Family Medicine Clinic: a case study of a hospital–family medicine practice redesign to improve chronic disease care in the community in Singapore

Family Medicine Clinic: a case study of a hospital–family medicine practice redesign to improve... Abstract Background Singapore’s health care system is strained by the health care needs of a rapidly aging population. The unprecedented collaboration between a public hospital and a private family practice to set up the Family Medicine Clinic (FMC) to co-manage patients with chronic disease is an example of efforts to shift care to the community. Objective To explore patients’ initial experience of shared chronic disease care in a private family practice setting. Methods In this exploratory case study, we surveyed 330 patients with stable chronic diseases and interviewed 10 complex care patients and their caregivers. Results Most patients were willing to transfer their care from the hospital to a FMC and satisfied with the care received. Patients reported enhanced access at FMC and appreciated the improvement in care continuity and care coordination across settings. Patients with complex care needs felt engaged with their case manager even though they did not understand case management. Despite the favourable assessment of FMC, patients sought care from other health care providers and a third of patients would leave if the subsidy for their care at FMC was removed. Families and caregivers felt that their needs could be better addressed and that FMC could play a role. Conclusions To ensure that patients’ initial positive experience translates to a long-term relationship with FMC, providers should move beyond providing improved access to care. It is necessary to help patients understand the comparative advantage of community-based care and its contribution to long-term health outcomes. Providers should also elicit patients’ desires and expectations when designing future models of care. At a policy level, higher cost of private primary care should be addressed. Health services accessibility, patient-centred care, patient participation, primary health care, quality of health care Introduction As in many developed countries, Singapore’s health care burden, especially with its aging population, will rise sharply in the next two decades. At present, private GPs make up 80% of all primary care providers, but the bulk of chronic disease care is delivered by public hospitals and public primary care clinics. Policymakers realize that the public health care system cannot cope and that there is a need to move from public, hospital-centric care to community-based care (1,2). The Singapore Ministry of Health’s Healthcare 2020 Master Plan targeted the enhancement and increased involvement of the private primary care sector. In line with the plan, the family medicine clinics (FMCs) initiative was launched in 2013 (3). An FMC is a collaboration between private GP groups and a public hospital to provide community-based integrated chronic disease care. In total, six FMCs were established in different regions of Singapore. In this exploratory case study, we examined an FMC pilot that started in mid-2013. One reason for selecting this FMC was that it was the first attempt to adopt the 2014 National Committee on Quality Assurance (NCQA) guidelines for patient-centred medical home (PCMH) (4). The FMC facility was purpose built and located in a suburban shopping mall, connected to public transport hubs. It was larger than the average GP clinic, with diagnostic facilities, podiatry and rooms for patient counselling. The two collaborators (the hospital and the private GP group) committed various resources to FMC: the hospital transferred a pharmacist, case manager and care coordinators to FMC, while the GP group relocated physicians and support staff from other practices. Shared care of complex cases between hospital and FMC was established. The electronic medical record systems of both institutions were linked. Such resource sharing and arrangements for hospital staff to work on-site and seamlessly with a GP practice were unprecedented in Singapore. The intention was to lay the foundation for better-coordinated, team-based care between the hospital and FMC. An initial study of 1000 patients (with 100 high-risk patients) showed that patients had better access to primary care and reduced their utilization of hospital care, including emergency room visits (5). Heterogeneity of health care utilization Unlike the norm in countries such as the UK, most Singaporeans do not have a family physician to act as a gatekeeper and be the main source of health care. Only 39% of Singaporeans reported having a regular family doctor or GP, of which 13% would also seek care from other providers (6,7). In the most recent Primary Care Survey (8), 4 of the top 10 medical conditions seen at public primary care clinics were chronic conditions, while at private GP practices only one condition among the top 10 was a chronic condition. Singaporeans often sought care with specialists, as evidenced by the Household Expenditure Survey (9), which showed that 58% of household expenditure on outpatient services was for specialty care. Without a primary care gatekeeper system, Singaporeans have the freedom to select providers based on convenience, medical needs and costs. With the ability to freely choose and change health care providers, it was uncertain how patients would react to a new form of care where chronic disease management was shifted from hospital specialist clinics to private primary care. The hospital and private GP who collaborated in the FMC recognized that there was a need to educate patients. In the first year of the FMC pilot, they developed patient education materials for FMC. A marketing video clip was developed and shown in the waiting areas of hospital specialist clinics, and the hospital assigned care coordinators to specialist clinics to recruit eligible patients to transfer care to FMC. However, patients were not involved in the development and implementation of FMC or in the production of the patient education material. The objective of this study was to explore patients’ initial experience of the new model of care. Specifically, we explored patients’ understanding of their transition to FMC, their initial assessment of the quality of FMC care and their perception of FMC compared with other providers. We hope the findings might inform the future development of FMCs or similar integrated community-based chronic care models in Singapore and other Asian countries. Methods Patient recruitment We adopted an exploratory case study approach to collect data from two groups of patients (from September 2014 to March 2015). The first group was patients with stable chronic diseases and they received their care at FMC (with little or no shared care with hospital specialists). The second group was patients with complex care needs who received case management, home visits and shared care between FMC GPs and hospital specialists. The reason for studying the two groups was because their care experiences were not entirely similar: e.g. complex care patients experienced hospitalizations for their chronic conditions, they had more interactions with hospital and FMC providers, and the intensity of care was higher. Patients with stable chronic diseases were recruited on-site at FMC and interviewed face-to-face using a structured questionnaire. We included patients aged 18 and above who had received care at least twice at FMC, were referred to FMC by the hospital and could speak English, Chinese or Malay. We excluded walk-in patients and those referred by emergency departments. The recruitment process took longer than anticipated because of the following reasons: (i) in the first few months of the FMC’s launch, the number of eligible patients referred from the hospital was low; (ii) two other research teams were recruiting patients and we attempted to avoid weeks when they were recruiting; (iii) there were periods such as holiday seasons in which patient recruitment did not occur and (iv) the research team relied on three fulltime students who were unable to recruit patients during examinations and holidays. Despite these challenges, we averaged about six to seven patients a day during the effective recruitment periods. Patients were selected across race, age, language and gender, at different times of day, and on weekdays and weekends. This was done to increase the representativeness of the sample. Of 414 patients approached, 313 agreed to be interviewed. The reasons for refusal were as follows: interviewed by other research teams (49%), busy (6%), unwell (4%), emotionally upset (4%) and unable to read (3%). Others did not give a reason. Patients with complex care needs were identified by the case manager who requested on our behalf for an interview. Semi-structured interviews were conducted at their homes. Interviews were conducted by a trained qualitative researcher with a clinical background. Each interview lasted between 60 and 75 minutes. Patients were recruited to represent different demographic groups. They had three