Integrating care for health equity: a third sector initiated primary care innovation in Singapore

Using a qualitative we also their strategies to strategic


Introduction
Chronic disease management involves both biomedical as socio-behavioural components. Increased chronic disease burden calls for better integration of social care. In Singapore, social care is traditionally provided by the third sector known as the 'Social Service Agencies' (SSAs), whose on-the-ground presence enables deeper understanding of the complexities when addressing the determinants of health. Hence, SSAs are increasingly engaged in public-privatethird sector collaborations to deliver integrated care as Singapore's population ages. In this paper, we describe an SSA-initiated integrated primary care innovation with a Restructured Hospital for older persons with complex care needs, called the "ComSA PCMH" (Community of Successful Ageing Patient-Centred Medical Home). Using a qualitative approach, we also explored their strategies to develop strategic partnerships and integrated services.

Theory / Methods
Nineteen semi-structured in-depth interviews were conducted with the implementers and partners of the innovation between November 2017 and July 2020. Purposive sampling and data analysis were guided by the theoretical framework on the diffusion of innovation by Greenhalgh et al (2004). Tacit knowledge about the innovation owned by two analysts was made explicit through reflexivity and discussions, then used in the analysis.
Results: ComSA PCMH underwent three-fold integration 1) service integration between a primary care clinic for older persons and a home-based care management team; 2) vertical integration between the primary care clinic and hospital-based specialist care; and 3) horizontal integration with other community-based providers.
Adoption of (2) and (3) required formal arrangements to create new structures (e.g., a new site for care) and revise processes (e.g., systematic referrals). It also required informal relationship building at all levels (i.e., strategic leaders, middle managers, on-the-ground providers) from the outset. Implementation of (1) was characterised by a non-linear assimilation process, facilitated by experimentation and negotiation, and punctuated by multiple meanings made of the innovation by providers from different service orientations. Lim: Integrating care for health equity: a third sector initiated primary care innovation in Singapore

Discussions
By integrating services for specialist, primary and social care, ComSA PCMH and its multi-sectoral implementation partners created an ecosystem of care that addresses equity at two levels for the: 1) individual: that socio-behavioural determinants in health are given equal attention; 2) system: with care shifted from hospital to the community and from health to social, health system resources are better allocated based on needs. However, this ecosystem is complex rendering its implementation experimental, with multiple adaptations based on learning-by-doing.

Conclusions
Given sufficient resources and effective partnership strategies, third sector's community orientation may be useful to address complex determinants of health through integrated care delivery. However, sensemaking of an innovation takes time, due to the need for relationship building, experimentation and negotiation.

Lessons learned
Integrating social care into the health system requires structural, functional and cultural change, which requires time. Multi-sectoral partnerships are crucial for sustaining the change and for leveraging on unique sets of skills, experience and resources.

Limitations
Limited application of a longitudinal perspective, barring deeper understanding of the evolution of the innovation.

Suggestions for future research
The continual development, evolution and assimilation of this new model of integrated care warrants longitudinal investigations.