SINGAPORE — National University Heart Centre, Singapore (NUHCS)’s Shared Care Programme is transforming the way stable heart patients receive long-term care by enabling them to receive routine follow-up closer to home while remaining under the care of their specialist cardiologist at NUHCS.
Launched in July 2024, the programme brought together NUHCS specialists and primary care physicians from polyclinics and general practitioner (GP) clinics to co-manage suitable patients with stable but complex cardiac conditions, allowing them to receive accessible, community-based care without losing access to specialist expertise.
Under the programme, suitable patients are identified by their specialist at NUHCS based on established clinical criteria, including having stable heart conditions, well-controlled risk factors and no recent hospital admissions for cardiac disease. Once enrolled, patients receive regular follow-up from their preferred primary care physician, who works closely with the specialist team and has access to relevant clinical information from NUHCS. The primary care physician monitors the patient's cardiovascular health, optimises medications and manages cardiovascular risk factors according to agreed care protocols. At the same time, patients remain under the oversight of their NUHCS specialist and continue to attend annual specialist reviews, ensuring continuity of care across both settings.
Importantly, patients are not discharged from NUHCS during this period. If their condition changes or concerns arise, they can be promptly referred back for specialist assessment without needing to restart the referral process, ensuring continuity and timely access to care.
Since its launch, more than 380 stable cardiac patients have been enrolled in the programme. A comparison of patients' clinical indicators one year before and one year after enrolment found that cardiovascular risk factors remained stable or improved under the shared care model. Average systolic blood pressure was maintained at 132 mmHg, while average blood sugar control remained stable, with HbA1c levels at 6.5 per cent before enrolment and 6.6 per cent after enrolment. Average cholesterol levels improved from 2.21 mmol/L to 1.59 mmol/L over the same period.
Patients also benefited from approximately 18 per cent lower care costs through reduced consultation fees at community-based primary care settings.
Adjunct Associate Professor Lim Toon Wei, Head of Community and Preventive Cardiology, NUHCS and clinical lead of the Shared Care Programme said, "Based on the programme's performance to date, our findings suggest that carefully selected patients can receive routine follow-up in the community without compromising clinical outcomes, while benefiting from greater convenience and affordability. As Singapore's population ages and the prevalence of chronic cardiovascular diseases continues to rise, shared care enables specialists and primary care physicians to work more closely together in supporting patients across different care settings, while ensuring specialist services remain available for those with more complex or urgent needs." Adj A/Prof Lim is also a Senior Consultant at the Department of Cardiology at NUHCS.
NUHCS has expanded the Shared Care Programme to their patients at the NUHCS Heart Clinic at Ng Teng Fong General Hospital, and will continue to review opportunities to further strengthen the model based on patients' needs and programme outcomes.
The programme's emphasis on bringing care closer to patients aligns with NUHCS’ wider efforts to strengthen heart health within the community. As part of World Heart Month, NUHCS hosted a community event on 6 September at Jurong Medical Centre, offering health screenings, heart health talks, physiotherapist-led exercise sessions and other activities aimed at helping the community better understand and manage their cardiovascular risk.
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