Background: A novel Teamlet care model was introduced in 2014 within Singapore polyclinics to improve care continuity and comprehensiveness for chronic disease patients. Patients were enrolled in smaller teams comprising two family physicians, one nurse, and one care coordinator for coordinated team-based care. This study assessed five-year outcomes focusing on clinical parameters, care adherence, healthcare utilization, and economic impact.

Methods: A retrospective matched cohort study examined patients with diabetes, hypertension, or hyperlipidemia enrolled in the Teamlet program from 2014-2016. Outcomes were compared to matched controls receiving usual care over six years. Data from Singapore's Ministry of Health databases were analyzed using difference-in-differences analysis, controlling for individual and cohort-time fixed effects. Missing values were imputed using K-Nearest Neighbours method.

Results: The Teamlet model achieved modest clinical improvements: glycated hemoglobin A1c (HbA1c) reduced by 0.1%, systolic blood pressure by 1 mmHg, and low-density lipoprotein (LDL) cholesterol by 0.04 mmol/L. However, diabetes screening adherence improved with 16% higher foot screening and 6% higher eye screening rates compared to controls. Healthcare utilization shifted toward primary care with decreased inpatient hospitalizations (saving SGD$2,432 over six years), reduced specialist outpatient visits (SGD$129 savings), and fewer emergency department visits (SGD$49 savings), and increased polyclinic utilization cost (SGD$479) over six years. Overall cost savings totalled SGD$2,160 per patient over six years.

Conclusion: Restructuring polyclinic workforces into smaller collaborative teams improved care processes and reduced high-cost healthcare utilization. These findings suggest that scaling team-based care models in high-volume primary care settings may improve overall healthcare system efficiency and costs.