An odd couple: A large public hospital working with a small private general practice group to integrate care

Introduction : For the first time in Singapore, a large public hospital partnered with a small for-profit general practice group to implement a patient-centered medical home pilot to provide collaborative care for patients with chronic diseases. The pilot, Family Medicine Clinic (FMC), is in its third year of operation. We studied the organizational processes and outcomes of the FMC implementation and share insights learned for future collaborations of similar nature. Practice change : A significant amount of chronic care in Singapore is provided by hospitals. The Ministry of Health of Singapore (MOH) and major healthcare system leaders recognize that the status quo is not sustainable. As a result, MOH recently launched health policies that attempt to encourage care integration across healthcare entities. One such policy was the development of FMCs where a private GP practice works with a regional health system and more specifically, a large public hospital, to provide integrated care for patients with chronic diseases. The aim was to move care out of hospitals to the community. In this study, we examined a specific FMC that was set up in 2012 with human and logistical resources from the public hospital and the private GP group, and additional financial support from the Ministry of Health for a three-year pilot. Patients with chronic diseases such as diabetes and heart failure who were previously managed by the public hospital specialists were transferred to FMC’s team of providers with continued linkages with the hospital. The purpose of this study is to examine the process and experiences of working together. Key findings : The study utilized a mixed-method approach that collected data from 44 healthcare providers, administrators and senior leaders from a large, public tertiary care hospital and private GP group. The data were collected using (1) an organizational survey that measured role clarity, role strain, role conflict, perceived organizational support, organizational citizenship behavior, and job satisfaction; and (2) a series of semi-structured interviews eliciting experiences and perceptions of the collaboration between the two organizations and the implementation process in the first two years. The analytic strategy was to complement the organizational survey findings with interviews, exploring deeper the development of the partnership as experienced by both sets of employees. Our key findings revealed the challenges of collaboration on a new venture by two very different partners – large public tertiary hospital and a smaller, more nimble private GP practice. First, the development of work and organizational processes at the FMC were often reactive rather than structured or planned, challenging employees to be adaptable while working within the framework and constraints of the two partners. For example, when the rate of patient referrals from the hospital to FMC was lower than expected, FMC’s medical director started a “roadshow” by introducing FMC through talks and presentation at various hospital clinical departments. Instead of being trained or prepared for their roles, case managers had to learn how to execute their role on the job, with new colleagues, in a new setting and with unfamiliar patients. As a consequence, role strain and perception of increased workload among FMC staff was not uncommon. The strain was exacerbated by differing perceptions of staffs’ roles in the partnership and differences in the understanding of the goals of setting up FMC. Some staff perceived that the goal of FMC was to shift care of hospital-based patients to the community; others saw the goal of FMC as developing a new model of primary care for the future. Nevertheless, despite the challenges in implementation, most employees from both organizations recognized the significance of the pilot and expressed a willingness to work together. Lessons learned : The development of a partnership to provide joint care between two organizations with different organizational settings and motivations may require more deliberate planning. In this case, both partners could have benefited from capacity building among their employees, a clear organization structure with roles and responsibilities and a planning process. Having said that, as can be seen in this unexpected challenges may arise so it is important to plan while allowing some flexibility in the implementation. A shared understanding of the goal and purpose of the partnership could have facilitated working together. Because the partners were so different - one public and large, the other for-profit and small - having a shared social goal was essential for a successful collaboration. Finally, active and regular dialogue and feedback between employees from both partners on work-related matters is important to sustaining the partnership. Conclusion : With a trend to shift chronic care to the community, collaboration between public hospitals and for-profit GP groups (as well other community-based providers) will become commonplace. This study has shown that in order to develop a productive and positively evolving collaboration, greater attention should be given in bringing the collaborating partners to acknowledge a shared social goal, and a willingness to allow implementation adjustments to take place as the collaboration unfolds.