Table 3 Key themes and exemplary quotes

Participant Responsiveness

Lack of confidence in PCC providers among specialists

“Sometimes, specialists are worried - because they are family physicians, and that these diseases are not common like diabetes or hypertension - whether they are able to handle. Although we try to move, but the apprehension of the doctors also are there. Due to the hassle of moving, they rather see them because at the end of the day, it’s only (every) four months or six months down the road. So these are the challenges that we face” (Care coordinator)

Limited understanding of the program

“(The specialists think that) “I discharge (patients), who do I discharge them to? If I discharge them to the black hole ... I don’t know these people, I don’t know the people in the polyclinic, I don’t know the primary care doctor, so if I discharge them to the black hole, anything can happen to my patient.” (Family physician)

Ethical Dilemma: conflict between ethos and program goals

“I mean that cost gradient is definitely not working out for patients and sometimes I wonder, am I doing the right thing for patients.” (Program manager)

“If the purpose was to do what right siting describes, which is to move people with lower needs out to a place where there is less care, I don’t find that meaningful, it’s not something I would not do as a human being. I get up in the morning, if that was my job, I rather do something else.” (Specialist)

Negative feedback about PCC from users

“When patients come back with feedback of not having enough medicines, service attitudes, they are also etched into the specialists’ mind because some patients may be with our consultants for eight to fifteen years already. If they discharge very familiar patients to primary care providers and they come back with poor feedbacks, it is not so good for their rapport.” (Care coordinator)

Complexity of program

Evolving dynamic of collaboration

“The relationship changed, we weren’t as deeply engaged as we were before, the team turned over as well, I mean X stepped down as medical director of the center and handed over to Y, who was a good guy! But it’s not exactly the same team anymore, I just get a sense that actually if all of the care was reverted back to the whole model, the passion for patient-centered care has to some extent died away.” (Specialist)

Mismatch between program goals and current healthcare financing

“I wasn’t clear in the direction of the program, I thought if you want to right-site to primary care partners, but yet you’re making SOCs even cheaper?” (Program manager)

Facilitating Strategies

Synergistic partnership between collaborators

“I think we found a very synergistic partnership in NUH and us when we decided that we want to bring the care of patients to the next level, we just say shoot for the stars, and do the best that we can just to make sure that the patient is really in the center. And then all this fragmentation of care is being reduced” (Family physician)

Training of the PCC providers by the SOC specialists

“One of the specialists went to the PCC on a regular basis, once a month to discuss cases. This was especially important in the first year, where the doctors there were still getting used to the idea of managing patients with more complex conditions who have been recently admitted in a tertiary hospital. So we just look at them to gain the confidence and comfort level in managing some of the patients. But this program has been running for a few years, so training is less frequent now as the need is (assumed) to be not so strong.” (Specialist)

Support system: care coordinators

“It’s crucial for the care coordinators to be there … Care coordinator must be part of the clinical team, for them to be familiar … We found that the most effective way is the team having one care coordinator and then outflow through that.” (Care Coordinator)

“I think having a care coordinator to explain things to patients is very helpful because usually clinicians can be very busy and rightfully the patients have a lot of questions to ask to get re-assured so they feel safe enough to get discharged.” (Specialist)

Support system: protocol for providers

“We have a systemic protocol for recruitment … Once we identify the patient, we just pass over to the clinic assistant and the clinic assistant will immediately call the care coordinator, so the coordinator will write down the patient’s needs. If they are free, they can see on the same day. If they are not, they will give them a call and arrange for a meeting.” (Specialist)

Support system: shared EMR

“With the same hospital system, they could see everything, they were able to look at the results, our train of thought, the way we have managed the patient so far. When the patient gets discharged to us, we could also see, knowingly or unknowingly, what the specialist has been thinking about and going through, the thought process in managing this patient … It gives us a better understanding of a patient’s condition and ammunition to advise the patient correctly.” (Family physician)

Support system: shared hospital pharmacy

“We gave up the pharmacy revenue which constitute usually a large percentage of the primary care physician’s revenue. We gave that up because we know that is going to be a plus for the patients, they are going to get subsidized drugs … cheap drugs, and they are going to take the drugs every day. So that takes off a chunk of our revenue.” (Family physician)

Care model

“The program helps because the greater access in the community will help the patient come and see us. If there’s any problem, we will escalate back to NUH.” (Family physician)

“I realize the good points of the program is … that the time is more flexible. Even let’s say after working hour(s). You can just walk in. It’s not like the SOC (where) we don’t accept walk in” (Care coordinator)

Recruitment

Reduction in the number of suitable patients

“I think primarily because over the years the number of patients that considerably could be placed out from the existing pool has been exhausted to some extent … It is the new patients who are entering the sub-specialty clinics.” (Specialist)

Insignificant cost gradient between hospitals and PCC

“The main barrier to recruitment right now is the specialists buying into this model and sending their patients (out). I feel that is the biggest barrier, because of (the patients’) trust and confidence on the doctors (it is hard to) let go of physician-patient relationship that was built for years.” (Specialist)

“Five years ago, when patients come to see a specialist at the hospital, they pay $25–27 to see a specialist in the hospital. When you go to see the GP, you pay the same amount but you are only going to see a GP so in terms of value for money, I think most people would say they would prefer to come and see a specialist.”(Specialist)

Context

Providers’ level

Lower motivation among hospital providers

“Now that the load in the clinic is more manageable, then doctors will sometimes forget about this program, they’ll just manage it day to day.” (Program manager)

High workload of hospital providers

“It is not that the doctors don’t want to get more involved, but we just don’t have the time and we probably cannot pull out the information off hand. And most of the time, patients need time to sit down, think about it, discuss with their family members, have the information leaflets to think about it and compare and weigh things in their mind. So I think that’s something that we don’t have time to do at our level.” (Specialist)

Context

Organizational level:

Lack of program reinforcement

“There are guidelines and criteria for seeing a specialist and discharge. If the patient has met the discharge criteria and we want to discharge, but no one enforces. No one audits.” (Specialist)

Competing agenda

“It has been tapering, we reached a peak about a year or two ago. We are dependent on referral letters from NUH and the numbers have been going down …. The understanding was, it’s also partly because the awareness of our center is weaning a little bit. I think we are no longer the flavor of the month. (Family Physician)

Organizational disincentive

“The hospital cut our headcount on the basis of the number of patients that we see in the outpatient clinic, so it was counterintuitive, to any right-siting program.” (Specialist)

Context

System level:

Limited capability within the PCC clinics

“Family physicians have been practicing for decades in this comfort zone, seeing patients with simple conditions, and suddenly you’re managing patients with rheumatoid arthritis, Parkinson’s patients who you’ve never managed before in your life. So that will make some doctors uncomfortable. (Family physician)

“When a patient went to see a doctor at the PCC clinic and doctor said “Oh I’ve never seen this condition before, the last I read about it was in medical school, you know how rare it is?” So obviously the patients were quite shocked when they hear that. And then they feel that they don’t have that assurance and or confidence, and they come back.” (Care coordinator)

Limited capacity at the PCC clinics

“After RSC program has (been implemented), we received feedback that one of the PCC clinic has reached their capacity at one point of time.” (Program manager)

Fragmentation in funding: disease-centric reimbursement

“Funding here is unfortunately on a per consult basis, not on a capitated basis, making things challenging. This is because generally patients with multiple specialty follow-ups require more time to sort through their problems, every time they see us. If I spend more time on these patients and there’s actually less time to see more patients to generate revenue for our center.” (Family physician)

Fragmentation in funding across care settings

“You can’t have a fragmented funding when you talk about integrated care. You must treat primary care and the hospital as a whole, and then you must fund both as a block. The hospital now have to make sure that the funding of primary care is well-supported to make sure the patients are cared for in a good way in the community so that they do not fall back into the hospital, which will cost even more.” (Family Physician)

Mismatch between providers’ reimbursement and program goals

“My bonus and performance depends on my workload. If I want to play the rules, I want to make sure that my clinic is always full. I’ll (repeatedly see the same patient). I can see 25 patients on their repeat visit. My workload will look very good so my bonus should be more and I don’t have to deal with the complicated new cases; life will be easier for me.” (Specialist)