Holistic Chronic Disease Management in Singapore
One doctor who understands the full picture — not just the condition on today's form.
Managing diabetes, hypertension, high cholesterol, asthma, and complex multi-morbidity in Tanjong Pagar, Singapore. Same doctor, every visit. CDMP subsidies available.
Chronic Disease Management at Angsana Medical
Managing the whole person, not just the diagnosis
Chronic conditions require a different kind of medicine — one built on continuity, pattern recognition, and a doctor who understands how your conditions interact with each other. At Angsana Medical, chronic disease appointments are given the time they need, and you will always see Dr Dhivian.
With access to the National Electronic Health Record (NEHR) system and a structured approach to multi-morbidity, we manage your conditions as a whole — not as separate, disconnected problems.
Same Doctor, Every Visit
Continuity of care is the foundation of effective chronic disease management.
CDMP & CHAS Clinic
Enrolled in the Chronic Disease Management Programme — subsidies up to $135 per visit.
Accredited Family Physician
Experienced primary care doctor with a Master of Medicine in Family Medicine.
Convenient Follow-Up Slots
Lunchtime, evening and Saturday appointments — chronic care without disrupting your week.
We Hear This Every Week
If any of these sound familiar, you are in the right place.
“I've been managing this for years and I'm still not where I want to be.”
You take the medications. You attend your appointments. But your numbers have not improved the way you hoped. You need a doctor who has time to understand why — not one who simply adjusts the dose and sends you on your way.
“I see a different doctor every time and have to repeat my whole history.”
Each visit feels like starting from scratch. No one has the full picture. Context is lost between appointments. You deserve a doctor who already knows your story before you walk in.
“I'm managing three conditions at once and I'm not sure my medications work well together.”
Multiple conditions, multiple medications, multiple specialists. No one is looking at it all together. That is exactly what a well-trained family physician is for — synthesising the full clinical picture and making sure everything is coherent.
What Good Chronic Care Looks Like
A doctor who tracks your progress. A plan that evolves with you.
We review your numbers, your medications, your lifestyle, and your goals — together. Every appointment builds on the last.
Not a 5-minute prescription refill. A proper review, every time.
What Is Chronic Disease Management and Why Does It Matter in Singapore?
Singapore has one of the highest rates of chronic disease in Asia. One in three Singaporeans aged 18 and above has at least one chronic condition, and many have two or more.1 The challenge is not just treating each condition — it is managing how they interact with each other, how medications affect each other, and how lifestyle factors drive all of them simultaneously.
"A patient with diabetes, hypertension, and depression is not three separate problems. They are one patient whose care needs to be understood as a whole."
— Dr Dhivian, Angsana Medical
Chronic disease management at a GP clinic is appropriate for most stable and moderately complex conditions. We will refer to specialists when clinically indicated, and co-manage with your specialist team where you are already under specialist care.
10 Common Chronic Conditions We Manage at Angsana Medical, Singapore
We begin with a comprehensive review of your full medical picture — not just the condition that brought you in today.
We manage Type 1 and Type 2 diabetes with individualised treatment plans — including lifestyle modification, oral medications, and insulin initiation where indicated. For pre-diabetes, early intervention with structured lifestyle guidance can prevent or significantly delay progression to Type 2 diabetes. Regular HbA1c monitoring, kidney function testing, and foot and eye referral coordination are part of our structured diabetes follow-up.
- Type 1 & Type 2 diabetes · Pre-diabetes
- HbA1c monitoring · Diabetic foot care referral · Eye screening coordination
Hypertension is often silent but significantly increases the risk of heart attack and stroke. We assess cardiovascular risk holistically, prescribe appropriate antihypertensive medications, and support lifestyle changes including dietary sodium reduction, weight management, and exercise. Home blood pressure monitoring is encouraged and reviewed at each visit.
- Blood pressure management · Cardiovascular risk assessment
- Lifestyle counselling · Medication review & titration
Elevated cholesterol is a major modifiable risk factor for heart disease and stroke. We assess your full lipid profile and cardiovascular risk, and develop a management plan that may include dietary changes, statins, or other lipid-lowering medications. We also manage familial hypercholesterolaemia where identified.
- Lipid profile monitoring · Statin management
- Dietary counselling · Cardiovascular risk stratification
We provide structured management for asthma, COPD, and chronic allergic rhinitis — including inhaler technique review, trigger identification, action plan development, and step-up or step-down of therapy based on symptom control. Allergic rhinitis is assessed alongside respiratory conditions as they frequently co-exist and share underlying mechanisms. Spirometry referral is arranged where needed for diagnostic confirmation or disease staging.
- Asthma · COPD · Chronic allergic rhinitis
- Inhaler review · Exacerbation management · Spirometry referral
For patients with ischaemic heart disease, previous stroke, gout, or obesity, we manage ongoing risk factor control and medication compliance alongside specialist co-management where required. Weight management programmes, including GLP-1 receptor agonist therapy (Ozempic/Wegovy), are available for eligible patients.
- Ischaemic heart disease · Post-stroke care · Gout
- Obesity management · GLP-1 therapy (Ozempic/Wegovy)
Depression, anxiety, bipolar disorder, ADHD, OCD, and schizophrenia are chronic conditions that require long-term management — not just acute crisis treatment. We provide structured medication management, regular mood monitoring, and in-house counselling through our registered counsellor Lilian Ong. Mental health comorbidities in chronic disease patients (e.g. depression in diabetes) are assessed and treated as part of holistic care.
