Introduction:
HealthPathways (HPW) is an online health information portal which provides General Practitioners (GPs), guidance on the assessment, management, and referral of a range of conditions linked to local resources. It has been adopted as an aid to improve the integration of patient care across the health system. However, there is a lack of understanding of the acceptance of pathways within primary health.


Theory/Methods
This qualitative study identified baseline factors that promote the successful implementation of HPW in a major Local Health District (LHD) in Australia. The development, implementation and acceptance of Diabetes HPW was evaluated using semi-structured interviews with purposive samples. Interviews were digitally recorded, transcribed, and analysed qualitatively using a thematic analysis approach.


Results
A total of 16 interview transcripts were analysed. Four core themes were identified in relation to the processing of implementing the HPW: 1. The importance of creating & maintaining collaborative partnerships through the development of the pathways (engagement); 2. the process promoted trust and understanding between organisations and made their individual aims, processes and values clearer to one another (transparency); 3. HPW implementation was also seen as means of committing individual organisations to provide standardised and consistent care across the Local Health District (accountability); and, 4. the importance of providing adequate funding and resources to support the ongoing development and revision of HPW (Sustainability).


Discussions
This process evaluation provides additional, qualitative evidence about what facilitates the successful implementation of HPW and identifies barriers that hinder its success. Researchers anticipated the interview protocol would elicit an overall discussion about the strengths and limitations of HPW, as opposed to only about the Type 2 DM pathways; in particular its usability and utility, and suggested improvements or factors that might contribute to its success. An inductive approach was employed to conduct an analysis that extracted common themes amongst the qualitative data.

Conclusions:
This study provides an insight into the development and implementation of Type 2 Diabetes Mellites HPW across different levels of the health system in the LHD. The feedback and experiences from implementation and utilisation of the HPW across different levels of the health system and program implementation, provides the GP with an overall informed perspective on the acceptability of the pathways, what the general consensus is on its applicability and a transparent view on the impacts that the HPW may have on its day-to-day use.

Lessons learned
Collaboration between individuals and organisations has strengthened the development and implementation of the HPW. Engagement and transparency have demonstrated the significance of establishing collaborative partnerships to implement HPW.

Limitations
Despite a number of strategies to encourage the participation of GPs, the recruitment of GPs to take part in interviews was a challenge for the research team.

Suggestions for future research
Further research would be useful to investigate and explore the health outcomes and impact of HPW on the community including broader scope for evaluation of multiple pathways to identify the best ways of ensuring sustainability and uptake of the program.

Introduction:Healthcare systems struggle to provide community-based care for increasingly complex older adults with multiple needs that require coordinated strategies to facilitate the complementary provision of health and social care services. Patient-centered medical home (PCMH) has been seen as a suitable community care model for complex older adults in Singapore as the regional health system is looking at addressing this issue longitudinally in the community. This study aimed to understand the fidelity, adaptation strategy and barriers in implementing a community-based geriatric hub that adopted a PCMH model in providing integrated primary care for complex older adults in Singapore.
Theory/Methods:Joint principles of PCMH with National Committee for Quality Assurance primary care practice recognition procedures and standards were adopted for the conceptual framework on practice transformation and implementation fidelity. We used an explanatory approach combining both deductive and inductive method in analysis. Qualitative data consisted of 14 semi-structured interviews and one focus group discussion with implementers, including practice’s staff, management, administrator and network partners, conducted between November 2017 and June 2018.
Results:Six themes emerged from the data - (1)transformation to PCMH required individual and organizational transformation to be supported by practice readiness, capability, integration and effective communication; (2)time, trust and buy-in together with effective outreach were needed to build strong partnerships with institutional network and primary care partners; (3)whole-person orientation with relationship-based care and shared-decision making; (4)care coordination and integration required sufficient level of clarity in workflow and in establishing feedback loops; (5)team-based effort was required to provide comprehensive care plan for complex patients with multiple needs, (6)sufficient resources are required for practice to be responsive to patients’ needs.
Discussions:PCMH required organizational change that focused on enhancing the patient experience. This required transformation in several levels including individual, organization, and the network affiliations/healthcare system. Unfamiliarity and confusion to the new care model was a challenge as the organization needed time to evolve to an integrated care model and continuous quality improvement to achieve the PCMH. Effective communication and effort for integration were cited to be vital in improving ownership within organization and to partner networks outside the organization.
Conclusions:Implementation was progressing towards aligning care goals to PCMH principles. However, there still existed challenges in adaptation towards the practice transformation which required continuous changes in several levels of organization.
Lessons learned:Building strong relationship and aligned understanding both within the organization and with network affiliations and partners were vital in implementing a seamless patient-centered care model that emphasized on enhancing patient experience. Moving toward becoming a learning organization with sharing, monitoring, and ongoing learning for continually improving patient-centered care are keys to adaptation strategy.
Limitations:Findings have not included views from patients, hence only reflect the PCMH experience from the implementers’ and network partners’ perception.
Suggestions for future research:Future research may consider having multiple qualitative data at different time points to fully capture the adaptation mechanism and theory of change. Action research framework could be adopted with active participation and collaborative working between researchers and implementers to gain practical knowledge in developing the programme.