overall state of health;
GPs to assess and ensure that care delivered for disease prevention and chronic condition management is timely and appropriate; and
GPs and enrollees to discuss and make shared decisions on health and lifestyle goals.

Upon enrolment, GPs should initiate a discussion with enrollee to develop the Health Plan. Details of the Health Plan will flow automatically into the enrollees' HealthHub for GPs who are using Healthier SG-compatible Clinic Management Systems (CMSes). Enrollees will also be able to show their Health Plan (via HealthHub) on their phone to other partners, e.g. Active Ageing Centres (AACs), to sync up on their health needs.

Relevant data from the digital version of the Health Plan as submitted by the GP will be shared with the Clusters over time, enabling them to support enrollees with more local and relevant activities and support.

Requirements for Health Plan Fulfilment by Healthier SG GPs

First Health Plan consultation

The Health Plan is an important document to facilitate health planning conversations between enrollees and the doctor at their enrolled HSG clinic. A resident's first Health Plan must be co-created in-person with a doctor at his/her enrolled Healthier SG clinic. The objective of requiring the first Health Plan to be conducted by a doctor at the resident's enrolled clinic are to:

i. Enable doctors to assess and/or monitor their enrollees' health status;

ii. Enable discussions and shared decision-making on actionable goals between residents and their doctor; and

iii. Establish the doctor-enrollee relationship and support the anchoring of care at the resident's enrolled clinic

Subsequent annual Health Plan check-in

GPs should have regular, scheduled check-ins to assess their enrollee's overall health condition and progress towards health goals. The annual Health Plan check-in can be done opportunistically during an acute or chronic visit. Otherwise, GPs should contact their enrollees to schedule an annual Health Plan check-in.

At each check-in, GPs should discuss their enrollee's progress in their health goals and assess if the goals need to be adjusted, or if additional intervention is required. The annual Health Plan check-in must be conducted by a doctor as it is a medical review and re-assessment of the enrollees' health goals from the last submitted Health Plan. One annual Health Plan check-in is required per calendar year.

i. For well enrollees, defined as enrollees with no Chronic Disease Management Programme (CDMP) conditions, the subsequent Health Plan check-ins can be done via tele-consult (phone or video consult) or in-person by the clinic doctor. One in-person check-in is required once every 3 years as long as the enrollee remains a well enrollee.

ii. For chronic enrollees, defined as enrollees with at least 1 CDMP condition, the Health Plan check-in can be conducted together with chronic visits. There must be at least 2 chronic visits annually with ≥ 1 conducted in-person by a doctor*. Dates of chronic consultation should be minimally 3 months apart. The Health Plan can be updated during the chronic visits.

*Part of requirement to receive ASF Fixed Payment for chronic enrollees.

While the annual Health Plan check-in must be conducted by a doctor from the resident's enrolled Healthier SG clinic, GPs are encouraged to tap on their Primary Care Network (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.

Data Submission Requirements for Health Plan and Healthier SG Care Report

A key aspect of the Health Plan is goal-setting with an enrollee to encourage ownership and action by the enrollee. To facilitate the process, a template of shared goals that will be iterated over time can be found in GPs' Healthier SG-compatible CMS . Upon GPs' submission of health goals, the goals will be reflected in the enrollees' HealthHub automatically . The list of goals will be reviewed and adjusted as Healthier SG includes other conditions over time and in consideration of enrollee 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 HealthHub.

The first Health Plan (for new enrollees) or the updated Health Plan during annual check-ins should be submitted through the Health Plan module in GPs' Healthier SG-compatible CMS. Apart from that, GPs are required to submit other health indicators through their enrollees' Healthier SG Care Report.

The HSG Care Report facilitates care continuity between providers, enables verification of care components completed for processing the Annual Service Fee (ASF) and Chronic Enrolment Grant (CEG), and tracking of patients' clinical outcomes to enable quality improvement work. Clinics should submit the care-reporting data of their enrollees through their HSG-compatible Clinic Management Systems (CMSes) promptly. Data fields to be submitted for the respective CPs and tied to ASF are marked with asterisk (*) in the Care Protocols on Primary Care Pages. The frequency and appropriateness of the care components should be performed in accordance with the respective Care Protocols, depending on enrollees' condition(s).

What are the key elements to cover in a Health Plan visit?

Health 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 their Healthier SG-compatible 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	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 enrollee 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/Active Ageing Centres, community programmes (e.g. HPB, SportSG, People's Association, etc); and to Specialist Outpatient Clinics/Emergency Departments This segment could be used to auto-trigger referrals to clusters over time
Health goals, activities, and follow-ups	Discuss and encourage enrollees to set health goals and plan activities relating to healthy lifestyles and chronic disease management . More information about suitable lifestyle activities can be found here. Goals should be specific, measurable, attainable, relevant, and time-based (SMART) Specify date (month/year) for the next Health Plan check-in

How soon do GPs need to complete the Health Plan for their enrollees?

It is recommended that an enrollee'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 a patient. For new patients who enrolled to the clinic via Healthhub, GPs should reach out to schedule appointments with them. GPs can also conduct Health Plan discussions opportunistically when the patient next visits the GP.

Do GPs still need to submit a Health Plan if an enrollee switched from another clinic to their clinic and already completed the Healthier SG Health Plan with the previous GP?

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

Reimbursement for the first Health Plan discussion is not applicable to enrollees who have already had their first Healthier SG discussion with a previous GP. The annual 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).

How can Active Ageing Centres (AACs) support enrollees with the goals and activities listed within the Health Plan?

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 “2Ss": Social Connector for social and lifestyle interventions, and Community Screening. The 2Ss support seniors who need further assistance following through with their Health Plan. As Social Connectors, AACs will assist seniors in registering for active ageing programmes as needed to achieve their social and lifestyle goals in their Health Plan. AACs will also serve as nodes for Community Screening. Specifically, they will assist seniors in monitoring and recording their vital signs as prescribed in their Health Plan.

Enrollees can find a recommended AAC and more information on AACs here. For seniors that need further assistance with finding an AAC, GPs can put up a referral to an AAC through their respective PCN headquarters and request to be updated when their enrollee is contacted by an AAC.

Financing

GPs will be paid a fixed fee upon completion and submission of the first Health Plan discussion. 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. However, if the enrollee seeks other treatment during the same visit, the clinic should inform the patient of the charges upfront and may charge the patient at the clinic's prevailing rates.

Annual Health Plan check-ins should not be charged as GPs will be remunerated with the ASF fixed payment. Should there be other services rendered during the Health Plan discussion or check-ins, HSG GPs are still allowed to charge for these separately, so long as the enrollee is made aware of these charges.

More details can be found in the Healthier SG Enrolment Programme Agreement and in the list of Healthier SG Frequently Asked Questions.