Table 3.

Focus group themes with representative quotes to understand how patients decide if care is needed and where to seek it.

Themes	Representative quotes
Factors impacting the decision to seek care	“If you were sick, like you really, really can’t take it, then you go; other than that it’s home remedies.”
	“Some of them try to be strong and with religion and stuff like that.”
	“I decide by the length of time that I’m sick and if I keep taking the over the counter medicines and if it keeps coming back, then I will go.”
	“But if I don’t know, then I want to go to the place that I have the most confidence in which, if I have a good MD, then it would probably be there but the ER would be next because they have more medical doctors on hand.”
	“I want you [the doctor] to tell me what is really going on with me. ...Just tell me what’s really wrong and help me to fix the problem.”
	“You know, a lot of time the cost plays a big factor whether you go to either place.”
	“That plays a lot because you won’t go to no hospital because you don’t got the money.”
	“...it matters and if you don’t got no insurance or if you’ve got a copay and all that because everybody don’t have like $75 or $25...”
Identifying an emergency	“...if somebody came in and got shot in the neck 20 times.”
	“Like you broke something; you’ve got a bone sticking out of your arm.”
	“...you have a seizure and you wake up and you don’t know where you at, stuff like that. Then you would go to the hospital.”
	“...if you fell down and your head is bleeding or something and you’re going to go to the hospital and do something about that”
	“...but it’s hard to tell when you got broken bones because a lot of people don’t know.”
Perceptions of sites of care	PCP
	“I would prefer to go to my physician but a lot of times when I am ill you will call them and they will say, well, I can’t see you for two or three days “
	“...I prefer to go to my MD because they know me and they have my records.”
	“I had the hardest time getting in there but now that I’m in, it’s so good because they take care of everything...But it’s hard getting in there. I had to know somebody who knew somebody who knew somebody on the inside.”
	ED
	“Like I guess you fear death or something like that, you know, in hospitals.”
	“That’s why people don’t like to waste their time because you’re there like three, four, five hours and then you go in there they check you out for like two minutes and then you have been there for five hours to get a two minute result and they send you home.”
	“...but if you’re not feeling well you don’t want to go to emergency knowing you will be there for four hours before someone can see you.”
	“When you go to emergency, you get chest radiographs; you get CAT scan, you get all of that and you still get no solution. And then you get this bill.”
	“Well, if we go to emergency—from my experience, they are going to run all types of tests.”
	Urgent Care
	“...but if you can’t get in your clinic because you don’t have an appointment, then, you know, we would just wait until after the five because 1) it’s closer and 2) we couldn’t get to our clinic.”
	“At the urgent care I think they give you more time and they are more prone to do like real life suggestions because they don’t want you to keep having to come back.”
	“…I will drive to Detroit to go to the same urgent care because I know my needs are going to be met. I’m not going to get all these prescriptions; I’m going to pay my one copay...”
Priorities to improve acute health care	“I would say the number one thing is being able to get the same treatment no matter what kind of insurance you got or if you have no insurance at all. Being able to get the same thing as the person who got Blue Cross and Blue Shield and you got Medicaid.”
	“…a good doctor that will care about you instead of what insurance you have.”
	“Give me a good MD that I can go see and not just to treat me but can treat my whole family.”
	“So if my MD had better hours and later times for walk ins and stuff like that, I think that would be—it would make me go there because he know my medical history and can better diagnose me and my son.”
	“And some of the transportation, you do have to call two or three days in advance like to make an appointment. But if you are sick then, you know…”
Difficulty navigating system	“Some hospitals won’t share their xrays and records of that patient with another hospital.”
	“They did all the radiographs and then sent him over to Saint John’s over here and they did the same radiographs.”
	“...I write the check for the copay. So we end up having to be transferred to another hospital that took care of pediatrics and I got another bill for…another copay.”
	“So it’s like I am doing a circle to find the right person to go to. And I’m getting told to go this place while actually I’m supposed to be at this place. And this place is sending me back to the other place but the other place is not letting you in the door. So it’s a big circle. Nobody knows who you are supposed to go see.”

PCP, primary care provider; ED, Emergency Department