or more hospitalizations a year, two or more chronic conditions and received case management. Ten patients and their caregivers participated in the interviews. Exploring patient experience The survey and in-depth interview questions were based on dimensions of frameworks of patient-centred care developed by the American Academy of Family Physicians and the Picker Institute (10,11). Topics covered were transition from hospital to primary care, access to services, respect for patients’ preferences and expressed needs, coordination of care services, education and communication, emotional support, and involvement of the family. Among patients receiving case management, we examined the case manager’s role and interactions with patients. Analysis Survey answers were transcribed into electronic form for analysis. Univariate and multivariate analyses were performed using IBM SPSS Statistics version 23 (12). Multivariate analyses examined the care experiences of vulnerable patient groups: the elderly, less educated and non-English speaking. In-depth interviews of complex care patients were audio-taped, transcribed and translated. Two researchers (YWL and JL) independently coded and analysed the in-depth interviews. Discrepancies and disagreements were discussed between the two researchers and reconciled. A third researcher (AC) examined the themes and analysis and provided feedback and validation. Interviews were conducted until data saturation was reached. Themes were explored and reported in relation to the dimensions of patient-centred care as described earlier. Results Patients were representative of the Singapore population by race, but were older and had a lower level of education (see Table 1). Patients were referred to FMC from specialist departments including endocrinology, cardiology, nephrology, neurology and general surgery. Most patients had been followed up at FMC for less than a year. 49.7% of patients reported having more than one chronic condition. Diabetes and hypertension were most commonly reported. Table 1. Demographic characteristics of the study population n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  COPD, chronic obstructive pulmonary disease; FMC, family medicine clinic. View Large Table 1. Demographic characteristics of the study population n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  COPD, chronic obstructive pulmonary disease; FMC, family medicine clinic. View Large Transition from hospital to family medicine clinic We examined whether patients were given explanations on why they were advised to seek chronic disease care at FMC. The three most common explanations provided to patients to shift care were as follows: proximity to home (33.9%), shorter wait time (26.7%) and stable conditions that did not require hospital care (23.3%). 10.6% of patients could not recall being given an explanation. Other reasons offered were varied (see Table 2), ranging from lower cost to hospital policy. 8.6% of patients were unable to recall whether the hospital staff mentioned FMC. None of the patients recalled being given reasons related to quality of care or long-term benefits. Despite the heterogeneous range of reasons given to patients, 86% were happy being transferred. There were no significantly different levels of satisfaction across age groups and educational levels. Half the patients did not know they could be transferred back to hospital specialist care if they chose to. Table 2. Reasons given to patients to encourage them to transfer to the family medicine clinic Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  FMC, family medicine clinic. View Large Table 2. Reasons given to patients to encourage them to transfer to the family medicine clinic Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  FMC, family medicine clinic. View Large The views of patients with complex care needs echoed those from the survey. One theme that emerged was the lack of explanation of the advantages of FMC care for their complex care needs compared with the status quo. Some did not even recall being given an explanation of why they were referred to FMC. Patients thought FMC was part of the hospital, an outpatient department in the community. One patient suggested that FMC was the hospital’s ‘sister company’. Patients explained that the hospital and FMC divided their care for the various medical conditions—there was no expectation that all their health care needs were managed at FMC. It was felt FMC could not do everything. Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient 2:  Yes. Interviewer: This is okay for you? Patient 2:  It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things… (can’t be done at FMC). Incomplete understanding of case management Patients did not fully understand the purpose of case management. They were aware that the case manager was a nurse but saw her more as an administrator, helping them with tasks such as making medical appointments. They initially found it puzzling that a health care provider would monitor their health from afar, via frequent telephone calls. Some even felt that the calls were unnecessary. However, over time, patients began to value the regular calls and were pleasantly surprised when the case manager visited them at home or when they were hospitalized. Patients valued the personal attention and the case manager’s extra effort to build a relationship with them (see Table 3 for quotes under ‘Case management’) Table 3. Interview quotes of complex care patients Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  COPD, chronic obstructive pulmonary disease; EMR, electronic medical records; FMC, family medicine clinic. View Large Table 3. Interview quotes of complex care patients Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  COPD, chronic obstructive pulmonary disease; EMR, electronic medical records; FMC, family medicine clinic. View Large Access to family medicine clinic care was improved Patients were generally satisfied with access to care at FMC. Among the surveyed patients, 60% reported shorter waiting times compared with the hospital or public primary care clinics; 49% said FMC was closer to their homes. Of the 50% of patients who telephoned FMC, 88% found it easy to reach someone who could help. Patients who used email (2.7%) to contact FMC physicians found they were replied promptly. Multivariate analyses did not show that vulnerable patient groups reported having poorer access to care. Complex care patients appreciated that FMC was open on Saturdays and FMC physicians and the case manager would usually respond to phone calls promptly. However, complex care patients, being frailer, expressed concerns about the long wait time for consultation when the clinic was busy. Even with an appointment, the wait time could be as long as 2 hours. Wheelchair access to the clinic was also poor. As a result of such challenges, one caregiver suggested that home visits by FMC physicians would be beneficial, not only for patients’ comfort but also to spare caregivers the burden of accompanying patients to FMC. Valuing continuity of care while still using other types of care Patients valued continuity of their care, in particular a sustained relationship with their physicians. Ninety-three per cent of patients indicated that having the same physician would ensure better care (72% of them did see the same physician at FMC). Patients with complex needs agreed, saying that it built trust that allowed them to share their concerns candidly. Patients valued visits by FMC physicians when they were hospitalized. (It is uncommon for GPs to visit patients in hospitals.) Ninety-one per cent of patients appreciated that FMC providers kept themselves informed of patients’ medical status and treatment plan. Compared with physicians at other primary care clinics, patients reported that FMC physicians showed greater patience, spent more time listening to their concerns and provided more explanation. Caregiver 3: Dr Z (FMC physician) was very good…she talks to my husband, advised him nicely, I am satisfied, my children are satisfied. Dr Z was so detailed in her explanation…she was very kind. Patient 2:  We feel comfortable when we see Dr X. When a patient see a doctor, he must feel…umm…good. Not like some doctors, when you see them you feel…a barrier. Dr X, we feel good when we see him. Despite their apparent satisfaction, patients divided their care needs among different providers: for minor illnesses, they visited the nearest GP; only 18% would go to FMC. When patients developed a new health problem (not a transient minor illness), 30% went to FMC, 30% to the hospital specialist and 40% to other primary care providers. For chronic diseases care, 35% of patients who received care at FMC sought care elsewhere, for example, with hospital specialists or a complementary and alternative medical practitioner. Half of all patients sought care from two or more different settings. Interviewer: If anything happened (in relation to chronic disease managed at FMC) you will first go to Dr Y (from the FMC). Caregiver 4: Yes. Interviewer: Even for minor illnesses? Or do you