Integrating rheumatology care in the community: can shared care work?

Introduction:  Singapore's rapidly ageing population and chronic disease burden at public hospital specialist clinics herald a silver tsunami. In Singapore, “right siting” aims to manage stable chronic disease in primary care at a lower cost. To improve the quality of rheumatology care, we created shared care between rheumatologist and family physician to reduce hospital visits. Methods:  Clinical practice improvement methodology was used to structure shared care of stable patients between hospital rheumatologists and eleven community family physicians; one ran a hospital clinic. A case manager coordinated the workflow. Results:  About 220 patients entered shared care over 29 months. Patients without hospital subsidies (private patients) and private family physicians independently predicted successful shared care, defined as one cycle of alternating care. Discussion:  Our shared care model incorporated a case manager, systematic workflows, patient selection criteria, willing family physician partners and rheumatologists in the absence of organizational integration. Health care affordability impacts successful shared care. Government subsidy hindered right siting to private primary care. Conclusions:  Financing systems in Singapore, at health policy level, must allow transfer of hospital subsidies to primary care, both private and public, to make it more affordable than hospital care. Structural integration will create a seamless continuum between hospital and primary care.