Establishing Continuity of Care Through a Team-Based Care Approach: Implementation Challenges

Abstract

Background:

Continuity of care (CoC) has been proven to improve patient-doctor relationship and patient health outcomes. However, challenges in providing CoC by a team, instead of a single care provider, is seldom explored. This study aimed to identify the implementation challenges in delivering CoC through a newly implemented team-based care model.

Methods:

A qualitative study involving interviews of 39 healthcare providers and 7 patients was conducted across 2 polyclinics between January and April 2023. Two researchers conducted the interviews using semi-structured interview guides. The interviews were audio-recorded, transcribed verbatim, and analysed in NVivo using a thematic approach.

Results:

While patients and providers recognised the importance of CoC, incorporating the concept into the existing clinical care pathway was challenging. The key barriers that hindered establishing CoC were: lack of manpower and prioritisation of the team-based care model, uncertainty of ‘who’ is in the team, lack of access to relevant and timely information to address patients’ care needs, and patients’ difficulty in understanding the ‘1-patient, 1-team’ concept.

Conclusion:

While the team-based care model was well received, systemic barriers hindered its implementation. Addressing issues like IT system redesign and manpower allocation is essential for successfully embedding CoC within team-based care in Singapore’s primary care setting.

Introduction

Continuity of care (CoC) refers to the long-standing relationship a patient has with 1 or more care providers. ¹ Practices strive to ensure care continuity as it offers better health and care outcomes to patients,^{2 -5} increases provider satisfaction and reduces healthcare expenditure.^{6 -9} In primary care, the delivery of high-quality care relies on 3 fundamental aspects of continuity: relational, informational, and managerial. ¹⁰ While relational continuity emphasises on the therapeutic relationship the patient has with 1 or more healthcare providers, informational continuity ensures that patient data is accessible by all healthcare providers and managerial continuity focusses on adopting a systematic approach to managing the patient’s health conditions. ¹

CoC in primary care was traditionally defined as a single physician managing a patient’s care, but it now often involves coordination among a team of healthcare providers. ¹¹ The increasing complexity in healthcare demands has triggered the healthcare systems to deliver care via multidisciplinary teams.^12,13 Despite the clear benefits and widespread implementation of team-based care,^{10,14 -16} successfully establishing CoC through this model remains challenging.^17,18 Some common challenges include lack of clarity of goals and roles among the different providers, communication barriers, inadequate digital or electronic health record support, lack of uniform education or training, and lack of feedback reports.^19,20

In Singapore, primary care is delivered through a network of public primary care polyclinics and private clinics run by general practitioners (GPs). ²¹ The concept of provider continuity where the patient follows up with a single provider has long been ingrained in the private GP setting, distinguishing it from the public primary care setting where patients may encounter different physicians for each visit. A national Primary Care Survey conducted in 2014 revealed that up to 52% of patient visits to polyclinics were for chronic disease management, compared to only 20% of the visits to GPs. ²² This is mainly due to the lower cost and subsidies available in the polyclinics ²³ and the presence of multidisciplinary teams which provides comprehensive and holistic care for patients. ²⁴ The national healthcare transformation initiative ‘Healthier SG’ was introduced in 2023 with the intent to improve population health by leveraging on strong doctor-patient relationships. ²⁵ ‘Healthier SG’ together with increasing complexity of patients due to ageing, served as a catalyst for 1 of the 3 public primary care providers in Singapore to restructure its model of care to introduce a team-based care model called the ‘My Care Team’ (MCT). ²⁶ By leveraging the expertise of a multidisciplinary care team, the goal was to improve health outcomes, enhance overall well-being, and provide added attention to patients with complex needs.

‘My Care Team’ (MCT).