- Depression · Anxiety · Bipolar disorder · ADHD · OCD
- In-house counselling · Medication management · Specialist referral when needed
Thyroid conditions — both hypothyroidism and hyperthyroidism — are common, often under-diagnosed, and affect energy, weight, mood, and multiple organ systems. We assess thyroid function through blood tests, initiate and titrate thyroid medications (thyroxine for hypothyroidism, and referral coordination for hyperthyroidism), and provide ongoing monitoring to keep your thyroid levels within the optimal range.
- Hypothyroidism · Hyperthyroidism · Subclinical thyroid disease
- Thyroid function monitoring · Medication titration · Endocrinology referral where indicated
Osteoarthritis and osteoporosis are among the most prevalent chronic musculoskeletal conditions in Singapore, particularly in older adults. We assess joint pain, initiate analgesic and anti-inflammatory management, advise on exercise and weight modification, and coordinate physiotherapy and specialist referrals. For osteoporosis, DEXA scan referral and bone-protective medications are managed as part of structured care.
- Osteoarthritis · Osteoporosis · Gout (joint manifestations)
- DEXA referral · Bisphosphonate therapy · Physiotherapy coordination
We manage a range of other complex chronic conditions with ongoing medication review, specialist co-management, and polypharmacy assessment to ensure care remains safe and clinically appropriate as your conditions evolve.
- Rheumatoid arthritis · Chronic kidney disease · Chronic Hepatitis B
- Benign prostatic hyperplasia · Dementia · Parkinson's disease · Epilepsy
Patients managing multiple chronic conditions often take several medications simultaneously. We conduct structured polypharmacy reviews to identify drug interactions, rationalise medications, reduce unnecessary prescriptions, and ensure each medication remains appropriate for your current clinical status. This is particularly important for older patients and those with complex multi-morbidity.
How Much Does Chronic Disease Management Cost in Singapore?
Consultation fees depend on the duration and complexity of your visit. Significant subsidies are available for eligible patients.
From
$30–$50
GP Consultation
In-person consultation and medication dispensed on-site. Fee depends on complexity and duration.
Book In-Person →From
$30–$50
Teleconsultation
Video consultation for suitable conditions and reviews. Medications can be delivered. Fee depends on complexity.
Book Teleconsult →From
$300
Home Visit
Dr Dhivian comes to you. Available subject to scheduling — contact us via WhatsApp to arrange.
Book a Home Visit →Up to $135 subsidy available per visit
For eligible CHAS Orange, Blue & Green, Pioneer Generation and Merdeka Generation Cardholders.
Medication costs charged separately. Fees subject to change — please enquire at the clinic for current rates.
How Your Chronic Disease Consultation at Angsana Medical Works
A thorough clinical review — here is what happens.
Step 01
Comprehensive Health Review
Full review of your medical history, current medications, past investigations, and lifestyle factors — not just the condition in isolation.
Step 02
Investigations & Monitoring
Blood tests, blood pressure checks, and other investigations reviewed and ordered. Results discussed in full at your follow-up.
Step 03
Personalised Management Plan
A clear treatment plan — medications, lifestyle targets, specialist referrals where needed, and a monitoring schedule tailored to your conditions.
Step 04
Consistent Long-Term Follow-Up
Regular review appointments with the same doctor. Adjustments made as your condition evolves. Nothing falls through the cracks.
Why Patients Choose Us
3 Reasons to Consider Angsana Medical for Chronic Disease Management in Singapore
A Master of Medicine in Family Medicine
Dr Dhivian's postgraduate MMed qualification means he is trained to manage the full complexity of multi-morbidity — not just individual conditions in isolation.
Continuity That Changes Outcomes
Chronic disease management improves measurably when the same doctor follows your care longitudinally. Patterns emerge. Context accumulates. Decisions become more accurate.
Integrated Care, Not Fragmented
We manage your chronic conditions alongside your mental health, lifestyle, and medications under one roof — with in-house dietetics and counselling available.
About Dr. Dhivian
Dr Dhivian
MBBS, MMed (Family Medicine) · NUS
Adjunct Tutor, College of Family Physicians Singapore
Dr Dhivian's postgraduate Master of Medicine in Family Medicine from NUS trained him specifically in the management of complex, multi-morbid patients — those with several chronic conditions simultaneously. His background spans polyclinics, hospital wards, and specialist settings, giving him the clinical range to synthesise your full picture.
As an Adjunct Tutor at the College of Family Physicians Singapore, he stays closely connected to evolving clinical guidelines for chronic disease management in Singapore.
Inside the Clinic
Calm, unhurried, and built for proper review.
Angsana Medical is not a high-volume clinic with a crowded waiting room and an assembly-line feel. Chronic disease consultations require time — to review investigations, adjust medications, discuss lifestyle, and address the things that do not fit neatly into a 5-minute slot.
You will leave each appointment with a clear understanding of where you are, where you are going, and exactly what the plan is.
Find Us
GP Clinic at Everton Park, Singapore
Located at 1 Everton Park, #01-39 — close to Spottiswoode Park, Pinnacle @ Duxton, and Cantonment Towers. Accessible from Outram Park, Maxwell, and Tanjong Pagar MRT.
Visit Us at Everton Park
Clinic Address
1 Everton Park, #01-39, Singapore 081001
Accessible from Outram Park, Maxwell, and Tanjong Pagar MRT
Get directions →Managing a Chronic Condition Is a Long Game. Having the Right Doctor Makes All the Difference.
Book a chronic disease consultation at Angsana Medical, Tanjong Pagar. In person or via teleconsult. No referral needed.
If you have any questions
Frequently Asked Questions About Chronic Disease Management in Singapore
Related Services
Chronic disease management often goes hand-in-hand with preventive care, lifestyle medicine, and mental health support.