Innovation I. Team-based care delivering integrated medical and psychosocial services
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1
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Change strategies – repurposing TF’s pre-existing resources and infrastructure
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“…the idea of having a comprehensive primary care that serves the needs of the patients and his caregivers and to integrate the care between outside providers as well as internal colleagues, is similar. The idea of developing a PCMH is similar (to existing TF services).” (Implementer #11)
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2
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Change strategies – integration between PC clinic and CM service
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"...to integrate them and make sure that the patients that is cared for by CM and the clinic can actually have a seamless coordination of care without having some care components falling through… working out how each of the different components work together… so there are the different work processes that we are learning as we operationalize the whole PCMH… we have morning huddles - where we actually have a quick word with each other twice a week… and we attend interdisciplinary meetings." (Implementer #11)
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3
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Change strategies – service redesign based on local needs
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“In the beginning, when we are still looking at rental houses (i.e., lower-income neighborhoods), you still know they have family but they are left alone, on their own. But right now, the clientele that we are seeing in the past one and a half year, I think we are seeing a lot more with families.” (Implementer #22)
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4
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Negotiations – ComSA-PCMH should be reserved for patients with highest needs (example 1)
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“This clinic is resource intensive, (so) we should not see low risk patients. Otherwise, no value because the GPs and polyclinics are doing a great job in that. However, I think (other implementers) want to see (patients) earlier. I think they want this clinic to be like a real clinic, across life-course.” (Implementer #21)
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5
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Adaptations – patient eligibility criteria were revised (example 1)
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“Initially we put at 4 (ComSA-BPS-RS risk category), then drop to 3, then drop to 2.” (Implementer #21)
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6
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Experimentation – ComSA-PCMH physician providing home medical service without supporting funding (example 2)
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“The home visit is not covered by the government, they don't subsidise, I can't charge him (the patient) for the home visit, because he has no means to pay and it will disengage, it will make things worse. So the only thing I can do is to go do a home visit.” (Implementer #02)
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7
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Negotiation – different perspectives on the need for ComSA-PCMH to provide home-based care (example 2)
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“I feel that, when you deal with frail elders, the primary care has to be more flexible than this. I know where they (i.e., implementers with different perspective) come from. They are coming from a place of financial sustainability (while) I come from a person-centered perspective.” (Implementer #21)
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8
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Adaptations – a new home medical program was introduce & nurse care managers provide some home nursing (example 2)
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“Now for home care in Whampoa, a new home medical service (would) go and see (the patients)... The doctors don’t do home visit, the (clinic) nurse don’t do home visit. Then the care managers – there’s a bit of tweaking. Now care managers can do direct nursing care. By right also cannot, care manager strictly no touching.” (Implementer #21)
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9
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Initial experience (by implementers) – assimilation (implementers collectively adopt new roles and workflow)
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“They (implementers) need to talk to each other, be comfortable negotiating about their role. Because they need some clarity of what each is supposed to do, but there's a lot of blurring in the middle, you kind of just have to figure out what's the best way of doing what… You kind of have to work out a collaborative arrangement, between the different team members.” (Implementer #13)
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10
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Initial experience (by implementers) – assimilation (challenged by soft peripheries and multiple perspectives)
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“So, everybody had their own way of working, their own ideas, they came with different baggage right, because they are all from different walks of professions. So to put them together and, I think also, ComSA-PCMH is a work in progress, it's evolving. So nobody really know you must go this way or not, so it was confusion.” (Implementer #11)
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11
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Barrier to assimilation – perceived lack of leadership in decision-making
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“Nobody really know you must go this way or not… so it was confusion because there wasn’t clear leadership…” (Implementer #11)
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12
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Barrier to assimilation – slow progress in transforming the clinical information systems
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“The information technology basically still functions in silo... So everyone uses their own little components, you know. But there is no function... there's no structure, so communication is happening in an unofficial way, which is very difficult to keep track. That's why when you research us, you want to find information, it's like everywhere.” (Implementer #11)