The ‘My Care Team’ model was developed by the Clinical Services Team at SingHealth Polyclinics based on current team-based care frameworks, taking into consideration existing services, population profile, and resources. It targets patients with chronic diseases and aims to deliver comprehensive chronic disease management and preventive care to this population using a team-based care approach. A care team ideally consisted of 4 doctors, 2 Care Managers, and 2 Health Pals. The Care Managers are nurses who conduct clinical assessments and provide health counseling. The role of the Health Pal was newly added and involved task-shifting of non-clinical staff who performed administrative tasks into performing certain clinical roles like recommending and coordinating patients’ preventive care needs. The multidisciplinary team was planned to have daily huddles* and be involved in regular monthly meetings to discuss complex patients.

*The planned daily huddles were not practiced in the clinics due to lack of time and an agenda for the huddle meetings.

Although existing evidence highlight common challenges in implementing team-based care, there may be other unique barriers to delivering this model in Singapore’s culturally diverse and complex primary care setting. Furthermore, there is limited understanding of how CoC can be achieved and sustained within such models, particularly in Asian contexts like Singapore which operates a mixed public-private health system. ²⁷ Most existing studies focus on single-provider continuity, with persistent knowledge gap about provider- and patient-level barriers encountered when implementing team-based continuity. Hence, this study aimed to explore the challenges faced in establishing CoC through this team-based care model. Understanding these challenges will help in ensuring care continuity while delivering care through team-based approach.

Methods

Study Design

This is a qualitative study aimed to understand the challenges of healthcare providers and patients in experiencing continuity of care within a team-based care model in primary care settings.

Study Setting

Individual in-depth interviews/focus group discussions were conducted at 2 public primary care clinics (PC1 and PC2) located in Eastern Singapore, where the MCT model was pilot-tested between July and December 2022. These newer polyclinics’ infrastructure was designed to facilitate team-based care and had at least 1 functioning pilot MCT. Both polyclinics served a diverse population of patients of varying ages, socio-economic status, and ethnicities. PC2 had a relatively higher patient load; consequently, patient MCT enrollment was much higher in PC2 (~1000) than in PC1 (~500). This contrast was important to understand the practice variations between the clinics and how it affected the continuity of care.

Study Duration

The interviews were conducted between January and April 2023.

Study Participants and Sampling

Healthcare providers aged 21 years and above from both clinics were purposively recruited to ensure that all gender, ethnicity, age groups, and professional cadre were included in the study to achieve maximum variation. The study participants included doctors (of varying seniority level), nurses (care managers), Health Pals (non-clinical administrative staff), and administrators (clinic director, deputy clinic director, clinic executive, nurse managers, and MCT management team including operations executive and trainers). Healthcare providers not involved in MCT were also interviewed to understand their perceptions and concerns about implementing this care model. The study team consulted the clinic leads to understand the involvement of the healthcare providers in the MCT and asked them to nominate participants with varying levels of involvement, professional cadre, years of experience, and those who were vocal in voicing their opinions. Patients aged 21 years and above who had 1 or more chronic conditions were enrolled into the My Care Team. Such enrolled patients who had attended at least 1 follow-up clinic visit after their enrolment were interviewed for this study.

The larger sample of providers (n = 39) was intentional, reflecting the need to capture diverse perspectives across different professional roles (doctors, nurses, health pals, and administrators) and levels of seniority involved in the implementation of the team-based care model. In contrast, patient recruitment (n = 7) was constrained by the limited number of eligible, English-speaking patients who had completed at least 1 MCT visit and had a scheduled appointment during the study period.

Data Collection

A Clinical Research Coordinator (CRC) facilitated data collection and transcript verification. An email invitation was sent by the CRC to invite selected healthcare providers to participate in the study. The CRC approached interested participants to schedule a face-to-face meeting for consent-taking and interviewing. On the day of their appointment, the participants were briefed on the study and given time to clarify their queries. After obtaining written informed consent, a male and a female researcher trained in qualitative methodology (CJN and SSK) conducted the interviews. To avoid coercion, CJN, a practicing Family Physician at PC1, was not involved in the consent taking process and none of CJN’s patients were included in the interviews. He was not involved in the planning and execution of the My Care Team in PC1. SSK, a non-clinician researcher also conducted the interviews.

