The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context

Abstract

In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory techniques. Power dynamics between the stakeholders and lack of shared decision-making among them in selecting the locale of the PCMH and formulating the practice fee and pharmacy structure were the key factors which negatively affected the implementation of PCMHs on a larger scale. Over time, lack of funding to hire dedicated staff to transfer patients and misalignment of various stakeholders’ interest to other right-siting programs also resulted in low number of patients with chronic conditions and revenue. Countries seeking to implement a successful PCMH may benefit from building trust and relationship between stakeholders, engaging in shared decision-making, ongoing cost-efficiency efforts, and formulating a clear delineation of responsibilities between stakeholders. For a healthcare delivery model to succeed in the primary care landscape, policies should be developed keeping mind the realities of primary care practice.

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

“…Strengths of this study include the PCMH program being a complex intervention that contained multiple components for meeting the multi-dimensional needs of patients, including aspects of comprehensive assessments in the clinic and the home setting, a multidisciplinary care team, individualised care plans, shared decision-making as well as empanelment, having strict inclusion criteria for study participants, a low loss to follow up rate, and using validated instruments to examine outcomes. Our study contributes to the literature by investigating the impact of PCMH on quantitative patientreported outcome measures in an Asian context, with current literature in Singapore focusing on qualitatively examining implementation challenges [27].…”

“…Findings from this investigation would have important implications on changes in the delivery of primary healthcare and health policies for older adults with complex needs. This study also addresses the knowledge gap in implementing a PCMH model in an Asian context [27]. We hypothesise that older persons identified as having biopsycho-social needs who receive the PCMH intervention would have improved self-reported QoL and patient activation over time.…”

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

“…However, relatively little has been published about these pioneering PCMH initiatives. One study evaluated patient experience (36), while another study examined implementation challenges, which included high setting-up costs, unfamiliarity with new care models and restrictions in utilizing RHS-based health nancing schemes (13).…”

“…However, it is well known that PC reform is time-consuming, costly, and unpredictable in its outcomes. Without appropriate change strategies, the possibility of failures, burnout and nancial losses are real for PC providers participating in these reforms (12,13).…”

“…(Implementer #13) ComSA-PCMH) model's different, and the competencies required is actually higher. And we almost cannot hire people with that kind of training background, experience nor certainly not people with that kind of mindset required in the service model… So when you hire somebody, you have to really train them up to the competencies of the model, while getting them to understand why we chose to do things the way we do" (Implementer #13)…”