go to a GP nearby? Caregiver 4: Yes, I will take her to the GP (using a wheelchair). Interviewer: Would you consider taking your grandmother to Dr Y (FMC)? Caregiver 4: No. It is quite difficult for her. She can’t walk. Employment-based insurance coverage also compelled some patients to seek care from an approved panel of doctors for conditions not under the care of FMC. Care coordination between the hospital and family medicine clinic Patients’ perceptions of care coordination between the hospital and FMC were favourable. Ninety per cent of patients felt the hospital and FMC providers worked well together, and 84% felt they shared information effectively. Complex care patients were satisfied with care coordination between hospital and FMC; many highlighted the importance of linked electronic medical record systems between the two sites, explaining that FMC providers kept abreast of their care plans. They appreciated that FMC doctors consulted hospital doctors when the need arose. Caregiver 1: Ms X (FMC case manager) shared my views with Dr Y (FMC physician). Dr Y called two days later and said that he had discussed (the medical problem) with the ENT and neurology doctors about my mom’s condition. The suggestion is to not see the ENT doctor until my mom has started physiotherapy (for her dizziness). The absence of coordinated care was one reason patients thought public polyclinics to be inadequate. Not only did patients not see the same doctor at every visit, doctors did not always know what was done for patients at the hospital. Patients had to repeat their medical history and explain recent developments in their chronic conditions. In contrast, patients felt reassured that FMC providers would communicate with hospital doctors when necessary. Personal attention and communication valued Patients perceived that a great strength of FMC was the time spent and attention provided by FMC physicians and the case manager. They valued the thoroughness of FMC physicians’ management of their medical problems, taking time to explain their problems and suggesting treatment options. Patients contrasted their FMC experience to that in hospitals or polyclinics, where doctors spent only a few minutes with them. Patients appreciated FMC physicians’ efforts to educate them on their conditions. However, treatment decisions were made by physicians—there was no joint decision making. Patient 3: When I speak to Ms X, it is building a relationship, makes us closer...makes me feel at home. Patient 3: My relationship with Dr Y is super, very close. He knows me, he calls me at home…he was the first person to visit me when I was readmitted, do you know? Cost of care an issue Both sets of patients—whether with stable or complex chronic conditions—agreed that cost was an important consideration. Eighty-seven per cent of patients received a financial subsidy for FMC care, but only 33% intended to continue with FMC if the subsidy was removed. Without the subsidy, the cost of care at FMC exceeded that of hospital specialist care. Patients would sometimes consider hospitalization so as to receive subsidized care. Patient 10: If FMC charges $50 per visit and the hospital charges $33, I think most people will go back to the hospital. Interviewer: If FMC could manage a few of your conditions, would it make sense for you to continue care there? Patient 10:  Yes, but my expenses will be more and they cannot be claimed (to receive reimbursement from government subsidy). There were other cost considerations. The cost of transport was not trivial, patients might have to hire a larger taxi that could accommodate a wheelchair and caregivers had to take time off to take patients to FMC and to the hospital for tests. Support for patient and caregivers Caregiver needs and social services were largely not addressed by FMC and the health care system in general. Lack of help in identifying sources of respite care and assistance in applying for financial subsidy caused much frustration, especially among low-income families. For example, patients and caregivers reported receiving inadequate post-discharge instructions, not knowing how FMC or other service providers would take over their care and what caregivers were supposed to do. Caregivers suggested improving support for elderly patients, such as having FMC coordinate with social service agencies to provide home-based support, respite for caregivers and help with activities of daily living. One caregiver wanted FMC to be a ‘one-stop shop’ for all health and social services. Patients also suggested that FMC could have more counselling and education sessions for patients and families. Discussion This study is the first to report patients’ initial experiences with the first PCMH-inspired practice in Singapore. On the whole, patients were satisfied with care received at FMC. They reported improved access to providers, better care coordination and increased attention by physicians to their medical needs. Patients who received case management appreciated the regular monitoring of their complex needs. Despite the favourable assessment, patients did not perceive or utilize FMC as a medical home, a place where they would seek all their health care needs. Family medicine clinic not perceived as a medical home Unlike the UK but similar to Asian countries such as Japan, South Korea, Taiwan and Hong Kong (China), Singapore does not have a primary care system built around a gatekeeper family physician who manages most care needs for individuals and their families. The lack of a primary care gatekeeper has resulted in Singaporeans seeking care with various providers depending on needs and preferences. Our study findings mirror those of Asian countries without a gatekeeper system (13–16). Half of FMC patients sought care from two or more providers. Even with the provision of an FMC-specific subsidy, patients sought care elsewhere based on convenience (e.g. proximity to home or workplace). Experiencing better access to care and greater continuity of personalized attention from physicians did not convince patients to consolidate care at FMC. Cost disparity Cost of care is a concern for Singaporeans. In a survey, 84% of Singaporeans ranked rising health care costs as their top concern (17). When hospital-based chronic care is subsidized, it is not surprising Singaporeans would be reluctant to utilize private primary care which could be more expensive and incurs out-of-pocket expenses. Our study showed that without a subsidy, patients would discontinue their chronic disease care at FMC. Similar cost-sensitive decision making was at play when patients in Hong Kong were asked about choosing between public and private health care providers (13,18). If FMC and similar public–private models of care are to succeed in the future, the disparity in cost between public and private providers would have to be addressed. Perception of primary care Another challenge is patients’ perception that private GP practices are small and lack hospitals’ capacity to provide comprehensive care. Patients in our study suggested that they did not expect FMC to fulfil all their chronic care needs. This aligns with the general perception in other Asian countries that GPs do not have the specialized expertise to treat chronic diseases (14,19,20). To convince patients that FMC—or primary care in general—is a viable and legitimate substitute for hospital specialist care, a multi-pronged approach should be used. First, private family practices would need to build capacity to manage chronic diseases and work in closer partnership with specialty care. Health care financing policies would need to value chronic disease care and dis-incentivize high throughout service provision that exists in practice. Patients need more than financial incentives to stay with primary care for their needs—greater efforts should be made to explain the value of long-term relationship with one primary care provider. Moreover, in public–private partnerships such as FMC, patients need to be reassured that they still receive shared care (from specialist and family physician) and that they are not ‘abandoned’ to the community (19,21,22). More patient engagement is needed The lack of patient engagement in the process of designing FMC, and the consequent deficit in understanding the needs of the patients in the community, probably contributed to patients’ perception that FMC was not different from other GP practices. Some patients in our study perceived FMC as an extension of the hospital and their suggestions for service improvements were hospital-based services. It would have been beneficial if the collaborators had sought patients’ ideas and aspirations for community-based care before the launch of FMCs. If patients’ views had been considered, they might have had greater ownership of FMC (23) and better health outcomes (24). Final thoughts On the surface, it seemed FMC was a success because a significant proportion of patients transferred their care from hospital to FMC. However, this success could be short-lived. Our study shows that patients will not gravitate to and stay with a new model