Semi-structured interview guides that were developed based on literature review and expert discussion were used to conduct the interviews. The interview guides for the healthcare providers, management team, and patients (provided as Supplemental Material) were initially developed to capture information pertaining to the implementation of the team-based care model. The key topics covered by the guides included: understanding of team roles, communication between team members, perceptions of continuity of care through this model, barriers and facilitators faced by providers/patient with this model, and suggestions for improvement. The interview guides were pilot-tested with 2 healthcare providers and 1 patient to assess the clarity and relevance of the questions. The feedback from the piloting only led to minor refinements like the ordering of the questions. However, during the subsequent interviews, the concept of difficulty in establishing continuity of care through team-based care constantly emerged and was explored further by using additional probes like ‘How did MCT affect CoC?’, ‘Was it possible to establish CoC through this model?’, ‘What were the challenges faced?’, ‘What do you think can be done to improve CoC through this model?’ when necessary. As the interviews progressed, the interviewers simultaneously adapted the guides and incorporated emergent topics, especially that of CoC.

The participants spent about 45 to 60 min to participate in the study. After the interview, the participants were given a S$20 shopping voucher to compensate for their time and effort. The participants were interviewed until no new findings emerged from the interviews (data saturation). Data saturation was determined independently for each group. For providers, saturation was considered achieved when analysis of 3 consecutive interviews across different roles from each clinic yielded no new themes or codes. For patients, saturation was ensured after the seventh interview, as no additional or novel perspectives were identified despite variation in age, gender, and chronic disease profile. Field notes taken during the interviews and simultaneous transcript review supported the assessment of saturation.^28,29

Data Analysis

All interviews were audio-recorded and transcribed verbatim by a professional transcriber. The transcripts were verified and checked for accuracy by the Research team (CRC and SSK). The study was guided by the interpretive-description approach and data analysis followed the principles of thematic analysis as described by Braun and Clarke, ³⁰ which involves familiarisation with the data, generating initial codes, searching for themes, reviewing themes, defining, and naming themes. The analysis involved 2 researchers (SSK and PO) who read, re-read, and coded 2 transcripts independently first, followed by another 3 transcripts. The transcripts were coded inductively line-by-line to generate an initial list of codes using version 12 of the Nvivo software. ³¹ The researchers (SSK and PO) had regular discussions with a third senior researcher (CJN) to discuss the codes and resolve any coding discrepancies. After the initial open coding, the researchers independently grouped codes with similar content into categories and themes. Once the final coding framework was formed, the 3 researchers coded the remaining transcripts. The research team met regularly to discuss any new themes that emerged from the analysis. To minimise researcher bias during analysis, a clinician researcher (PO) from a non-MCT clinic, who was not involved in the interview process, performed the coding independently on some of the transcripts.

Ethical Approval

The study was approved by the Centralised Institutional Review Board (CIRB Ref: 2022/2620).

Results

A total of 46 participants, including 18 doctors, 6 health pals, 6 nurses, 9 management team members, and 7 patients, were purposively recruited and interviewed. Participants’ age ranged from 24 to 72 years. The profile of the study participants is given in Table 1 (healthcare team) and Table 2 (patients). The key areas explored through the interviews included the perceptions of how team-based care can enhance CoC and the barriers experienced in ensuring CoC when delivering team-based care. The key findings are highlighted in Table 3.

Table 1.

Profile of the Healthcare Team (MCT and Non-MCT) Interviewed for the Study (N = 39).

Characteristic	n	%
Profession
Doctors	18	46.1
Nurses	6	15.4
Health Pals	6	15.4
Management team	9	23.1
Age (in years)
≤35	16	41.0
36-50	16	41.0
51-65	7	18.0
Gender
Male	11	28.2
Female	28	71.8
Ethnicity
Chinese	34	87.2
Malay	4	10.3
Others	1	2.5
Highest professional degree
Postgraduate level	19	48.7
Undergraduate level	14	35.9
Diploma	1	2.6
School level	5	12.8
Number of years working in primary care
<5	16	41.0
6-10	7	18.0
11-15	9	23.0
>15	7	18.0

Table 2.

