As illustrated in Table 2, the majority (4 out of 6) of program components were implemented with low fidelity. Stratification of care and preparation of transition from SOCs to PCC clinics by CC were found to be implemented with high fidelity.
The RSC program database showed that a total 9,112 unique suitable patients were referred to the program since program initiation. Out of which, 3,032 (33.3%) declined to be enrolled. Since the initiation of the program, decreasing coverage was observed (Figure 3).
Key themes of moderating factors and their corresponding exemplary quotes found in the study were described in Table 3.
Providers’ perception of the program influenced their level of engagement
Different levels of responsiveness were observed among specialists, depending on how they perceived the program. Expectedly, those who had positive views of the program saw it as a strategy to overcome issues related to congestion within the SOCs and were better well-engaged by the program than those who were not. Varied perceptions were influenced predominantly by specialists’ understanding about the program and their trust levels of the PCC providers. Specialists were accustomed to working within their disease specialties, with services typically charged to patients based on disease, service, and provider type within the respective speciality clinics. Such disease-centric reimbursement limited the specialists’ understanding of the program and familiarity with how the program ran. In addition, with disease-centric clinic set-up and little coordination among specialities, fragmentation of care services persisted within the acute care setting. Therefore, the concept of “one-stop shop” was considered different by providers as patients with multimorbidity commonly had to shuttle between different clinics for their treatments. Scepticism among hospital-based providers about the collaboration was also reported, likely due to little experience working with others outside of the hospitals.
Providers’ experiences of the program determined their level of responsiveness
Among those who were initially supportive of the program, ethical dilemma surrounding the benefits of the program to patients led to diminishing responsiveness. Providers had to balance their perceived benefits of the program to patients with the program mission of referring as many patients as possible out of the hospital. This is because the program required users to pay less “out of pocket” cost for the services utilized within the community compared to when services were utilized in the hospitals due to the large subsidy provided by government for the use of public hospital based care. Furthermore, fee incurred within the hospital can be paid through Medisave (compulsory medical saving account).
Some specialists also felt conflicted as they perceived PCC providers to be providing “inferior” quality of care compared to the hospitals, and described the program to be “against the specialists’ ethos of patient care”.
Some patients returned to the specialists due to suboptimal experience in the PCC clinics related to providers’ capability and service quality. Poor feedback from patients adversely affected the hospital providers’ confidence of PCC which was then subsequently translated into lower responsiveness to the program.
Complexity of program
Despite the system-wide emphasis for collaboration, our findings showed slow progression in collaboration within the program. Dynamics of the collaborations was described to change over the years in an unpredicted manner. Level of engagement of various stakeholders fluctuated with changes in the team structure and leadership. Consequently, it adversely affected the passion for and commitment to the program among stakeholders.
Even with best efforts to explain and convince suitable patients to enroll in the program, it was challenging to shift chronic care from the hospital to the community. Existing healthcare financing was reported to contradict with the goals of the program. Heavily subsidized hospital care was said to inevitably shape patients’ preference for hospital care. However, despite feedback from staff about the mismatch, the problem persisted and caused great frustration among providers.
Synergistic partnership, training of PCC providers by specialists, and supportive structures including CCs, guiding protocol for the providers, shared electronic medical records (EMR), and shared pharmacy were found to facilitate program implementation. With the ultimate goal of providing people-centered care, synergistic partnership was fostered to enable collaboration. The common goal united stakeholders between the NUH and PCC providers. Upon which, an appropriate model of care and new workflow was developed, resources were invested, and collaborative working relationships were established.
As part of the program, training for PCC providers by the specialists were initiated to equip them with necessary knowledge and confidence. Specialists organized seminars to discuss about management of chronic diseases and visited the PCC clinics to see patients and/or discuss cases. These activities also helped to build rapport between providers across healthcare settings, which in turn facilitated efficient and effective communication. However, training was reportedly conducted less frequently as the program was assumed to have reached a stable stage. With decreased contact time with specialists, PCC providers felt less supported and confident in managing more complicated conditions. Thus, patients were noticeably referred back to the SOCs more frequently than before. At the same time, the PCC providers’ decreasing confidence adversely influenced patients’ confidence in PCC, leading to an increased number of patients’ voluntary returns to the SOCs.
In supporting the program, CCs were noted to play important roles as care integrators to connect between healthcare providers from varied SOCs and healthcare users (patients and caregivers) in care consolidation and to prepare for and support the care transition. Some CCs also went the extra mile to review the patient list in an effort to assist the specialists in identifying the stable patients suitable to be discharged/transitioned, thus enhancing the patient recruitment numbers. Busy specialists regarded the coordination by the CCs to be useful and was key to the success of implementation of the program.
Guiding protocols describing selection criteria and main steps for program delivery were developed at the beginning of the program. It helped the healthcare providers in managing patients’ complex conditions according to the intended model of care in a standardized manner. Furthermore, it also included an escalation workflow to be used in the event of unexpected deterioration of patients’ conditions. The RSC program was favored by some providers as the model of care was said to provide greater accessibility for patients because of PCC clinics’ convenient locations within the community and their flexible opening hours and acceptance of “walk-ins”.
