Primary Care Based Integrated Community Care Team Intervention

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