Profile of the Patients Interviewed for the Study (N = 7).

Characteristic	N	%
Age (in years)
36-50	1	14.2
51-60	3	42.9
>61	3	42.9
Gender
Male	5	71.4
Female	2	28.6
Ethnicity
Chinese	5	71.4
Malay	2	28.6
Educational level
Undergraduate level	2	28.6
Diploma	1	14.3
School level	4	57.1
Occupation
Employed	2	28.6
Unemployed	1	14.3
Retired	4	57.1

Table 3.

Summary of the Key Findings From the Study.

Perceptions of how team-based care can enhance CoC
• Opportunity for doctors to deliver CoC in Singapore’s public primary care setting
• Improved healthcare providers’ commitment towards documentation and patient management
• Task delegation and redistribution to ensure seamless care coordination • Patients preferred being cared by a team of healthcare professionals who would be aware of their health conditions
Barriers faced in ensuring CoC when delivering team-based care
• Inadequate allocation of manpower for prioritisation of the team-based care model
- Healthcare providers perceived a lack of relational continuity due to frequent rotations within and across different clinics	- Patients lacked clear understanding of My Care Team, perceiving it to be similar to standard care
• Uncertainty of ‘who’ is in the team
- Healthcare providers lacked clarity on their care team members and patients	- Patients’ lack of awareness of team members led to confusion and disappointment
• Lack of access to relevant, timely, and consistent information to address patient’s care needs
- Healthcare providers lacked informational continuity due to limited access to electronic health records	- Patients were dissatisfied with receiving conflicting information from different healthcare providers
• Patients’ difficulty in understanding the ‘1-patient, 1-team’ concept
- Healthcare providers had to periodically reiterate the MCT concept to patients as they often forgot or misunderstood it	- Patients confused the ‘1 patient, 1-team’ MCT model with the ‘1 patient-1 doctor’ model practiced in private GP settings

Perceptions of How Team-Based Care Can Enhance CoC

The benefits offered by team-based care, especially for complex patients, were well acknowledged by the healthcare providers. They believed the MCT model provided an opportunity for the doctors to deliver continuity of care by establishing a stronger relationship with a stable pool of patients with chronic conditions.

We develop a patient-doctor relationship with them (the patient) and so we get to know them quite well. We know their medical problems, their social background, and every time they come and see us, because we have that relationship (with them), we sort of know them already and we are not starting from scratch. Not having to catch up on, especially the complicated ones.

- MCT doctor, PC1

Similarly, patients favoured seeing the same doctor or team, eliminating the need to constantly repeat their health history to multiple providers.

At least you know they know you well. You also know them. Roughly same person or few persons different. At least this system I think will help you to keep track. The hospital can also keep track, polyclinic also keep track. I just understand when you visit (the polyclinic) at least there is a doctor inside the team who will attend to you. So, I feel okay.

- MCT patient, PC1

The Health Pals liked their new re-designed role that involved interactions with patients beyond attending to their administrative needs. This was seen as an effective way to improve communication and strengthen their relationship with patients.

This type of MCT (My Care Team) is also good for us (the health pals); it’s patient oriented, not like admin job where we just do check-in, registration, payment. There is a lot of interaction with the patient, talking to the patient, which is good.

- Health pal, PC1

Additionally, working in a team made the healthcare providers feel more accountable and committed to documenting and managing the patients better as other team members subsequently see the patient.

I think I tend to make sure that their (the patients’) chronic diseases are better-controlled. Because I know that they are going to be with us for the next few years. Then, it’s people that we’ve seen before that our colleagues will be looking at the next time to see whether you titrated your HBA1C properly and things like that. So there’s a bit of like responsibilities.