of care just because it is convenient, accessible and relatively affordable. The introduction of any new model of care is challenging. The challenge is intensified when patients have alternatives. Even if patients do switch, they may not use the new model of care as intended. In the case of FMC, patients used some chronic care services but did not treat FMC as a medical home, defeating one of its original purposes. Our study shows that for shared chronic care models (partnership) to succeed, health care providers and policymakers should remember that the benefits of new models of care are not readily apparent. Efforts must be made to explain the unique and differentiating strengths of the new model, which are absent in existing models of care. These explanations should as far as possible be made not from providers’ perspective but from the patients’ perspective. In the long run, a model of care can be sustained only if patients believe it was designed for them and appreciate its value and advantages over other competing models. Declaration Funding: This study was supported by National University of Singapore, Office of the Deputy President (Research and Technology). Ethical approval: This study was approved by the National University of Singapore Institutional Review Board. Conflict of interest: The authors on this paper declare that there is no conflict of interest. The funder of this research project, National University of Singapore, Office of the Deputy President (Research and Technology), was not involved in the design and implementation of the study. References 1. George PP, Oh CM, Loh PT, Heng BH, Lim FS. Right-siting chronic kidney disease care-a survey of general practitioners in Singapore. Ann Acad Med Singapore  2013; 42: 646– 56. Google Scholar PubMed  2. Tan S. 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Joint Principles of the Patient-Centered Medical Home. 2007; http://www.medicalhomeinfo.org/Joint%20Statement.pdf (accessed on 10 November 2017). 11. Picker Institute. Principles of Patient-Centered Care. http://pickerinstitute.org/about/picker-principles/ (accessed on 6 February 2018). 12. IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 22.0 . Armonk, NY: IBM Corp, 2015. 13. Lee A, Siu S, Lam Aet al.   The concepts of family doctor and factors affecting choice of family doctors among Hong Kong people. Hong Kong Med J  2010; 16: 106– 15. Google Scholar PubMed  14. Lynn AM, Shih TC, Hung CHet al.   Characteristics of ambulatory care visits to family medicine specialists in Taiwan: a nationwide analysis. PeerJ  2015; 3: e1145. Google Scholar CrossRef Search ADS PubMed  15. OECD Reviews of Health Care Quality: Japan 2015: Raising Standards . 2015; http://dx.doi.org/10.1787/9789264225817-en (accessed on 20 November 2017). 16. OECD Reviews of Health Care Quality: Korea 2012: Raising Standards . 2012; http://dx.doi.org/10.1787/9789264173446-en (accessed on 17 November 2017). 17. Wong K. Housing, Jobs and Healthcare Weigh Heaviest on Minds of Singaporeans, Survey Finds . 2015; http://www.channelnewsasia.com/news/singapore/housing-jobs-and-healthcare-weigh-heaviest-on-minds-of-singapore-8232062 (accessed on 24 November 2017). 18. Liu S, Yam CH, Huang OH, Griffiths SM. Willingness to pay for private primary care services in Hong Kong: are elderly ready to move from the public sector? Health Policy Plan  2013; 28: 717– 29. Google Scholar CrossRef Search ADS PubMed  19. Ock M, Kim JE, Jo MWet al.   Perceptions of primary care in Korea: a comparison of patient and physician focus group discussions. BMC Fam Pract  2014; 15: 178. Google Scholar CrossRef Search ADS PubMed  20. Takamura A. The present circumstance of primary care in Japan. Qual Prim Care  2015; 23: 262–6. 21. van Weel C, Kassai R, Tsoi GWet al.   Evolving health policy for primary care in the Asia Pacific region. Br J Gen Pract  2016; 66: e451– 3. Google Scholar CrossRef Search ADS PubMed  22. Mercer SW, Siu JY, Hillier SMet al.   A qualitative study of the views of patients with long-term conditions on family doctors in Hong Kong. BMC Fam Pract  2010; 11: 46. Google Scholar CrossRef Search ADS PubMed  23. Spanjol J, Cui AS, Nakata Cet al.   Co-production of prolonged, complex, and negative services: an examination of medication adherence in chronically ill individuals. J Serv Res  2015; 18: 284– 302. Google Scholar CrossRef Search ADS   24. Health Policy Brief: Patient Engagement. Health Affairs . February 14, 2013. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Family Medicine Clinic: a case study of a hospital–family medicine practice redesign to improve chronic disease care in the community in Singapore

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Background Singapore’s health care system is strained by the health care needs of a rapidly aging population. The unprecedented collaboration between a public hospital and a private family practice to set up the Family Medicine Clinic (FMC) to co-manage patients with chronic disease is an example of efforts to shift care to the community. Objective To explore patients’ initial experience of shared chronic disease care in a private family practice setting. Methods In this exploratory case study, we surveyed 330 patients with stable chronic diseases and interviewed 10 complex care patients and their caregivers. Results Most patients were willing to transfer their care from the hospital to a FMC and satisfied with the care received. Patients reported enhanced access at FMC and appreciated the improvement in care continuity and care coordination across settings. Patients with complex care needs felt engaged with their case manager even though they did not understand case management. Despite the favourable assessment of FMC, patients sought care from other health care providers and a third of patients would leave if the subsidy for their care at FMC was removed. Families and caregivers felt that their needs could be better addressed and that FMC could play a role. Conclusions To ensure that patients’ initial positive experience translates to a long-term relationship with FMC, providers should move beyond providing improved access to care. It is necessary to help patients understand the comparative advantage of community-based care and its contribution to long-term health outcomes. Providers should also elicit patients’ desires and expectations when designing future models of care. At a policy level, higher cost of private primary care should be addressed. Health services accessibility, patient-centred care, patient participation, primary health care, quality of health care Introduction As in many developed countries, Singapore’s health care burden, especially with its aging population, will rise sharply in the next two decades. At present, private GPs make up 80% of all primary care providers, but the bulk of chronic disease care is delivered by public hospitals and public primary care clinics. Policymakers realize that the public health care system cannot cope and that there is a need to move from public, hospital-centric care to community-based care (1,2). The Singapore Ministry of Health’s Healthcare 2020 Master Plan targeted the enhancement and increased involvement of the private primary care sector. In line with the plan, the family medicine clinics (FMCs) initiative was launched in 2013 (3). An FMC is a collaboration between private GP groups and a public hospital to provide community-based integrated chronic disease care. In total, six FMCs were established in different regions of Singapore. In this exploratory case study, we examined an FMC pilot that started in mid-2013. One reason for selecting this FMC was that it was the first attempt to adopt the 2014 National Committee on Quality Assurance (NCQA) guidelines for patient-centred medical home (PCMH) (4). The FMC facility was purpose built and located in a suburban shopping mall, connected to public transport hubs. It was larger than the average GP clinic, with diagnostic facilities, podiatry and rooms for patient counselling. The two collaborators (the hospital and the private GP group) committed various resources to FMC: the hospital transferred a pharmacist, case manager and care coordinators to FMC, while the GP group relocated physicians and support staff from other practices. Shared care of complex cases between hospital and FMC was established. The electronic medical record systems of both institutions were linked. Such resource sharing and arrangements for hospital staff to work on-site and seamlessly with a GP practice were unprecedented in Singapore. The intention was to lay the foundation for better-coordinated, team-based care between the hospital and FMC. An initial study of 1000 patients (with 100 high-risk patients) showed that patients had better access to primary care and reduced their utilization of hospital care, including emergency room visits (5). Heterogeneity of health care utilization Unlike the norm in countries such as the UK, most Singaporeans do not have a family physician to act as a gatekeeper and be the main source of health care. Only 39% of Singaporeans reported having a regular family