Shared infrastructures including the common EMR and shared pharmacy adopted as part of the program were identified to be pivotal for the success of the program. All healthcare providers involved were granted access to the common EMR which they would not have if they were not part of the program. The common EMR functioned to systematically consolidate medical information and allowed sharing of information between actors across disciplines and care settings, thus facilitating care continuity. Hospital-based CCs were also given access to arrange for appointments with the PCC providers, streamlining the process for patients so as to reduce barrier to enrollment.
Nonetheless, shared EMR was found to be not fully compatible to the needs of PCC as it was created for hospital-based care and processes. Therefore, in addition to the shared EMR, PCC providers had to use their own system for billing purposes and used the shared EMR solely for clinical information. This created unhappiness within the PCC providers as it created unnecessary workload for their employees.
To lower the barrier for program enrollment, satellite hospital pharmacies were established within PCC clinics to provide specialists drugs at a similar subsidized hospital rate. This was found to be particularly well received by patients as they could obtain their medications easily near their homes. Nevertheless, the strategy substantially reduced PCC clinics’ revenues from dispensing medications. Even though PCC clinics received funding to support the RSC program, the PCC providers were concerned about the sustainability of their clinics with the reduction of revenues from medication dispensing.
The number of suitable patients was found to decline over time. This was partly because most suitable stable patients were discharged in the early phase of the program. Specialists’ “buy-in”, a reflection of their responsiveness to the program, was acknowledged to be the main determining factor behind decreasing recruitment numbers. As patients who were identified and sent directly by the specialists were more likely to agree to enroll in the program compared to those referred by other sources, decreasing referral from specialists expectedly resulted in lower recruitment number.
With insignificant cost gradient between the hospital SOCs and PCC clinics, seeing a specialist in the hospital cost patients the same or cheaper than having their care managed by the PCC providers. This was considered “not of value” for patients. Consequently, despite having greater access to PCC, patients refused to move out of the SOCs. This in turn reduced providers’ motivation to promote the program as they perceived that the program was “not value for money” for patients and hence not “worth the effort”.
At the providers’ level, lesser congestion in SOCs due to the transfer of patients in the initial phase of the program lowered motivations among the specialists to actively recruit patients for the program. Furthermore, some specialists regarded the introduction of the program to the patients to be time consuming. They would rather monitor existing patients annually or bi-annually than spend the extra amount of time explaining about the program and convincing patients to see the CC to learn about the program.
At the organizational level, sharing about program at the beginning through roadshows by representatives from PCC had prompted active participation of providers. Nonetheless, without continuous organizational reinforcement, specialists lost sight of the program, resulting in lower responsiveness and subsequently lower recruitment numbers over time.
Besides the RSC program, the NUHS RHS Planning Office was reported to be heavily involved in the implementation of other existing programs and development of new programs aimed at fostering integrated care within its geographic region. Given the limited resources within the NUHS RHS to manage numerous projects under its purview, the RSC program’s visibility was perceived to have been diluted by uncertainty in its future directions relative to other programs.
While the initial decrease in patient load within the SOCs was well received by providers, a reduction in resources that came with the decrease in the number of patients managed at the SOCs discouraged further referral of patients out of the SOCs. There was a constant pressure within the SOCs to keep patient volume relatively high so as to avoid removal of resources.
At the system level, fragmentation in care capabilities among providers were also observed. CCs could not consolidate care of patients under one physician after discharge from the hospital as PCC providers lacked confidence and capability to continue management of multi-morbidity. This dampened patients’ confidence of the PCC providers.
Limited capacity at the PCC clinics also prevented the clinics to take in more patients as they were overwhelmed with the high number of patients. The disease-centric reimbursement created fragmentation of the funding across the different care settings and was found to impede the implementation of the program. Without a mechanism to pool charges across services and sectors, it was challenging to convince patients to agree to enrol in the program given the long withstanding perception of inferiority of community care in Singapore.
Likewise, fragmentation in funding segregated the healthcare system, making integration of care across separate entities difficult. Since healthcare funding was largely concentrated within the hospitals, there was limited resources available within the PCC clinics to raise their capacity and capability to manage the rising load of individuals with multi-morbidity. As a result, the introduction of new models of care like the RSC program was difficult as incentives were not aligned across patients and providers.
Providers’ motivation was also found to be influenced by how they were reimbursed. Typically, productivity of providers was measured by the number of patients they managed and they were reimbursed by volume regardless of complexity. With this model of reimbursement, it was not profitable for the specialists to refer stable patients to be discharged to free up slots for intake of new patients/complex cases. New and/or complex cases were reported to usually take up more time for consultation and adversely affect the volume of patients the specialists can see. Therefore, it was considered counterintuitive for specialists to refer their patients to the program. Instead, specialists chose to retain their existing patients who were easier to manage so as to maintain a high volume within their clinics.
Using a narrative approach for data merging and interpretation, Figure 4 illustrated our study findings and revealed the interrelated influence of moderating factors specified by the modified CFIF on the adherence of the program.