Table 2 Thematic findings and exemplary quotes

Participant responsiveness:

Users

Appreciative: convenience and providers’ positive attributes

“(The CC is) very friendly, very approachable, and helpful. You can ask them questions and they have answers.” (Patient)

Limited understanding of the program

“I think they (patients) are still not sure of this program yet. This program is about 2 to 3 years old. So it’s quite new I don’t think people take note that there is such home care service.” (CC)

Misconception of program

“I don’t know whether how satisfied patient and family are. Sometimes, they really think that the home visit is just ‘trying to disrupt my usual routine’.” (CC)

Participant responsiveness: Providers

Confused: regarding the program direction

“We don’t have the clear guidelines. My departments doesn’t know what is coming is next. You do not want to walk a journey or road where you don’t know where it is leading to.” (CC)

Frustrated: impossible to avoid hospitalization

“Elderly patients are more fragile, they get broken skin and more delicate. They are also more susceptible to side effects of the chemotherapy and the drug that we are giving them. So then in this case is we educate family on how to take care of the symptoms. When patient has fever, (drowsiness) … we (call) them few times to bring him in. This is an example we cannot avoid hospitalization.” (CC)

Lack of training: communication and psychological issues

“We are not trained to (do) psychological assessment. Actually our boss thinks that we should be trained so he has actually liaised with the psychological department but they are still liaising.”(CC)

Anxious: Job security

“The security of our job is very real (concerns) to us … If the program suddenly shuts down, where can we go?” (CC)

Low morale: no confidence or satisfaction

“You don’t feel the sense of confidence, you don’t feel satisfied because you feel that this piece of work you are doing can close up anytime you know. In the end they (client) die natural death.” (CC)

Complexity of program

Multiple complex needs: require many components of interventions

“The patients need intensive rehabilitation because: i. their medical conditions are very complex, ii. they may or may not have severe illnesses, iii. They have combination of many chronic diseases so families can’t manage.” (Program manager)

Evolving agendas:

changes in recruitment criteria

“They actually changed their recruitment criteria. Initially, they mentioned that as long as a patient has 3 admissions in any hospital, then we can recruit. But now they change it – out of the 3 admissions, at least have one admission must be in National University Hospital – then we can recruit the patient.” (CC)

Changes in leadership: changed program direction

“We have done this model and got used to it. So suddenly there’s (new leadership) and a new model coming. Any changes (in the model) people are like, “oh what is our position?” We are still unclear, where should we place ourselves, so that makes people think" where’s the future?” (CC)

Facilitating strategies

Use of common electronic medical records (EMR)

“We (the healthcare providers) share the same electronic platform … physicians can look through the system at all the investigations (done for the patients).” (Physician)

Guiding protocols

“We have a checklist to go through the process, standardized protocol. So we started with in-patient, (do) the assessment, then each component (like) medical, social.” (Program manager)

Healthcare financing: funding and subsidy

“There are two main sources of funding, there is program funding and “get well” funding. Based on the means testing levels, there is the corresponding funding or (subsidy).” (Physician)

“This program is heavily subsidised, so typically every week, the full cost will range to be about $600 weekly, so after subsidy it comes out to $80–100. For this program, majority of the patients, we are charging them about 20% of the cost, and the remaining is actually funded through our Ministry of Health funding sources … For needy patients, they would not need to pay anything.” (Program manager)

Recruitment

Selection criteria: to guide recruitment

“If the patient has 3 times or more admissions, then we will enroll the patient. Of course we will have to ask (for) patient’s permission.” (CC)

Conflict in professional opinions of CC and the program selection criteria

“Ok, this one (client has) limited mobility and I will say if patient gets home care will be better. It’s not like they cannot walk. (This homecare service is only for non-ambulatory) patients. But if you can pay a visit to them, they can do better during the time period and minimise the readmission.” (Allied health)

Out of pocket cost

“The (out of pocket) cost of the services is the main barrier for the patients to enroll in the program, it needs to be revised to cater wider range of the patients.” (Program manager)

Context: Users

High financial support within hospitals

“They rather be admitted to the hospital, because in the hospital they are supported by MediSave (government medical saving scheme) and receive subsidised care.” (CC)

Perceived hierarchy of hospital care

“I rather come here (to the hospital). The apparatus are all here, if any problem the doctors are around, so I think it’s easier to just come and sit and then do what you need to do.” (Patient)

Perceived lower hierarchy of non-doctors

“Only the doctor will understand the situation and issues. I don’t think (the CC) will be able to describe the situation to me unlike the doctor who is helping us.” (Patient)

Passive healthcare users

“So some patients are quite passive, are not concerned or update us on their conditions. When we call them and dig up the problems they have, it’s too late. You know every time we call, either the patients already have problem or the patients is already admitted.” (CC)

Healthcare users with privacy concerns - less likely to enroll

“Because some clients are more private, they don’t like people to invade into their privacy, so they don’t welcome people to (their) house.” (CC)

Context: Providers

Multidisciplinary team work: organizational and national focus

“I think what has worked for us is that we have the support of all the other professions, the multi-disciplinary professions. Doctors at the clinics, the nurses at the clinics, the day rehab centre, the social workers coming into the picture. The doctors giving us input into how to manage better. And that network of services that we have.” (Social worker)

Lack of interdisciplinary training

“We mainly focus on the medical aspects. So, if there are any social issues, and if we cannot handle, then we will tap on the medical social worker. We will bring in our colleagues.” (CC)

Context: Organization

Multiple information system

“Currently we are (using) CDOC for documentation and our clients are enrolled in CCMS (another system) which is from MOH. We have to enter patient into CCMS that means it is enrollment to the program, but the thing is CCMS is not linked to what we are using currently so it is actually very challenging for us.” (CC)

Differing capabilities across healthcare settings

“I think we have some service gap in the community (providers). Some of them (do not cater) especially for dementia patient (as) they have behavior issue.” (CC)