title: Integrating rheumatology care in the community: can shared care work?
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.
authors: Anita Yn
authors: AY
authors: Lim
authors: Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
authors: Chuen Seng
authors: CS
authors: Tan
authors: Care Integration and Alliances, National University Health System, Singapore.
authors: Bernadette Pl
authors: BP
authors: Low
authors: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.
authors: Tang Ching
authors: TC
authors: Lau
authors: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors: Tze Lee
authors: TL
authors: Tan
authors: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors: Lee Gan
authors: LG
authors: Goh
authors: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.
authors: Gim Gee
authors: GG
authors: Teng
keywords: Singapore; family physician; financing; integrated care; musculoskeletal diseases; rheumatology