Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations

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 with ClinicalTrials.gov (Protocol ID: NCT04594967).

Early Implementation of a Patient-centered Medical Home in Singapore: a Qualitative Study Using Theories on Diffusion of Innovations

Background: Primary care (PC) reform is imperative to meet the demands of a rising number of chronically ill patients with complex needs. Patient-Centered Medical Home (PCMH) is a new care model that was found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. Guided by the PCMH principles, “ComSA-PCMH” was developed to proactively deliver integrated PC to a specific population with complex needs. This study explored the change strategies, initial experience and perception, and lessons learnt during its early implementation.Methods: A grounded theory approach was employed. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners and other PC providers. The theoretical framework on diffusion of innovations by Greenhalgh and colleagues (2015) was used to determine theoretical saturation, reorganize data, and provide insights to the emerging themes.Results: “Diffusion of innovation” emerged as an overarching theory to contextualize ComSA-PCMH and its early implementation. ComSA-PCMH was differentiated from usual PC through three innovations: i) team-based and integrated care; ii) empanelment; and iii) shared care with private general practitioners. Their corresponding change strategies were: i) repurposing pre-existing services and infrastructure; ii) partnership to create supporting infrastructure and pathways in the delivery system; and iii) targeted outreach. Initial experience of the implementers was characterized by “assimilation”, which was a cyclical process of experimentation, negotiations, and adaptations. Initial perception of the implementation partners was characterized by “adoption”, which was affected by perceived value of ComSA-PCMH and perceived burden in implementation. Initial perception of the private general practitioners was also characterized by adoption, which was affected by a lack of awareness and understanding of ComSA-PCMH. Lessons were learnt about ways to work with the complexity and novelty of the innovations.Conclusions: ComSA-PCMH employed creative and pragmatic strategies to overcome country-specific contextual challenges and the inherent complexities of the care model. Assimilation and adoption were identified as the challenging steps, as they involve complex processes participated by multiple players who might exhibit less predictable, self-organizing behaviors.Trial Registration: This study was retrospectively registered with ClinicalTrials.gov (Protocol ID: NCT04594967).

Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

Background The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation. Methods The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline. Results We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (β= -0.01, p-value = 0.35) and EQ VAS score (β=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (β = 1.34, p-value = 0.05) and 6 months post-enrolment (β = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (β = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment. Conclusions Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.