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Featuring the Trans-Disciplinary Diabetes Care Team

Updated: Aug 5, 2022

Have you ever wondered what can pharmacists do other than dispensing medications? What roles we might play amongst other healthcare professionals? For Pharmacy Week 2022, we will be featuring 3 multidisciplinary projects involving pharmacists that serves to empower our patients!

In this week's post, we are thrilled to introduce the Trans-Disciplinary Diabetes Care Team from Tan Tock Seng Hospital (TTSH) where different healthcare disciplines, including Pharmacy, work together to improve the health literacy of patients with diabetes.

Trans-Disciplinary Diabetes Care Team

1 in 3 Singaporeans risk getting diabetes mellitus (DM) in their lifetime. In line with the Pharmacy Week 2022 theme, "Empowering a Healthier You", a team of Clinical Diabetes Educators (CDE) and Enhanced Allied Health professionals in Tan Tock Seng Hospital (TTSH) has joined the nationwide effort to fight diabetes. In TTSH, the Trans-Disciplinary diabetes team consists of Pharmacists, Diabetic Nurse Clinicians, Dietitians, Medical Social Workers and Podiatrists. Together with Endocrinologists, they work to improve health literacy among patients with diabetes.

"The Trans-Disciplinary diabetes care model is supported by the Centre for Allied Health and Pharmacy Excellence (CAPE) in TTSH, in the form of a grant, to manage expenses related to patient educational materials such as DM consumables, food models, footwear and foot care products."

Let us hear interesting thoughts from the CDE team!

"Leading the CDE Pharmacists in our transdisciplinary diabetes care team has been a rewarding journey as we teach and learn from our inter-professional practitioners. Our CDEs are now empowered with the skills and competencies to improve patient experience while providing patient-centered holistic diabetes care within a single visit.” - Dr Lim Shu Fang, Principal Pharmacist (Clinical), CDE

"The CDE pharmacists have been generous and helpful in sharing their wealth of knowledge about medications with the CDE team. It has been a pleasure learning from their experience! This helps us greatly as CDEs advise patients about all aspects of diabetes management to make consultations targeted, effective and appropriate for their needs." - Melissa Ho, Senior Dietitian, CDE

So, what exactly do Clinical Diabetes Educators (CDEs) do?

Traditionally, patients with diabetes are managed by a multidisciplinary DM care team involving multiple appointments with their doctor, nurse, pharmacist and Allied Health professionals. With the aim to provide coordinated care, "Trans-Disciplinary Diabetes Care Model" was pioneered in TTSH. In this model, the CDE team manages patients with diabetes and its various complications in a single appointment, in collaboration with the endocrinologist.

During the clinic visit, the CDE reviews and educates the patient on various aspects of diabetes care. The CDEs are armed with the knowledge necessary to carry out this assessment through training conducted by other CDE members with expertise in their respective fields. This allows the CDE team to assess patients holistically in a coordinated manner.

In the trans-disciplinary model, CDE pharmacists are actively involved in:

  • Carrying out clinic consultations, where they manage diabetes and other related issues like high blood pressure and cholesterol and advise on medication adjustments and laboratory investigations

  • Conducting holistic diabetes education for patients (e.g. teaching insulin injection techniques, teaching self-monitoring of blood glucose, giving dietary and foot care advice, and performing basic foot screening)

  • Prescribing of medications under the Collaborative Practice Agreement (CPA) after undergoing training via the National Collaborative Prescribing Programme (NCPP)

  • Providing endocrinology-related drug information services

The provision of additional CDE services on top of medication review under the Trans-D model allows for the upskilling of pharmacists and other Allied Health professionals to provide value-added services and holistic care to patients. Furthermore, greater respect and understanding of one another's expertise through this initiative drives stronger teamwork among the various healthcare professionals.

Let's hear it from more CDE pharmacists!

"I feel honoured to be given this opportunity to be a Clinical Diabetes Educator (CDE). The role of a CDE is forward-looking and patient-centric. With the knowledge and skills that we learnt from physicians and other allied health groups in the transdisciplinary diabetes care team, we are now able to provide patients with care that is of greater value as more diabetes-related concerns can be addressed in a single visit. This has, in turn, improved both patient experience and satisfaction. It feels great to be able to practice on top of our license!" - Dr See Toh Wei Yann, Senior Pharmacist (Clinical), CDE

"Being a CDE pharmacist has greatly widened my perspective of diabetes mellitus (DM) care. DM management is complex as patients have different needs and social circumstances. As a CDE, I feel empowered to provide targeted and comprehensive DM education on medication, self-monitoring glucose monitoring, and dietary and basic foot care advice to patients. The journey is challenging, but it has been enriching and meaningful working in the team to provide holistic care to patients.” - Ong Wan Qin, Senior Pharmacist (Clinical), CDE

To date, the project has seen over 1000 patients and received positive feedback from patients!

Given the risk of complications from diabetes, it is important that patients are empowered to manage the disease themselves. The ability of the CDE team to provide holistic care and education supports the imparting of knowledge to patients. Let us all anticipate further development of the trans-disciplinary model that value-adds to patient care!


  1. Synergising Care - A Multi-disciplinary And Trans-Disciplinary Care Model For Diabetes Management (Tan Tock Seng Hospital, CEO Tribune, 15 October 2020)

  2. Wong, M. S., Gu, K., Heng, D., Chew, S. K., Chew, L. S., & Tai, E. S. (2003). The Singapore impaired glucose tolerance follow-up study: does the ticking clock go backward as well as forward?. Diabetes care, 26(11), 3024–3030.

Written by:

Toh Jia Hui, Lim Shu Fang, Debra Chan

We would also like to thank the Trans-Disciplinary Diabetes Care Team for their contributions:

Dr Lim Shu Fang (Principal Pharmacist - Clinical) | Cynthia Goh (Principal Pharmacist - Clinical) | Theresa Choo (Principal Pharmacist - Clinical) | Dr See Toh Wei Yann (Senior Pharmacist - Clinical) | Debra Chan (Senior Pharmacist - Clinical) | Lim Pei Qi (Senior Pharmacist - Clinical) | Ong Jiamin (Senior Pharmacist) | Ong Wan Qin (Senior Pharmacist) | Shaun Eric Lopez (Senior Pharmacist) | Melissa Ho (Senior Dietitian) | Melissa Phua (Principal Podiatrist) | Kenneth Koh (Senior Podiatrist) | Tiffany Chew (Senior Podiatrist) | Dr Ivan Woo Mun Hong (Principal Medical Social Worker) | Regina Huang Xiaofen (Senior Medical Social Worker)


Do you like this article and wish to find out what more can be done to empower a healthier you? Our Pharmacy Week 2022 health carnival will be happening live on 24 September 2022 (Saturday). There will be an exciting lineup of health talks, fitness and cooking activities, and interactive booths! This event is FREE and suitable for all ages. Register with us to reserve a slot today!


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