Continuing Chronic Disease Care During COVID-19 and Beyond.

Patients with chronic diseases incur indirect costs to health care through recurrent hospital admissions, generate congestion in emergency rooms, and present challenges with transportation for those with mobility impairment. In Singapore, the proportion of older adults with 3 or more chronic diseases nearly doubled from 2009 to 2017. In our local setting, patients with complex chronic diseases maintain scheduled in-person consultations with hospital-based specialists. The COVID-19 pandemic has prompted us to explore innovative ways of continuing outpatient care.

We have introduced the following outpatient-based measures to cope with the COVID-19 surge: (1) preemptive chart reviews and triaging of patients ahead of their appointments to determine the urgency of upcoming reviews; (2) postponing nonurgent follow-up visits while conducting phone, e-mail, or video consultations for selected patients; (3) limiting the number of accompanying acquaintances for patients attending clinics to reduce human traffic; (4) reconciling routine investigations common among different specialty clinics to be done at the same sitting; and (5) arranging for patients whose primary physicians are deployed to attend to patients with COVID-19 infections to be seen by other physicians. The implementation of these changes has led us to evaluate the utility and limitations of our current clinic structure.

We examine the current checkpoints for a patient during a typical clinic visit in our centers, which have become chokepoints due to the increasing complexity of interim care processes. These checkpoints include (1) triage point for routine parameters; (2) venipuncture room for completion of laboratory investigations; (3) waiting area for patients before in-person consultations; and (4) waiting areas at pharmacies. We see the redundancy of the triage point as it provides an inaccurate 1-time snapshot of a patient's clinical parameters that can also be confounded by a white-coat effect. Telemonitoring of these parameters between in-person consultations, coupled with graded and progressive medical interventions, would be more accurate and reflective of chronic care, as opposed to 1-time intervention based on snapshot parameters. To avoid overcrowding of patients in the venipuncture room, we could reorganize the phlebotomy service and completion of laboratory investigations at various primary care or community-based medical facilities that are within the vicinity of patients' residential areas. Such an arrangement would be especially convenient for frail older patients with mobility impairment.

Our vision of a chronic disease clinic of the future is that of virtual consultations interspersed with ad hoc in-person consultations when necessary. Telemedicine helps facilitate remote patient contact with the health care team and has previously been shown to reduce mortality and hospitalizations and lead to an improvement in the quality of life when applied to the management of chronic diseases. , Telemonitoring of relevant clinical parameters, together with protocolized investigations, can be consolidated into a virtual monitoring system supported in real-time by a multidisciplinary team, in regular communication with the patient's primary physician. Interventions, including lifestyle modifications, dietary counseling, and medication compliance, can be effected based on these parameters between in-person consultations. In our pandemic experience, processes that were conventionally performed in-person, such as counseling patients on their disease trajectories, personalized advice on preventing disease progression, discussions about advance care planning, and renal replacement therapy, could be effectively done over an extended phone discussion or via videoconferencing. Patient satisfaction is derived from the reduction in travel time and transportation costs, which, in turn, might be spent on that of telehealth and home delivery of medications. The digital literacy of our patients is also crucial in determining the success of a telemedicine-based outpatient framework. Locally, a national survey by the Infocomm Development Authority of Singapore showed that the computer usage rate among senior citizens aged 50 to 59 and 60 and older rose to 63% and 27%, respectively, in 2014: an increase of 14 and 11 percentage points from 2012, respectively.

COVID-19 has prompted us to review the utility and limitations of the conventional clinic structure, led us to implement measures to enable continuity of our clinics, and inspired us to envision a novel clinic structure built on virtual consultation and remote monitoring (Table 1 ). This pandemic has ironically integrated care by bringing together a patient's multiple health care providers in closer communication with one another. Although the pandemic has disrupted much of our medical services, it has prompted us to implement changes to our health care system, which will hopefully remain relevant beyond COVID-19.

Table 1

Outpatient-based Strategies During COVID-19 and the Vision Beyond

Outpatient Clinic Framework and Measures
Conventional (Before COVID-19)	Scheduled, regularly timed clinic visits consisting of in-person consultations by patients' primary physicians.Mandatory checkpoints at each clinic visit:(i) Triage point (ii) Venipuncture room:• Designated area where laboratory investigations in preparation for the planned clinic session are completed. (iii) Designated waiting area for patients before consultation (iv) Hospital-based pharmacies where patients collect their medications following every clinic visit.
Current (During COVID-19)	(i) For every scheduled clinic review, the physician will determine the suitability of 1 of the following 3 options:1. Deferment of the in-person consultation to a later date. 2. Conduct a phone consultation or video consultation in place of an in-person consultation. 3. If a patient requires an in-person consultation that cannot be postponed to a later date:a. Arrange for cover by another physician if the patient's primary physician is deployed to attend to patients with COVID-19 infections. Phone or video consultations:• Ideal for patients who are currently able to do home-based blood pressure monitoring, weight trending, and glycemia monitoring. • Enables continuity of care by physicians deployed to attend to patients with COVID-19 infections. (ii) Specialists may work together to arrange for completion of laboratory investigations at the same sitting, or reconcile routine tests to be done at regular intervals to avoid repetition. (iii) Promote the use of home delivery of medications to avoid patients having to congregate at pharmacy waiting areas. (iv) Limit the number of accompanying acquaintances for patients attending clinics.
Beyond COVID-19	(i) Implementation of home-based telemonitoring capabilities for all patients with chronic diseases who require them.• Removes the need for a triage point in the clinic (ii) Develop a multidisciplinary team (nurse practitioner, allied health professional) to• Monitor clinical parameters between clinic visits • Highlight any strikingly abnormal trends in clinical parameters to relevant physician(s) to effect interventions between clinic visits. (iii) Spread out the phlebotomy service and completion of laboratory investigations to more locations, including community-based medical facilities. (iv) Design an individualized outpatient schedule that combines teleconsultations with in-person consultations, coordinated between specialties and primary care providers.

For every scheduled clinic review, the physician will determine the suitability of 1 of the following 3 options:

If a patient requires an in-person consultation that cannot be postponed to a later date: