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Table 2 Examples of the category ‘Contributions to improving clinical management and administrative coordination’

From: Can care coordination across levels be improved through the implementation of participatory action research interventions? Outcomes and conditions for sustaining changes in five Latin American countries

2.1. Improved direct communication between PC and SC doctors
- Encouraged the use of informal communication mechanisms
“A communication channel was set up on WhatsApp (for endocrinopathies) (...) it was a great help that may have helped to reduce the waiting list (...) Primary care felt more confident about leading [the care management of the patient], because they had the secondary care professional on rearguard” (Healthcare manager, Brazil)
- Significant change compared to previous lack of communication
“Up until the moment the intervention started, I’d been working in the institution two and a half years (…) as a specialist and I hadn’t had the opportunity in those two and a half years to share a single academic space or even say hello to a general doctor from other units” (PP, Colombia)
- Allowed clinical cases on the waiting list or complex cases to be resolved in primary care
“(..) it was shown to be useful [joint virtual clinical conferences], it’s very useful, for example when the general doctor who has a grandma with dementia that wakes everyone up at 3 in the morning, so he doesn’t just have one patient now but 5, which is the whole family that hasn’t slept… and we [SC doctors] can say to him: ‘well let’s have a look at this, or that, we’ll treat it with this medicine, we’ll do these tests, and it’s not necessary for her to come over here’” (Healthcare professional, Chile)
2.2. Fostered clinical agreement on treatments, diagnostic tests and referral criteria
“on going over the meeting topics and all that, well let’s just say that we get a space in which to air our differences or opinions, which us general doctors also have on the management of cases (…). So there are discussions, there’s a space for discussion and so somehow more agreements are reached” (PP, Colombia).
“(…) I think the most positive aspect [of the videoconferences] is about coming to an agreement on the type of pathology we’re working on, you know? Through a protocol, so that each one of us understands what they have to do and what their responsibilities are” (Healthcare professional, Chile)
- Contributed to better control of chronic patients
“I’ve seen that when patients are managed by the specialist in the same way [as by the PC doctor], their illness improves, their blood pressure readings are more under control, especially diabetic patients. You can see that they’re better controlled because there’s just one sole voice saying what needs to be done” (PP, Colombia)
2.3. Contributed to reducing unnecessary referrals to secondary care
Over the course of this meeting we realised that us general doctors sometimes referred patients that we could manage, and we learnt that from the specialists. You don’t necessarily have to refer hypertensive patients to the specialist. If they prepare us better it might also make their activities more effective, their services may not be so backed up” (PP, Colombia)
2.4. Improved administrative coordination of patient access across care levels
- Fostered direct communication to facilitate access to SC and cross-level monitoring
“We exchanged phone numbers and emails (…) to be able to refer the patient. They generally respond really quickly but there are some cases that are kind of special that always have to be explained, so in those cases we communicate directly with each other” (Administrative professional, Chile)
- Improved knowledge of administrative pathways and requirements for access to the other care level
“I thought it was really interesting because it gives us the chance to get to know how the other services work, because we don’t know how they work and we’re suddenly just referring patients over there without knowing (…) and the truth is that the patients are going to waste money on buses and time” (Administrative professional, Chile)
- Contributed to faster access for patients on waiting lists
“The latest case was a lady who had an advanced stage of cancer and was in a lot of pain and she hadn’t been referred to palliative care because she’d also been in the private system. So the processes were greatly eased through this and we were able to give her the care she needed” (Administrative professional, Chile)
- Contributed to a reduction in administratively inadequate referrals
“(...) various questions would come up [in the cross-level visits]: ‘So do you provide this service here? Yes. And the drugs? Look, we’ve got so many people to deal with here, that when you guys send people here to get drugs with a prescription from the hospital, we can’t give them to them, and they keep on coming in’. So they’re also moments of conversation about everyday things, but they don’t get discussed at any other time” (Administrative professional, Chile)
2.5. Impact limited to the specialities that participated, or little impact on coordination
“Well yes I think so, in the areas we had contact with. Of course the hospital is huge, there’s a lot of different specialities that also need the chance to get to know each other and that’s the main reservation I have, that one person can only do so much (…) So that’s why I think it may be important to repeat it [cross-level visits] to cover more specialities” (Administrative professional, Chile)
“The relationship between general doctor and the specialist that was directing, leading the progress of the meeting (…) was great because they talked to each other, communicated, they got to ask each other questions and they used tools like WhatsApp text messages. In terms of specialists of the [whole] healthcare network with general doctors of the healthcare network, there’s still a long way to go. There’s a huge gap, a persistent void, I’ve yet to hear any news of a first meeting between specialist doctors of the healthcare network and general doctors from primary care” (LSC, Colombia)
“There have been no changes with regard to referrals at all, nothing’s changed, they don’t make use of the system, two questions [consultations of specialists by PC doctors] in so many months...the truth is that it’s precarious” (PP, Mexico)
“Very few replies [reply letter in response to PC doctors’ consultations] were received. Some were replied to so that was good, but if I had to give a general overview of the process, it didn’t work” (Healthcare professional, Uruguay)