Table 2.

Themes related to successful transition identified by primary care physicians

Primary care physician readiness for transition of care from specialist
• Degree to which PCP expectations of specialist referral have been met-"support received for complex patients", patient has had "access to specialized multidisciplinary team"
• PCP perceptions of "time" and "workload" associated with diabetes care
• PCP "knowledge" and "confidence" related to medication adjustment and behaviour change
• Alignment of PCP expectations and "attitudes" with those of patient/specialist referral center.
Patient readiness for discharge
• "Self management" abilities, "compliance", attitude about "seriousness of diabetes"
• "Ongoing access to education" and resources
• Level of patient " trust" in primary care provider, strength of relationship with specialist team
• Degree of alignment of "patient self management expectations" and treatment goals with PCP/specialist center.
Systems factors and transition of care from specialist
• Use of "effective communication, coordination of care", "individualized care plans", "ongoing phone advice", "diabetes passport".
• Ease of "access to support" services, timely re-referral for patients and physicians
• "High costs" of diabetes medications and supplies.