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13
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Facilitator for assimilation – intrinsic motivation to contribute to aged care
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“My impression of them (i.e., the implementers from TF) is that they are very passionate about their work. So lots of energy and enthusiasm to do more and do better.” (Implementation partner #18)
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14
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Facilitator for assimilation – relevant competencies and/or training
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“the (ComSA-PCMH) model's different, and the competencies required is actually higher. And we almost cannot hire people with that kind of training background, experience nor certainly not people with that kind of mindset required in the service model… So when you hire somebody, you have to really train them up to the competencies of the model, while getting them to understand why we chose to do things the way we do” (Implementer #13)
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15
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Facilitator for assimilation – observability of impacts from invested efforts
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“I think the direction is clearer (after 1.5 years), and people could see their contributions. Then, they would, they work happier because they know that what they're doing is of value. And that it's not so frustrating you know.” (Implementer #11)
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Innovation II. Empanelment of a specific population
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16
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Innovation – targeting patients in a specific risk stratum between primary and specialist care (whose needs are unmet by usual PC)
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“…you need some provider who can interface with the hospital and the community. Because the rest of the community providers, particularly the doctors like the GPs or the polyclinics, are not yet at the level where they want to provide the kind of care that older people – especially the frail, complex ones - that they really need. So until such time, you need a more specialised unit that sits between the hospital and community that can really provide intervention at a population level as well as at the individual-care level by looking at catalysing health systems and connecting all the dots between hospitals, providers and the people.” (Implementer #13)
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17
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Change strategies – partnering with RHS to create supporting infrastructure and pathways in the delivery system
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“ComSA was then a service provider partner, in this whole setup. So, I guess then one can see that the collaboration grew from not just the support of subsidized medications but that of actually the RHS hosting the infrastructure in terms of holding the tenancy for the building where they were sited, and along with the various factors such as enabling factors such as finance, flow of patients.” (Implementation partner #12)
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18
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Change strategies – processes involved in referral management
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“One of the executives will churn out a list of patients that fulfil the (eligibility) criteria. This list is then sent to one of our care facilitators, who then… prompts the doctor that when the patient arrives, discuss ComSA-PCMH referral with the patient… And then the patient gets transferred to one of our care facilitators... What she then does is to dive into greater detail about the COMSA clinic… And then she will set up appointments if patient's agreeable… then we will create a referral letter and send it across.” (Implementation partner #18)
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19
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Change strategies – options for patients to return to medical specialists if necessary
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“If there's anything (that warrants patient care to be transferred back to the hospital), let's say patient condition worsens or what, there's this telecommunication that the doctors there (in ComSA-PCMH) and our doctor (in the hospital) can communicate to update each other whether there's a need to come back or what or, you know.” (Implementation partner #17)
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20
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Perceived value – comparison to usual PC (ComSA-PCMH more experienced in aged care)
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“But again the level of care between GP and ComSA-PCMH (can) provide might be very different. ComSA-PCMH does provide a more holistic kind of care to patients. That's why we see value and we see that in fact, they may feel safer that if our geriatric patients are cared for by ComSA-PCMH.” (Implementation partner #16)
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21
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Perceived value – comparison to usual PC (access to RHS-based health financing schemes in the community)
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“So the advantage of this is that... in the near future, ComSA-PCMH patients will be able to receive their medications, their very competitively priced chronic medications on the same day of the consult. Now I say competitively priced because the moment they moved onto this model... ComSA-PCMH would then be receiving medications at that price which typically no non-RHS primary care provider would normally receive it at." (Implementation partner #12)
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22
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Perceived value – influenced by opportunity for direct communication with implementers