doctor or GP, of which 13% would also seek care from other providers (6,7). In the most recent Primary Care Survey (8), 4 of the top 10 medical conditions seen at public primary care clinics were chronic conditions, while at private GP practices only one condition among the top 10 was a chronic condition. Singaporeans often sought care with specialists, as evidenced by the Household Expenditure Survey (9), which showed that 58% of household expenditure on outpatient services was for specialty care. Without a primary care gatekeeper system, Singaporeans have the freedom to select providers based on convenience, medical needs and costs. With the ability to freely choose and change health care providers, it was uncertain how patients would react to a new form of care where chronic disease management was shifted from hospital specialist clinics to private primary care. The hospital and private GP who collaborated in the FMC recognized that there was a need to educate patients. In the first year of the FMC pilot, they developed patient education materials for FMC. A marketing video clip was developed and shown in the waiting areas of hospital specialist clinics, and the hospital assigned care coordinators to specialist clinics to recruit eligible patients to transfer care to FMC. However, patients were not involved in the development and implementation of FMC or in the production of the patient education material. The objective of this study was to explore patients’ initial experience of the new model of care. Specifically, we explored patients’ understanding of their transition to FMC, their initial assessment of the quality of FMC care and their perception of FMC compared with other providers. We hope the findings might inform the future development of FMCs or similar integrated community-based chronic care models in Singapore and other Asian countries. Methods Patient recruitment We adopted an exploratory case study approach to collect data from two groups of patients (from September 2014 to March 2015). The first group was patients with stable chronic diseases and they received their care at FMC (with little or no shared care with hospital specialists). The second group was patients with complex care needs who received case management, home visits and shared care between FMC GPs and hospital specialists. The reason for studying the two groups was because their care experiences were not entirely similar: e.g. complex care patients experienced hospitalizations for their chronic conditions, they had more interactions with hospital and FMC providers, and the intensity of care was higher. Patients with stable chronic diseases were recruited on-site at FMC and interviewed face-to-face using a structured questionnaire. We included patients aged 18 and above who had received care at least twice at FMC, were referred to FMC by the hospital and could speak English, Chinese or Malay. We excluded walk-in patients and those referred by emergency departments. The recruitment process took longer than anticipated because of the following reasons: (i) in the first few months of the FMC’s launch, the number of eligible patients referred from the hospital was low; (ii) two other research teams were recruiting patients and we attempted to avoid weeks when they were recruiting; (iii) there were periods such as holiday seasons in which patient recruitment did not occur and (iv) the research team relied on three fulltime students who were unable to recruit patients during examinations and holidays. Despite these challenges, we averaged about six to seven patients a day during the effective recruitment periods. Patients were selected across race, age, language and gender, at different times of day, and on weekdays and weekends. This was done to increase the representativeness of the sample. Of 414 patients approached, 313 agreed to be interviewed. The reasons for refusal were as follows: interviewed by other research teams (49%), busy (6%), unwell (4%), emotionally upset (4%) and unable to read (3%). Others did not give a reason. Patients with complex care needs were identified by the case manager who requested on our behalf for an interview. Semi-structured interviews were conducted at their homes. Interviews were conducted by a trained qualitative researcher with a clinical background. Each interview lasted between 60 and 75 minutes. Patients were recruited to represent different demographic groups. They had three or more hospitalizations a year, two or more chronic conditions and received case management. Ten patients and their caregivers participated in the interviews. Exploring patient experience The survey and in-depth interview questions were based on dimensions of frameworks of patient-centred care developed by the American Academy of Family Physicians and the Picker Institute (10,11). Topics covered were transition from hospital to primary care, access to services, respect for patients’ preferences and expressed needs, coordination of care services, education and communication, emotional support, and involvement of the family. Among patients receiving case management, we examined the case manager’s role and interactions with patients. Analysis Survey answers were transcribed into electronic form for analysis. Univariate and multivariate analyses were performed using IBM SPSS Statistics version 23 (12). Multivariate analyses examined the care experiences of vulnerable patient groups: the elderly, less educated and non-English speaking. In-depth interviews of complex care patients were audio-taped, transcribed and translated. Two researchers (YWL and JL) independently coded and analysed the in-depth interviews. Discrepancies and disagreements were discussed between the two researchers and reconciled. A third researcher (AC) examined the themes and analysis and provided feedback and validation. Interviews were conducted until data saturation was reached. Themes were explored and reported in relation to the dimensions of patient-centred care as described earlier. Results Patients were representative of the Singapore population by race, but were older and had a lower level of education (see Table 1). Patients were referred to FMC from specialist departments including endocrinology, cardiology, nephrology, neurology and general surgery. Most patients had been followed up at FMC for less than a year. 49.7% of patients reported having more than one chronic condition. Diabetes and hypertension were most commonly reported. Table 1. Demographic characteristics of the study population n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  COPD, chronic obstructive pulmonary disease; FMC, family medicine clinic. View Large Table 1. Demographic characteristics of the study population n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  n = 330  Total, n (%)  Male  172 (52.1)  Age, mean (SD)  64 (13.5)  Race   Chinese  250 (75.8)   Malay  49 (14.8)   Indian  26 (7.9)   Others  5 (1.5)  Marital status   Married  240 (72.7)   Widowed  51 (15.5)   Single  20 (6.1)   Divorced/separated  19 (5.8)  Highest education level   No formal education/incomplete primary  118 (35.8)   Primary/incomplete secondary  86 (26.1)   Secondary education  72 (21.8)   Tertiary (university or polytechnic)  54 (16.4)  Mean duration of care received at FMC   <6 months  135 (40.9)   6 months to a year  98 (29.7)   1–2 years  88 (26.7)   >2 years  4 (1.2)  Self-rated health   Excellent  8 (2.4)   Very good  31 (9.4)   Good  142 (43.0)   Fair  133 (40.3)   Poor  15 (4.5)  Self-reported existing chronic conditions   Diabetes  108 (32.7)   Hypertension  101 (30.6)   Cardiovascular disease (including heart failure and ischaemic heart diseases)  89 (27.0)   Hyperlipidaemia  56 (17.0)   Stroke  38 (11.5)   Gastrointestinal disease (peptic ulcer and gastric reflux disease)  34 (10.3)   Asthma/COPD  27 (8.2)   Eye conditions (such as glaucoma)  23 (7.0)   Arthritis/rheumatism  18 (5.5)  Neurological conditions: unspecified  17 (5.2)  Patients with two or more chronic conditions  164 (49.7)  Language spoken   English  174 (52.7)   Non-English  156 (47.3)  COPD, chronic obstructive pulmonary disease; FMC, family medicine clinic. View Large Transition from hospital to family medicine clinic We examined whether patients were given explanations on why they were advised to seek chronic disease care at FMC. The three most common explanations provided to patients to shift care were as follows: proximity to home (33.9%), shorter wait time (26.7%) and stable conditions that did not require hospital care (23.3%). 10.6% of patients could not recall being given an explanation. Other reasons offered were varied (see Table 2), ranging from lower cost to hospital policy. 