Table 3 Examples of the category ‘Contribution to improving factors that influence coordination across care levels’

3.1. Improvement in interactional factors between health professionals in the network

- Helped to get to know professionals of the other level and their work context and fostered personal connections

“I’ve got the impression, as I also participate in the consultations and videoconferences, that ties have been made between primary care and the specialists (…). We often have that frank conversation of: look, this is what’s going on, or this is the real case scenario, as seen from primary care and also as seen from the hospital perspective (…) so that leads to this kind of ‘Ohhh, right! Well let’s see how we can put our heads together and solve this then’” (Healthcare Manager, Chile).

“(…) despite having worked a long time in the network, they didn’t know their counterparts, at the hospital level in this case (…) We noted a high level of interest among the staff in participating in the implementation of this activity [cross-level visits]” (Healthcare manager, Chile)

“From the specialist point of view, we started to understand a bit more about the limitations of patient management and diagnosis at the primary level. It wasn’t necessarily that the general doctors didn’t know how to manage the patient” (PP, Colombia)

- Improved opinion of the other care level

“Interpersonal relationships, and interprofessional ones too. Creating empathy, putting yourself in the other person’s shoes (...) understanding the problems of many professionals in health care, and how we were going to come together to achieve it” (Healthcare manager, Brazil)

“When we started these meetings, seeing as we wanted to improve communication between levels, we noticed that general doctors had a lot of preconceptions about specialist doctors, and specialists about general doctors, which we started to discuss and we realised that a lot of those preconceptions were wrong” (PP, Colombia)

- Improved trust, willingness to collaborate, communication between participants

“Yes, the specialists are always on hand, they’ll give you their email, not their personal one but the work one, of the unit, and they are available to chat about complicated cases and all that. So that’s been really good” (Healthcare professional, Chile)

“After that they felt more at ease in making queries, and that the doctor could call the specialist, the internal medicine doctor in this case, and consult them on something” (LSC, Colombia)

“It’s important that regular contact is maintained with the specialist doctors because that builds trust, integrates the care levels, ties us closer together and makes it easier to manage the patient’s care pathway, I mean without feeling so apprehensive and knowing they can refer them back again [if necessary]. That mustn’t be lost” (PP, Mexico)

- The PAR process improved interactional factors between managers of the network

“(…) Hospital: “There’s nothing more I can do because primary care is doing such a terrible job”. Primary care centre: “There’s nothing more I can do because the hospital is doing such a bad job” (…) And with that we don’t get anywhere constructive (…) I would say that this in some way....means we basically see ourselves as one and the same. So we’ve really managed to lower our defensive barriers (…) and start to understand that what we really need to do is help each other out” (LSC, Chile).

“it’s like a sign that a shared vision of the network is appearing, which was the problem we had in the first place (…) Of course, and people perceive it and everyone can feel it now. If I’ve got a problem I know who to speak to and I know they’re going to help, you know? And the certainty that they’ll help me, that they’ll collaborate with me for the sake of the patient” (LSC, Chile)

3.2. Improved training/updating of PC and SC doctors

“We acquired a greater ability to resolve pathologies. You generally come in fresh out of medical school and then you don’t keep up a formal study routine, or get like an update on things, so you stick with how things were when you graduated, and carry on working in the same way for the next 10, 15, 20 years” (PP, Colombia)

- The PC doctors who participated became sources of reference in their units

“(…) they [participating PC doctors] turned into sources of reference on patient management in their health centres (…) the other general doctor could ask them when they had a query or concern about clinical management” (LSC, Colombia)

- Contributed to improving PC doctors’ management of patients and the appropriateness of referrals to SC

“We’re managing to gradually reduce the number of hospital referrals, (...) anything to do with surgical specialities has to be sent over, there’s no way round that, but we’ve been able to solve a lot of things though this, you know?” (Healthcare manager, Chile)

“When they give this type of training, it’s great, because they focus precisely on common problems that come up all the time, that we ourselves see and that we’re helping to transmit to the hospital. ‘Oh, yeah right! I had a patient like that, I didn’t manage it right’, and so now we go back to primary care level and improve on that way of treating the patient” (PP, Mexico)

“As a result of this [training] it turns out they [the patients] have come in with their case management well established and they pretty much go straight to the hospital without wasting any time. In obstetrics, every minute and second counts” (PP, Mexico).

3.3. The PAR process fostered professionals’ interest in participating in the interventions

“I think that makes it more credible, because it’s not a structure, it’s something you gradually shape (…) to all the needs that arise in the moment. Some get involved (…) and that makes people start to feel part of it, they feel motivated (…) we’re building up motivation throughout the whole process. That’s been the most wonderful thing that this whole process of implementation and design has brought” (LSC, Chile)