- MCT doctor, PC1

Barriers Faced in Ensuring CoC When Delivering Team-Based Care

Despite acknowledging the importance of continuity of care, the healthcare providers and patients faced the following challenges in experiencing it in routine clinical practice:

Inadequate Allocation of Manpower for Prioritisation of the Team-Based Care Model

The current practice in the polyclinics involved the weekly rostering of doctors to MCT rooms where MCT patients were tagged. However, manpower shortages and a lack of prioritisation of MCT resulted in last-minute rostering changes and doctors potentially not stationed in MCT rooms. Furthermore, there was a lack of stability within the care teams due to manpower movement across clinics caused by medical and urgent leaves. As a result, some doctors felt dejected and did not see the value of enrolling patients into MCT to ensure CoC.

Because over the years there have been a lot of doctor movements. We have sort of lost sight of putting the same doctor back to the same room on specific days. So, yes, the team structure is there, but the members are not there.

- A doctor in a managerial position, PC2

Last Tuesday I was supposed to be sitting in the MCT room, then I had to relief to another clinic. So, they (clinic management) asked another doctor who was not even part of the Care Team to sit in that same room. I think they probably didn’t even notice that it will affect the Care Team. So, it doesn’t seem like a priority. At least get another doctor who is part of the Care Team to run that room.

- MCT doctor, PC2

The team members keep getting sent out of the clinic, or get sent to the fever clinic, we are moved here and there to cover this, cover that. Yeah, so we have not seen the same patients back. Every time we see a patient, the last few doctors will be a different doctor. So theoretically yes, it should make sense that a team is in charge of a patient, the team itself will be more invested in the patient, but it’s really not working now because, number one, we just keep cycling among people so we don’t recognize even our own patients; and number two is, My Care Team is not one of their primary job focus.

- MCT doctor, PC1

Due to the lack of prioritisation and frequent manpower movements, patients often ended up seeing doctors outside their assigned care teams. Moreover, they did not have a clear understanding of MCT and perceived it to be similar to the routine standard care where they saw different doctors.

I realised everything is still the same, no difference. Every time I come as before, I register, then I will be assigned to the room and then see a different doctor every time. So, I think it is about three times and all different doctors. And different doctor got different view. So, that’s what I feel. No difference (from the routine care), still the same.

- MCT Patient, PC1

When the doctor asked me to join, she mentioned that I’ll be taken care of under a team, that they’ll look into my problems. So, that’s all. So far, I’ve been seeing three to four times. But I realise that it’s still no difference. It’s like every time I see a different doctor. I can’t remember.

- MCT patient, PC1

Uncertainty of ‘Who’ is in the Team

Operationally, the originally planned team size of 4 doctors-2 nurses-2 health pals per team was difficult to implement. Instead, 4 doctors were selected daily from a larger pool of 7 to 8 doctors reducing the likelihood of patients being seen by the same team doctor. The larger team size also hindered team bonding, affecting the sense of belonging the team members felt towards their teams. Moreover, during the initial pilot, patients were not automatically tagged under a care team in the electronic medical record that made it difficult for doctors to identify their team patients. This led to some doctors feeling a diminished sense of ownership in caring for these patients whose appointments were not tagged under them.

The doctors say (to the patients) ‘Okay, you come back and see me’. I think we need to ensure that the doctors also start to change their language. It needs to happen both sides. The patients need to know they belong to the team, the team needs to know that they belong to the team.

- MCT doctor, PC2

I’ve not seen many patients who I’ve enrolled at their second visit. In fact, I see more of patients that other doctors have enrolled. Most of the time it is within the team but there is also the challenge of not knowing who is enrolled. Because there is no marker or indicator to say that this patient has been enrolled, unless the previous doctor documented to enroll into Care Team. Sometimes it’s not documented.

- MCT doctor, PC2

The patient is still tagged to a doctor who is considered the main person. So, that’s the mentality. It’s still that this is that doctor’s patient, it’s not my team’s patient. It’s my colleague’s patient who happens to be in the same team as me. And if my colleague is not around, ya probably then I’ll take care of the patient. That mentality is still there because the patient is still tagged to a doctor on the IT system.

- MCT doctor, PC2

It was also highlighted by the patients that they were unaware of their MCT team members; they were seldom introduced to their teams, and his made it difficult for them to recognise if they were being seen by their MCT doctors. This created confusion and disappointment among the patients.

This lady doctor, I’m not sure who, she said I’ll be taken care of by a team under her care. That’s all I know. They said this team will look after me. But after that I can see that I’m seeing a different doctor, so not sure how they coordinate together behind the scene. She said “under her care”, that’s all. So, after that I’m not sure whether I’m seeing the doctor under the same team or not. I’m not really sure.

- MCT patient, PC1

I don’t know whether I will be seeing this same doctor I saw today after half a year and whether he is my appointed doctor. It was not made clear to me. I think by right should be better to know my team of doctors. As a team it should be transparent in terms of the members. And then how many doctors and patients are inside this one Care team? At least then it’s called a team. Otherwise I don’t know why it’s called a team.

- MCT patient, PC2

I don’t know the doctor’s names. I don’t know if it’s a team. It’s good if I know it’s the same team. Not so many doctors. At least, two or three different doctors, but I know it’s still these few doctors. But every time I come and see, I am so disappointed because it’s always different doctors.

- MCT patient, PC2

Lack of Access to Relevant, Timely, and Consistent Information to Address Patient’s Care Needs

MCT aimed to provide comprehensive care for patients, focussing on the majority with chronic diseases using a team-based care approach to proactively manage their preventive care needs. However, healthcare providers highlighted the difficulty in identifying, tracking, and following up with patients’ care needs due to limited access to each others’ clinical notes that impaired flow of information across patients’ clinical visits. Additionally, any screenings or immunisations performed at other facilities were not readily available to the healthcare providers. This affected the informational continuity often leading to repetition or missing of addressing patients’ care needs.

I think we cannot really see what happens in the discussion with the Health Pal and the patient itself. And then, we’re not too sure whether there’s a proper follow-up plan. We just trust that they’re going to book for the patients. So, if they’re enrolled, then maybe the preventive health (screenings) has all been done. But we’re not too sure because sometimes patients might feel that they don’t want to do it now. They want it later. Not too sure whether there is the ability to pick up that information again and discuss with the patient.

- MCT doctor, PC2

When I counsel diabetic patients, I don't know whether my health pal has already talked about the flu and the pneumococcal vaccination. So I will ask again. I can't tell (from the notes) whether my health pals have communicated the information. Because when I open up the counselling notes, their (health pal’s) notes will not flow in.

- MCT nurse, PC2

For nurses, we can see the clinical summary, but for the health pal they have restrictions. So I do have some health pals who come up to the nurses and ask “Can you check for me, this one when was it done, when is it due?”

- MCT nurse, PC1

With regards to communication, patients highlighted the need for consistent information from all care team members to improve their MCT experience. They reported receiving conflicting information about their health from different MCT members. While most preferred seeing the same doctor, they were willing to accept the team model if there was considerable alignment between all team members, thereby reducing confusion and building trust in their care.

If I am not seeing the same doctor all the time, at least make me feel that they’re in the same team. How to let me know that they’re in the team? It’ll be good if all doctors have same things to say. . . Like there’s one time when I came, the doctor was making some statement that I was quite worried, like you’re in stage two diabetes, so and so. . which I’m not so clear. He is very different, his explanation is not the same as the other doctors. Same team, you want them to say the same things. I think more important thing is that they are all in the same line.

- MCT patient, PC1

Patients’ Difficulty in Understanding The ‘1-Patient, 1-Team’ Concept

The concept of My Care Team was new to patients and the healthcare providers recognised patients’ lack of awareness of this model. While providers tried to explain that patients would be cared for by the whole team, patients often focussed on the idea of seeing the same doctor each visit and often forgot about the team. Hence, the care teams had to provide regular reiterations to the patients and readjust their expectations.

So we tell the patients “Ya, you can come back and see me. But if I’m not around, my other team members will cover you as well”. So, sometimes they only hear, “Ya, you can come back and see me again”. And then the next time they come and don’t get to see the same doctor then we have to re-adjust their expectations to say that, “No, you see the same team. So you’re always going to be here in these few rooms. And over time, probably you eventually will get to see the same familiar faces.”

- MCT doctor, PC2

Despite being informed during their onboarding that MCT followed a ‘1 patient, 1 team’ approach, some patients struggled to remember this. Media promotion of the ‘1 patient, 1 doctor’ model practiced in the private GP setting further confused patients leading to perceived lack of continuity when encountering different doctors within the same team.

One thing I’m not happy is, the government showing in the TV (television) like, we are seeing the same doctor. I mean every time I come here since I signed up to the team, I think four times already. I see different doctors. I don’t see the same doctor at all. So it’s not what I see from the government advertisement in the TV - “You’re seeing the doctor, they will know everything about you.” It’s so different from what I see. So, every time I come I am so disappointed. Every time I go to different room. So, I’m not happy with it.

- MCT patient, PC1

Discussion

Our study identified key barriers to in achieving CoC through a team-based approach in Singapore’s public primary care setting, stemming from disruptions in relational, informational, and managerial continuity. Although the 2 polyclinics differed in My Care Team enrollment numbers, patient load and population profiles, our analysis did not identify significant differences in barriers or perceptions between sites. Providers and patients at both clinics described similar challenges with manpower, team continuity, and information flow; and reported comparable experiences regarding team-based care. This could be attributed to the ‘sharing’ of manpower, common electronic medical record system, and staff composition across all clinics.

Inadequate Allocation of Manpower for Prioritisation of the Team-Based Care Model

The lack of human resources has been established as one of the fundamental barriers to establishing CoC in a team-based care model. ³² This is primarily due to the inability of maintaining a stable pool of doctors within the care teams. Task-shifting and the introduction of medical assistants (non-clinical staff trained to take up clinical tasks) help to tackle manpower shortages and improve CoC.^33,34 This is similar to the introduction of health pals in our setting. Similar to the rostering issues faced in our setting, literature shows the existence of issues with staffing patterns and unnecessary movement of doctors within clinics due to the lack of prioritisation of team-based care.^19,35 Effective implementation of team-based care relies on organisational prioritisation, change communication, and system functionality to enhance commitment. ³⁶ Strategic alignment of administrative priorities during initial implementation phase was identified as an important enabler. ³⁷ Thus, efforts to prioritise MCT in the clinic setting are essential to avoid disruptions in patient’s care continuity.

Uncertainty of ‘Who’ is in the Team

Familiarity among team members is crucial in determining team success and influences how patients and team members perceived relational continuity. Globally, regular team meetings and co-located workspaces are important facilitators in improving team relationship.^35,38 Strikingly contradicting the conventional belief that familiarity improves patient satisfaction and health outcomes, some studies found no association between doctor-patient familiarity and care quality.^39,40 However, consistent with our findings, literature supports that knowing team members builds trust while unfamiliarity poses challenges to effective teamwork. ⁴¹ Similarly, patients prefer familiar care providers; A study conducted in Hong Kong showed that patients preferred seeing the same physician even within the team-based care model, though absences and rotations made this difficult to sustain. ⁴² Introducing MCT members to patients helps them to know their care team, while including MCT members in clinic brochures, booklets, and name boards supports recognition during subsequent patient visits. Tagging patients in the electronic medical record system ensures healthcare providers to recognise their team patients.