8.6% of patients were unable to recall whether the hospital staff mentioned FMC. None of the patients recalled being given reasons related to quality of care or long-term benefits. Despite the heterogeneous range of reasons given to patients, 86% were happy being transferred. There were no significantly different levels of satisfaction across age groups and educational levels. Half the patients did not know they could be transferred back to hospital specialist care if they chose to. Table 2. Reasons given to patients to encourage them to transfer to the family medicine clinic Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  FMC, family medicine clinic. View Large Table 2. Reasons given to patients to encourage them to transfer to the family medicine clinic Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  Reason for referral  Percentage of patients  Proximity to patients’ home  33.9  Shorter wait time  26.7  Stable chronic condition(s)  23.3  FMC’s connection with the hospital  15.5  No reason provided  10.6  Similar quality of care to hospital specialist  7.9  Subsidy provided  7.0  Convenience (e.g. transportation, opening hours)  4.8  Easier to follow up on chronic condition(s)  4.8  Less expensive  3.3  Availability of the same doctor  3.3  ‘One stop shop’ for all care needs  1.2  Availability of medications from the hospital  0.9  Hospital doctors on foreign travel  0.9  Easier access to doctors, e.g. via phone or email  0.9  Hospital policy  0.6  FMC, family medicine clinic. View Large The views of patients with complex care needs echoed those from the survey. One theme that emerged was the lack of explanation of the advantages of FMC care for their complex care needs compared with the status quo. Some did not even recall being given an explanation of why they were referred to FMC. Patients thought FMC was part of the hospital, an outpatient department in the community. One patient suggested that FMC was the hospital’s ‘sister company’. Patients explained that the hospital and FMC divided their care for the various medical conditions—there was no expectation that all their health care needs were managed at FMC. It was felt FMC could not do everything. Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient 2:  Yes. Interviewer: This is okay for you? Patient 2:  It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things… (can’t be done at FMC). Incomplete understanding of case management Patients did not fully understand the purpose of case management. They were aware that the case manager was a nurse but saw her more as an administrator, helping them with tasks such as making medical appointments. They initially found it puzzling that a health care provider would monitor their health from afar, via frequent telephone calls. Some even felt that the calls were unnecessary. However, over time, patients began to value the regular calls and were pleasantly surprised when the case manager visited them at home or when they were hospitalized. Patients valued the personal attention and the case manager’s extra effort to build a relationship with them (see Table 3 for quotes under ‘Case management’) Table 3. Interview quotes of complex care patients Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  COPD, chronic obstructive pulmonary disease; EMR, electronic medical records; FMC, family medicine clinic. View Large Table 3. Interview quotes of complex care patients Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  Perception that FMC is linked to hospital  FMC and the hospital are like sister companies, right? (Patient 3) I think they (hospital and FMC) are linked. That’s why they are discharging hospital patients here (FMC) (Patient 10) FMC should be a center where everything is provided for the patient. (Caregiver 2) Interviewer: Do you mean FMC is a ‘department’ that manages blood pressure, diabetes, and her lung problems, while hospital specialist departments take care of the rest (cardiac and liver conditions)? Patient: Yes (Patient 6) Interviewer: This is okay for you? Patient: It’s okay for me, because FMC can’t take care of everything. They (hospital) have to do scans and tests, such as blood test…all these things…(can’t be done at FMC). (Patient 6)  Seeking care beyond FMC  I will take her [patient] to the GP for small matters like cough, fever because it’s quite difficult for my granny to go to FMC. She can’t walk. (Caregiver 4) I might as well seek care for all my conditions in the hospital…because all of my health records are there. Case notes (in paper form) are there (in the hospital), whereas the FMC doctor is only looking at what’s in the system (hospital-linked electronic medical record system). (Patient 6) We occasionally see a GP who we consider our family doctor because FMC is not open on Sundays. (Patient 1)  FMC’s access to care  If he [FMC doctor] speaks Hokkien (Chinese dialect), I will understand. If he speaks Chinese (Mandarin) I can’t understand. (Patient 5) Dr X (FMC doctor) will call us back if we say that we need something. (Patient 3) He [FMC doctor] asked us to call him. He is very concerned about his patients. Sometimes he will call us to check how our mom is doing. He said, ‘if you don’t understand anything, you can call me. Even if I am busy, I will return your call afterwards.’ And he did return our calls. (Caregiver 3) There are many patients nowadays. For treatment there are only two nurses at FMC. I think they need to improve that. We won’t have to wait for regular appointments. For my mother, how long can she sit in the wheelchair? She is very fragile. When FMC was new it was less crowded. And we can stick with the same doctor. That’s what we want. (Caregiver 2) My mother is very fragile. Of course I understand this must be done on a case by case basis; if there was a (regular) doctor who does home visits, it would be helpful. All my savings and annual leave are used to take my mother to the clinic. (Caregiver 2)  Care coordination  That’s why I like FMC. Because they have my records in their system. I think he (FMC doctor) reads through my records. He knows what is going on with me visiting different doctors. (Patient 4) They (FMC) could read my information (in the EMR). I mentioned I have COPD (diagnosed at the hospital), the FMC staff said they know my entire (medical) history. (Patient 3) (But) I find certain decisions I have to go back to hospital doctors. He (FMC doctor) has to leave it to them. I don’t expect him to make all the decisions, one doctor versus seven specialists. (Patient 3) I think the doctor (at FMC) knows what is going on in the hospital because the other day when we went (to FMC), he wanted to do a blood test but the nurse told us ‘I noticed that you just had a blood test in the morning. It’s a bit too soon to do another…let’s wait for the result.’ (Patient 7) I did not receive clear instructions on what to do when the same thing (hospitalization) happens again. There were no instructions regarding what needs to be done or when the patient needs to go back to the doctor (FMC). (Patient 1) Dr X (doctor) or Ms J (case manager) …both of them coordinate well. (Patient 1)  The value of a personal physician  Every time we visit the government primary care clinic we see a different doctor and we have to repeat the same thing over and over again. And the wait time is long at the government clinic. (Patient 2) It is very far from home to FMC and we were offered to see a nearer clinic but we refused because we wanted to stick to the same doctor at this FMC. (Patient 1) I was shocked when Dr X (FMC) came…this is the first time a doctor visited me in hospital. And then Ms J (FMC case manager) corresponded with me. This is very good. (Patient 6) He (FMC physician) knows what happened during my granny’s admission and her past history in the hospital. And when my granny was admitted, the FMC doctor went down to visit my granny. (Caregiver 3) He (FMC doctor) is very detailed and asks about everything. Government primary clinic doctors don’t. (Patient 7) Dr X (FMC doctor) is better than the hospital specialist doctor. (Caregiver 3) You can ask questions and you feel comfortable with the doctor. You can say: ‘I don’t want this medication, is there a problem? I like using the nebulizer. Can you prescribe that instead?’ (Patient 4) If I trust the doctor I leave it to him. Dr X, said he wanted to talk to Dr Y about my condition, my pain and the next stage of medication. I said, ‘You know what is best for me, I leave it to you’. (Patient 8)  Case management  Later on he (FMC doctor) introduced Ms J [case manager] to us. So now, if anything happens, we call Ms J first because the doctor is very busy. Sometimes the case manager calls us too. (Patient 1) There is a difference having [the case manager]. The case manager will call and ask about the [Patient’s] sugar level every day for the whole week. If the sugar level is too high or too low, she will tell the caregiver what to do. (Caregiver 2) The calls from [the case manager] are good. It helps build closer relationships. I feel that someone cares about me. (Patient 4) [The case manager] used to call and ask about the sugar level. She is very good, very friendly; she came and visit my husband in the hospital. Somebody is there to monitor my husband; I like this type of service. (Caregiver 2) I find it troublesome. Somebody calls you out of the blue. When I was in the kitchen, I had to rush to turn off the stove because [the case manager] called. (Patient 3) She [case manager] is quite hard to contact. Sometimes she doesn’t reply. Then out of the blue she would reply—not very accessible. The last appointment I could not make it so I texted her… she didn’t reply. I had to call the clinic that I could not make it and needed to change to another day. (Patient 10)  COPD, chronic obstructive pulmonary disease; EMR, electronic medical records; FMC, family medicine clinic. View Large Access to family medicine clinic care was improved Patients were generally satisfied with access to care at FMC. Among the surveyed patients, 60% reported shorter waiting times compared with the hospital or public primary care clinics; 49% said FMC was closer to their homes. Of the 50% of patients who telephoned FMC, 88% found it easy to reach someone who could help. Patients who used email (2.7%) to contact FMC physicians found they were replied promptly. Multivariate analyses did not show that vulnerable patient groups reported having poorer access to care. Complex care patients appreciated that FMC was open on Saturdays and FMC physicians and the case manager would usually respond to phone calls promptly. However, complex care patients, being frailer, expressed concerns about the long wait time for consultation when the clinic was busy. Even with an appointment, the wait time could be as long as 2 hours. Wheelchair access to the clinic was also poor. As a result of such challenges, one caregiver suggested that home visits by FMC physicians would be beneficial, not only for patients’ comfort but also to spare caregivers the burden of accompanying patients to FMC. Valuing continuity of care while still using other types of care Patients valued continuity of their care, in particular a sustained relationship with their physicians. Ninety-three per cent of patients indicated that having the same physician would ensure better care (72% of them did see the same physician at FMC). Patients with complex needs agreed, saying that it built trust that allowed them to share their concerns candidly. Patients valued visits by FMC physicians when they were hospitalized. (It is uncommon for GPs to visit patients in hospitals.) Ninety-one per cent of patients appreciated that FMC providers kept themselves informed of patients’ medical status and treatment plan. Compared with physicians at other primary care clinics, patients reported that FMC physicians showed greater patience, spent more time listening to their concerns and provided more explanation. Caregiver 3: Dr Z (FMC physician) was very good…she talks to my husband, advised him nicely, I am satisfied, my children are satisfied. Dr Z was so detailed in her explanation…she was very kind. Patient 2:  We feel comfortable when we see Dr X. When a patient see a doctor, he must feel…umm…good. Not like some doctors, when you see them you feel…a barrier. Dr X, we feel good when we see him. Despite their apparent satisfaction, patients divided their care needs among different providers: for minor illnesses, they visited the nearest GP; only 18% would go to FMC. When patients developed a new health problem (not a transient minor illness), 30% went to FMC, 30% to the hospital specialist and 40% to other primary care providers. For chronic diseases care, 35% of patients who received care at FMC sought care elsewhere, for example, with hospital specialists or a complementary and alternative medical practitioner. Half of all patients sought care from two or more different settings. Interviewer: If anything happened (in relation to chronic disease managed at FMC) you will first go to Dr Y (from the FMC). Caregiver 4: Yes. Interviewer: Even for minor illnesses? Or do you go to a GP nearby? Caregiver 4: Yes, I will take her to the GP (using a wheelchair). Interviewer: Would you consider taking your grandmother to Dr Y (FMC)? Caregiver 4: No. It is quite difficult for her. She can’t walk. Employment-based insurance coverage also compelled some patients to seek care from an approved panel of doctors for conditions not under the care of FMC. Care coordination between the hospital and family medicine clinic Patients’ perceptions of care coordination between the hospital and FMC were favourable. Ninety per cent of patients felt the hospital and FMC providers worked well together, and 84% felt they shared information effectively. Complex care patients were satisfied with care coordination between hospital and FMC; many highlighted the importance of linked electronic medical record systems between the two sites, explaining that FMC providers kept abreast of their care plans. They appreciated that FMC doctors consulted hospital doctors when the need arose. Caregiver 1: Ms X (FMC case manager) shared my views with Dr Y (FMC physician). Dr Y called two days later and said that he had discussed (the medical problem) with the ENT and neurology doctors about my mom’s condition. The suggestion is to not see the ENT doctor until my mom has started physiotherapy (for her dizziness). The absence of coordinated care was one reason patients thought public polyclinics to be inadequate. Not only did patients not see the same doctor at every visit, doctors did not always know what was done for patients at the hospital. Patients had to repeat their medical history and explain recent developments in their chronic conditions. In contrast, patients felt reassured that FMC providers would communicate with hospital doctors when necessary. Personal attention and communication valued Patients perceived that a great strength of FMC was the time spent and attention provided by FMC physicians and the case manager. They valued the thoroughness of FMC physicians’ management of their medical problems, taking time to explain their problems and suggesting treatment options. Patients contrasted their FMC experience to that in hospitals or polyclinics, where doctors spent only a few minutes with them. Patients appreciated FMC physicians’ efforts to educate them on their conditions. However, treatment decisions were made by physicians—there was no joint decision making. Patient 3: When I speak to Ms X, it is building a relationship, makes us closer...makes me feel at home. Patient 3: My relationship with Dr Y is super, very close. He knows me, he calls me at home…he was the first person to visit me when I was readmitted, do you know? Cost of care an issue Both sets of patients—whether with stable or complex chronic conditions—agreed that cost was an important consideration. Eighty-seven per cent of patients received a financial subsidy for FMC care, but only 33% intended to continue with FMC if the subsidy was removed. Without the subsidy, the cost of care at FMC exceeded that of hospital specialist care. Patients would sometimes consider hospitalization so as to receive subsidized care. Patient 10: If FMC charges $50 per visit and the hospital charges $33, I think most people will go back to the hospital. Interviewer: If FMC could manage a few of your conditions, would it make sense for you to continue care there? Patient 10:  Yes, but my expenses will be more and they cannot be claimed (to receive reimbursement from government subsidy). There were other cost considerations. The cost of transport was not trivial, patients might have to hire a larger taxi that could accommodate a wheelchair and caregivers had to take time off to take patients to FMC and to the hospital for tests. Support for patient and caregivers Caregiver needs and social services were largely not addressed by FMC and the health care system in general. Lack of help in identifying sources of respite care and assistance in applying for financial subsidy caused much frustration, especially among low-income families. For example, patients and caregivers reported receiving inadequate post-discharge instructions, not knowing how FMC or other service providers would take over their care and what caregivers were supposed to do. Caregivers suggested improving support for elderly patients, such as having FMC coordinate with social service agencies to provide home-based support, respite for caregivers and help with activities of daily living. One caregiver wanted FMC to be a ‘one-stop shop’ for all health and social services. Patients also suggested that FMC could have more counselling and education sessions for patients and families. Discussion This study is the first to report patients’ initial experiences with the first PCMH-inspired practice in Singapore. On the whole, patients were satisfied with care received at FMC. They reported improved access to providers, better care coordination and increased attention by physicians to their medical needs. Patients who received case management appreciated the regular monitoring of their complex needs. Despite the favourable assessment, patients did not perceive or utilize FMC as a medical home, a place where they would seek all their health care needs. Family medicine clinic not perceived as a medical home Unlike the UK but similar to Asian countries such as Japan, South Korea, Taiwan and Hong Kong (China), Singapore does not have a primary care system built around a gatekeeper family physician who manages most care needs for individuals and their families. The lack of