Primary Care Based Integrated Community Care Team Intervention (PACE-It)

This is an interventional treatment trial for Diabetes Read More

Inclusion Criteria:

• Living within the designated geographical zone
• 50 years and above

• Satisfy the Medical Criteria below:

  1. Diabetes with HbA1c ≥ 9% (within past 6 months), and

  2. At least 1 complication

     1. chronic kidney impairment stage 3 and above, or diabetes overt nephropathy,
     2. ischaemic heart disease, or congestive cardiac failure,
     3. peripheral arterial disease, or diabetes foot/ diabetes foot-related complications,
     4. diabetic retinopathy/ treatment for retinopathy, and
     5. stroke, or transient ischaemic attack

• Satisfy at least 2 conditions in the psycho-social, functional or activation domain of which 1 criteria must be from the psycho-social domain:

  1. Psycho-social issues

     a. Lack of care giver support i. No care-giver (when indicated) ii. Care-giver skills gap/ stress iii. Inability of copy when patient is the care-giver b. Difficult relationships (family/ workplace/ social network) c. Social isolation/ lack of social connectivity i. Lives alone ii. Lack of social network support d. Financial i. Financial difficulty/ insecurity ii. Housing/ shelter issues iii. Poor money management

  2. Functional

     1. Clinical Frailty Score ≥ 4, requiring help in instrumental activities of daily living (iADL)
     2. Requires assistance in ADL or iADL
  3. Activation a. Lack of ability to manage health - disengaged or overwhelmed i. Anxiety or disease-related distress ii. Confusion or lack of understanding of care plans iii. Non-adherence to medications/ follow up
• Patient gives consent to participate
• For patients who may be seeing a Primary Care Physician (PCP) outside of the polyclinic for chronic disease management and where the PCP has indicated consent to co-manage the patient with the PACE-It team including the polyclinic physician
• Patient must be willing to receive care in the polyclinic

Exclusion Criteria:

• Patients who are on follow up with Primary Care Physicians or General Practitioners elsewhere for management of their chronic conditions and they do not consent to co-managing patient with the PACE-It team
• Patients who have severe cognitive impairment, depression or psychiatric conditions that interfere with the ability to engage with the healthcare team
• Patients who are (i) not community ambulant or (ii) bed bound
• Patients with terminal illness
• Patients who have are in other programs or research studies
• Patients who do not give consent