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“I think two different people would have different opinions depending on how they receive the information… at different points in time. So, staff who knew about this service early on, knew that it was a service meant for patients who had psychosocial challenges. They knew that they would be able to fill a service gap that the polyclinic has problems trying to fill, so they were much more happy to, and receptive towards referring patients who would fulfil their criteria. However, in current state where we inform the doctors that this is another collaboration, then to them it is another collaboration. Just that the referral criteria, the inclusion criteria is somewhat different. So they may not be able to understand the true meaning and the intentions and the vision and mission that the ComSA clinic has… So they may just look upon it as a business as usual, rather than something that may value add to the patient.” (Implementation partner #18)
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23
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Perceived burden – systematic case finding was labor intensive and producing low yield
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“In one month, I pull (i.e., case find) 40 plus (potentially eligible patients). But out of the 40 plus – this is just a rough number – maybe I already taken out, like, uh, 10 because of various reasons: maybe they are still not stable or they haven't concluded their diagnosis... Yeah then after that there's patient choice (i.e., that patients might not agree to be referred) and all that… So you really have to funnel, funnel, funnel, funnel. Then the number will not be a lot.” (Implementation partner #14)
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24
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Perceived value – ComSA-PCMH is resource intensive hence should be reserved for complex needs patients
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“If we have abundant resources, then we can shift the (ComSA-BPS-RS risk category) cut-off for delivering that service at a lower ComSA-BPS-RS score (i.e., lower-risk patients). But if I were to tell you that we are very scarce in terms of resources, then we need to shift the ComSA-BPS-RS cut-off very high. …hence, the point about sustainability lah. I don’t think that's a question about whether you should or should not have this service. The question then really is who do you deliver this service for, given the resources you have.” (Implementation partner #18)
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25
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Perceived burden – replacing ComSA-BPS-RS with biomedical markers
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“So patients who would be seen and followed up by ComSA-PCMH were those who were ComSA-RS positive plus medical problems. But we basically told them (i.e., TF implementers) that, for us to try and do the ComSA-BPS-RS for you… (it) would be challenging because there are very few patients who will satisfy the ComSA-BPS-RS positive criteria. So we actually said, we just use biomedical markers, is that okay? So they eventually said okay.” (Implementation partner #18)
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Innovation III. Shared care with local private GPs for complex chronic patients
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26
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Innovation – shared care with private GPs for complex chronic patients
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“Reaching out to the GPs definitely is a very key thing… We thought that the GPs were not seeing as many older people for several reasons. One is that, it takes a lot of time, and, and they get paid very little, right. So, having been in private practice, I understand that you really cannot see too many, so therefore they maybe see fewer (older patients). Secondly, older patients are very complex. And some of the GPs may not have been practicing that way, and there may be some knowledge gap, I would think, in terms of taking care of older people… a lot of things are just social problems and they (i.e., the private GPs) can't take care of their social problems… (while) ComSA-PCMH has coverage (for complex needs patients), but we’re not open (on weekends and evenings). So, one GP was very happy to see them during those hours, but he feels like it may be better to work with us so we can share the care. We take on the ongoing, long term kind of like, care for the chronic diseases and the social problems and all that. But they're happy to see them for the ad-hoc, acute things, and then there'll just be communication.” (Implementer #13)
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27
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Change strategies – targeted outreach to private GPs
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"Certainly the previous chief physician had more than done their fair share of making their rounds (in) the (private) GPs in the Whampoa neighbourhood. They have organized what they term as brown bag engagement sessions, where they just buy simple lunch, unlike the buffet spread that people, drug companies offer. But what they make up for in lack in food they make up for with sincerity." (Implementation partner #12)
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28
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Initial perception – understand ComSA-PCMH’s intent to provide complex care needs but misunderstand its care provision as free
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“I think they have done a good job you know, taking care of the elderly in this area… You know, offering free services to them.. rehabilitation and management chronic diseases and I think that's a good outlet for the people here to go to. I think they are quite comprehensive in the care of the elderly.” (Private GP #1)
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29
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Initial perception – perceived complementarity of ComSA-PCMH services to private GPs’ in social care only
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“We are getting more and more dementia patients. And that’s very hard for us (i.e., private GPs) to manage. So that’s where you all (i.e., ComSA-PCMH) have the time and the facilities to get them (i.e., the patients), get together, mix together, and socialise together. That’s important. Because a lot of them are lonely you see. So that’s what community centre is about, and you facilitate that. And then you give… erm… You have the gym, you have the dancing classes, that’s useful, and maybe once in a while have a visiting physiotherapist, something like that. That’ll be useful. But to have clinics to take over from GPs… I don’t think GPs will be happy with that… we don’t refer at the same level (i.e., to physicians in ComSA-PCMH). We refer to specialists. You know what I mean?” (Private GP #2)
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