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

Abstract

Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. "Diffusion of innovations" emerged as an overarching theory to contextualize PCMH in its early implementation. Three core "innovations" differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to "adopt" and "assimilate" the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).

Keywords: Patient-Centered Medical Home; adoption; assimilation; complex needs; implementation; innovation; primary care.

Conflict of interest statement

C.H.W. is employed by Tsao Foundation by the time following manuscript writing, but not affiliated to it at the time of study conception, data collection, data analysis, and manuscript writing. H.J.M.V. has received previous funding from Tsao Foundation as the advisor for this study and currently receiving funding for other studies. The remaining authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Figures

Figure 1

Simplified theoretical framework on the diffusion of innovation with definitions for its key constructs. Adapted from [25].

Figure 2

Key themes for Innovations, Change Strategies, Initial Experience and Perception, and Lessons Learnt. TF: Tsao Foundation; RHS: Regional Health System; GPs: General Practitioners; PC: Primary Care; CM: Care Management.

Figure 3

The theme of assimilation emerged from the cyclical relationships between three categories (negotiation, experimentation, and adaptation). Categories were developed from clusters of related codes (examples in italics). Supporting theory (in shaded boxes, adapted from [25,50]) was used to identify categories and emerging themes.

Figure 4

The “hard core” and the “soft peripheries” in a complex innovation. Adapted from [25].