Abstract
Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).
Highlights
A robust primary care (PC) system is the foundation to a high-functioning health system and healthy populations [1,2]
Diffusion of innovations—which is a theory explaining the process experienced by individuals when adopting new ideas, products, services, etc.—emerged as the overarching theory to contextualize ComSA-Patient-Centered Medical Home (PCMH)’s early implementation
Using a grounded theory approach, this study unpacked the complexities in change strategies, initial experience and perception, and lessons learned from implementing a new PCMH in Singapore
Summary
A robust primary care (PC) system is the foundation to a high-functioning health system and healthy populations [1,2]. With the aging of the population, there are increasing pressures for PC to manage older, chronically ill patients with complex needs such as multimorbidity, geriatric syndromes, co-existing cognitive impairments, mental illness, or psychosocial vulnerabilities [3,4,5]. Complex chronic patients require the provision of care that is person-centered, comprehensive, coordinated, and longitudinal. These requirements are often unmet by PC practices that lack adequate training, multidisciplinary care teams, appropriate practice infrastructure, and payment systems [5,6,7]. PC, complex chronic patients experience worse health outcomes and consume higher proportions of healthcare services and costs [8,9].
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