Lack of Access to Relevant, Timely, and Consistent Information to Address Patient’s Care Needs

Tracking and following up on patient’s preventive and clinical needs is a critical yet challenging aspect of care continuity. Various practices have redesigned their care models to effectively provide informational continuity for patients with chronic disease.^4,42,43 Regular team huddles and ‘huddle sheets’ helped remind team members of the outstanding screenings before clinical visits. ⁴² Some of the high-performing team-based care models employed data systems to monitior critical indicators by engaging multiple team members to review data and address patient needs. ⁴³ However, limitations like restricted access and lack of system integration hindered information flow. ⁴⁴ Our study identified challenges in accessing information among the team members due to different access rights based on their role and across public-private sectors. Strategies such as pre-visit planning and expanded rooming where a team member identified patients’ care needs and highlighted them to the attending physician proved effective. ⁴⁵ To achieve similar informational continuity the health pals in our study preferred complete access to their team patients' records.

Patients’ Difficulty in Understanding the ‘1-Patient, 1-Team’ Concept

In our polyclinic setting, patients routinely see different doctors, making it challenging to differentiate and explain the team concept to them. Patient’s forgetfulness and the discrepancy in the information provided by the media could be other reasons for the lack of understanding. For example, public platforms advertised and emphasised the concept of ‘1 patient, 1 doctor’ pertaining to the GP setting, which was in contrast to the concept of ‘1 patient, 1 team’ practiced in the polyclinic setting. Studies found that patients often lack CoC when managed by multidisciplinary teams ⁴⁶ ; this can be addressed by effective communication and information sharing. ⁴⁷ A survey conducted in Canada found that most patients favoured team-based care and were comfortable seeing another team member if recommended by their usual physician or family member. ⁴⁸ In some practices, patients appreciated the care and insights provided by multiple physicians and regarded team care as ‘organised and coordinated’ care. ⁴⁹ However, a study in the US revealed how some patients were confused and concerned to see a different provider without prior notice and had negative feedback for such team-based encounters. ⁴⁹ Thus, to enhance understanding, healthcare providers should clearly discuss the team-based model with the patients and explain the CoC received through the care team. Constant reminders and reinforcement of the team concept through posters, pamphlets, and media advertisements may be helpful to keep patients aware.

The findings of this study highlight the challenges faced by Singapore’s public primary care clinics in providing CoC through multidisciplinary team-based care for patients. Some of the barriers may also be attributed to Singapore’s public-private split: public primary care clinics struggle with resource and workflow challenges due to a higher chronic disease load, while private GPs face logistic and financial obstacles in providing multidisciplinary, coordinated chronic care. Similar challenges are observed across Asia where public clinics deliver comprehensive and coordinated care, yet private clinics offer better accessibility and continuity.^50,51 At a policy-level, efforts such as the Primary Care Network (PCN) and the ‘Healthier SG’ initiative are designed to bridge this gap by organising private GPs into networks, providing team-based care, incentivising, and improving data sharing. ⁵²

Strengths and Limitations

The main strength of this study was the inclusion of healthcare providers and patients, yielding valuable insights from both sides of the healthcare system. These insights helped triangulate and validate information provided by both groups. Furthermore, conducting the study during the initial piloting phase allowed us to identify and rectify any challenges before the MCT was fully implemented. Key insights from this study were crucial in informing the management to revisit existing clinical processes, to streamline the delivery of patient care, and establish better continuity of care.

A limitation was the inclusion of 2 newer clinics that were infrastructurally designed to support team-based care; other clinics may face additional implementation challenges due to structural limitations and heavier patient load. This study only included English-speaking patients, thereby limiting us from capturing challenges faced by non-English speaking patients who may experience communication-related issues.

Conclusion

Establishing CoC through a team-based approach requires a streamlined and coordinated effort. Organisational structure and prioritisation, supported by effective communication on the value and concept of CoC are paramount to establishing CoC while implementing a new care model. Specific recommendations to addressing informational and coordination barriers include team-based patient tagging in the EMR and pre-visit preparations that would facilitate consistent delivery of coordinated care. ⁵³