a primary care gatekeeper has resulted in Singaporeans seeking care with various providers depending on needs and preferences. Our study findings mirror those of Asian countries without a gatekeeper system (13–16). Half of FMC patients sought care from two or more providers. Even with the provision of an FMC-specific subsidy, patients sought care elsewhere based on convenience (e.g. proximity to home or workplace). Experiencing better access to care and greater continuity of personalized attention from physicians did not convince patients to consolidate care at FMC. Cost disparity Cost of care is a concern for Singaporeans. In a survey, 84% of Singaporeans ranked rising health care costs as their top concern (17). When hospital-based chronic care is subsidized, it is not surprising Singaporeans would be reluctant to utilize private primary care which could be more expensive and incurs out-of-pocket expenses. Our study showed that without a subsidy, patients would discontinue their chronic disease care at FMC. Similar cost-sensitive decision making was at play when patients in Hong Kong were asked about choosing between public and private health care providers (13,18). If FMC and similar public–private models of care are to succeed in the future, the disparity in cost between public and private providers would have to be addressed. Perception of primary care Another challenge is patients’ perception that private GP practices are small and lack hospitals’ capacity to provide comprehensive care. Patients in our study suggested that they did not expect FMC to fulfil all their chronic care needs. This aligns with the general perception in other Asian countries that GPs do not have the specialized expertise to treat chronic diseases (14,19,20). To convince patients that FMC—or primary care in general—is a viable and legitimate substitute for hospital specialist care, a multi-pronged approach should be used. First, private family practices would need to build capacity to manage chronic diseases and work in closer partnership with specialty care. Health care financing policies would need to value chronic disease care and dis-incentivize high throughout service provision that exists in practice. Patients need more than financial incentives to stay with primary care for their needs—greater efforts should be made to explain the value of long-term relationship with one primary care provider. Moreover, in public–private partnerships such as FMC, patients need to be reassured that they still receive shared care (from specialist and family physician) and that they are not ‘abandoned’ to the community (19,21,22). More patient engagement is needed The lack of patient engagement in the process of designing FMC, and the consequent deficit in understanding the needs of the patients in the community, probably contributed to patients’ perception that FMC was not different from other GP practices. Some patients in our study perceived FMC as an extension of the hospital and their suggestions for service improvements were hospital-based services. It would have been beneficial if the collaborators had sought patients’ ideas and aspirations for community-based care before the launch of FMCs. If patients’ views had been considered, they might have had greater ownership of FMC (23) and better health outcomes (24). Final thoughts On the surface, it seemed FMC was a success because a significant proportion of patients transferred their care from hospital to FMC. However, this success could be short-lived. Our study shows that patients will not gravitate to and stay with a new model of care just because it is convenient, accessible and relatively affordable. The introduction of any new model of care is challenging. The challenge is intensified when patients have alternatives. Even if patients do switch, they may not use the new model of care as intended. In the case of FMC, patients used some chronic care services but did not treat FMC as a medical home, defeating one of its original purposes. Our study shows that for shared chronic care models (partnership) to succeed, health care providers and policymakers should remember that the benefits of new models of care are not readily apparent. Efforts must be made to explain the unique and differentiating strengths of the new model, which are absent in existing models of care. These explanations should as far as possible be made not from providers’ perspective but from the patients’ perspective. In the long run, a model of care can be sustained only if patients believe it was designed for them and appreciate its value and advantages over other competing models. Declaration Funding: This study was supported by National University of Singapore, Office of the Deputy President (Research and Technology). Ethical approval: This study was approved by the National University of Singapore Institutional Review Board. Conflict of interest: The authors on this paper declare that there is no conflict of interest. The funder of this research project, National University of Singapore, Office of the Deputy President (Research and Technology), was not involved in the design and implementation of the study. References 1. George PP, Oh CM, Loh PT, Heng BH, Lim FS. Right-siting chronic kidney disease care-a survey of general practitioners in Singapore. Ann Acad Med Singapore  2013; 42: 646– 56. Google Scholar PubMed  2. Tan S. 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Stick to a Regular Doctor, Urges Health Promotion Board . The Straits Times. Jul 14, 2014; http://www.straitstimes.com/singapore/health/stick- to-a-regular-doctor-urges-health-promotion-board (accessed on 9 November 2017). 7. National Health Survey 2010. The Ministry of Health, Singapore. 2010; https://www.moh.gov.sg/content/moh_web/home/Publications/Reports/2011/national_health_survey2010.html (accessed on 7 November 2017). 8. Primary Care Survey 2010. The Ministry of Health, Singapore. 2010; https://www.moh.gov.sg/content/moh_web/home/Publications/Reports/2014/primary-care-survey-2010-report.html (accessed on 8 November 2017). 9. Household Expenditure Survey 2012/13. The Singapore Department of Statistics. 2014; http://www.singstat.gov.sg/publications/household-expenditure-survey (accessed on 10 November 2017). 10. American Academy of Family Physicians, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. 2007; http://www.medicalhomeinfo.org/Joint%20Statement.pdf (accessed on 10 November 2017). 11. Picker Institute. Principles of Patient-Centered Care. http://pickerinstitute.org/about/picker-principles/ (accessed on 6 February 2018). 12. IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 22.0 . Armonk, NY: IBM Corp, 2015. 13. Lee A, Siu S, Lam Aet al.   The concepts of family doctor and factors affecting choice of family doctors among Hong Kong people. Hong Kong Med J  2010; 16: 106– 15. Google Scholar PubMed  14. Lynn AM, Shih TC, Hung CHet al.   Characteristics of ambulatory care visits to family medicine specialists in Taiwan: a nationwide analysis. PeerJ  2015; 3: e1145. Google Scholar CrossRef Search ADS PubMed  15. OECD Reviews of Health Care Quality: Japan 2015: Raising Standards . 2015; http://dx.doi.org/10.1787/9789264225817-en (accessed on 20 November 2017). 16. OECD Reviews of Health Care Quality: Korea 2012: Raising Standards . 2012; http://dx.doi.org/10.1787/9789264173446-en (accessed on 17 November 2017). 17. Wong K. Housing, Jobs and Healthcare Weigh Heaviest on Minds of Singaporeans, Survey Finds . 2015; http://www.channelnewsasia.com/news/singapore/housing-jobs-and-healthcare-weigh-heaviest-on-minds-of-singapore-8232062 (accessed on 24 November 2017). 18. Liu S, Yam CH, Huang OH, Griffiths SM. Willingness to pay for private primary care services in Hong Kong: are elderly ready to move from the public sector? Health Policy Plan  2013; 28: 717– 29. Google Scholar CrossRef Search ADS PubMed  19. Ock M, Kim JE, Jo MWet al.   Perceptions of primary care in Korea: a comparison of patient and physician focus group discussions. BMC Fam Pract  2014; 15: 178. Google Scholar CrossRef Search ADS PubMed  20. Takamura A. The present circumstance of primary care in Japan. Qual Prim Care  2015; 23: 262–6. 21. van Weel C, Kassai R, Tsoi GWet al.   Evolving health policy for primary care in the Asia Pacific region. Br J Gen Pract  2016; 66: e451– 3. Google Scholar CrossRef Search ADS PubMed  22. Mercer SW, Siu JY, Hillier SMet al.   A qualitative study of the views of patients with long-term conditions on family doctors in Hong Kong. BMC Fam Pract  2010; 11: 46. Google Scholar CrossRef Search ADS PubMed  23. Spanjol J, Cui AS, Nakata Cet al.   Co-production of prolonged, complex, and negative services: an examination of medication adherence in chronically ill individuals. J Serv Res  2015; 18: 284– 302. Google Scholar CrossRef Search ADS   24. Health Policy Brief: Patient Engagement. Health Affairs . February 14, 2013. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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Family PracticeOxford University Press

Published: Feb 17, 2018

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