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Background: In Singapore where patients choose and pay for their preferred primary care doctor, chronic disease care centres itself in tertiary specialist clinics. Transition of such stabilized patients back into the community is often fragmented. Methodology: We describe a model where right-siting officers (RSOs) sited at tertiary clinics facilitate personalized patient management through matching primary care providers, providing social care advisory, coordinating clinical information transfer and tracking clinical outcomes during the intermediate period of transition to general practitioners (GPs). Such support by RSOs ensures continuity, good clinical outcomes and improved patient satisfaction. Clinical outcomes and patient satisfaction of 382 stable ischaemic heart disease patients right-sited from a tertiary cardiology clinic was analysed for 1 year. Results: Regular follow-up by RSOs ensured that mean BP, LDL- and HDL-cholesterol of patients managed by GPs remained clinically stable. Majority (92.7%) of the patients reported satisfied with their management and remained with the GPs for continue care. Conclusions: Coordinated care services and outcome tracking ensures quality of patient care during transition from tertiary clinic to GPs. Future coordination of social provisions such as home visits and day care services can truly promote care integration in the community. Such emphasis on social support by RSOs will complement the clinical management by GPs. Our model suggests that personalised care coordination benefits all patients transiting back into the community from tertiary outpatient settings.

A model of right-siting to facilitate seamless care transition from tertiary cardiology clinic to general practitioners