First, the patient consults a Class PCN GP for his or her chronic condition(s).
The Class PCN GP assesses and diagnoses the patient’s condition and
registers patient on Class PCN’s Chronic Disease Registry (CDR) if
applicable. Patient will be referred to see a nurse counsellor and the
relevant ancillary services (such as diabetic foot or eye screenings) if
required.
The care coordinator at Class PCN-HQ level will then work with the respective clinic assistant to schedule the patient for the ancillary service(s) appointment. Upon completion of the ancillary service(s), the doctor will review the test results and follow up with the patient.
The patient’s progress and clinical outcomes will be tracked and monitored under Class PCN CDR to ensure that they follow through with their personalised care plans and treatment. The overall aim is to help patients better manage their chronic conditions and improve their health outcomes.