Table 4. Findings of the phase 3 –key priorities and illustrative quotes.

Priority	Illustrative quotes
Empower residents to take charge of their health	“I think why we have a problem on diabetes, the “war on diabetes”, is that there is a lack of understanding of what diabetes can do to a person beyond just oral medications. Even in our direct encounters with patients, they have very poor lifestyle habits.” (service provider #32, primary care) “For certain medications, patients can titrate themselves, they can stop taking if they have this symptom for example. So rather than telling patients to come back to hospital if they have problems…more education is needed…we need to build the rapport.” (service provider, # 20, intermediate & long term care)
Establish a network of collaborators/community partners with defined roles	“I think we [care professionals] should be aware of each other. Maybe we should come out with a list of community partners so that we know which organisation would be responsible for certain things.” (service provider #2, intermediate & long term care) “I find networking very important for us. You can meet multiple partners and share knowledge and experiences. Networking is a platform to communicate.” (service provider #65, end of life care)
Improve effective handover between partners, and localised plan for individuals	“If our client [elderly patient] is discharged, it would be great if the hospital can inform us [senior activity centre]. Let’s say his living condition is so bad. The hygiene of his house is not there. He is on wheelchair. His meals are not in place…what will happen to him if he is discharged?” (service provider #5, intermediate & long term care) “I feel that it is not so much about what we want to give to the elderly, but about what they need. Sometimes they have different opinions and we tend to push for ours.” (service provider #35, intermediate & long term care)
Enhance information-sharing and communication across health and social care sectors	“The next thing we [VWO] should be doing is to work with the other VWOs. I don’t know how to start…maybe we can organise a regular platform to share information such as workshops.” (service provider #47, intermediate & long term care)
Improve respite care services for mental wellness of long-term caregivers	“I think for the younger generation, they have so-called camps or holiday programmes. Caregivers should have a time off from home on weekend. It is already a respite for them.” (service provider #19, mental health) “I think this [respite services] is lacking in our system right now. Respite care not just for mental illness but also for more general illness…we need night respite, day respite etc.” (service provider #7, end of life care)
Develop primary care as a driving force behind the affordable health care	“The information, the medical record the private GP has is not linked to the hospitals. You got to bring your records over to the hospital. If you lose your medical records, then they [hospital] will ask you to do another round of x-rays and tests.” (service user # 12, primary care) “As a primary care liaison, I wish we can do better in terms of being fully aware of our community partners. How do we draw in primary care as part of the team as we are talking about population and stratification?” (service provider #51, primary care)
Increase outreach to social and health community on end-of-life issues and dying well	“Had they [acute hospital] told us earlier about the duration of [my wife’s] life span and all the information, we would have checked out various options and gotten things in place much earlier. At the almost last stage, I didn’t even know what palliative care was.” (service user #3, end of life care) “It [end of life issue] is more of social norms kind of situation…there are other social implications because people have this notion that I should leave my dying in the hands of my children, because this is the filial thing.” (service provider #17, end of life care)
Enhance the work experience of social and health care providers	“We need to improve the competency of community mental health providers for a proper psychological intervention and assessment. This is a missing gap we noticed in most of our VWOs.” (service provider #31, mental health) “I hope government will change policies to retain trained foreign nurses because we really need them in our nursing home.” (service provider #40, intermediate & long term care)
Provide a personalised care that enables residents to stay well and achieve the best health outcomes	“Our model of care is a patient-centred care approach. So that comes under the priority of empowerment of patient and caregivers.” (service provider #27, end of life care) “Everybody is unique in their own ways. We should view their values in their perspectives….this is called empowerment and choice…availability of choices.” (service provider, #3, intermediate & long term care)
Segment population into mutually distinct groups for targeted interventions	“This is important but may be similar to the other priorities [empowerment of patients, personalised care]…” (service provider #29, end of life care) “I can prioritise a bit more for you. The empowerment of patients is linked with personalised care and targeted intervention.” (service provider # 61, mental health)
Enhance community resources and capacity to prevent hospitalisation and institutionalisation*	“We should do this community support aspect well, pump in more resources on that, so that people don't have to go back to hospitals.” (service provider #22, mental health) “When you run an institution, a residential set up is more costly than to provide community support. When patients are in the community, they can be active citizens of the society to contribute. Being the community will give them a sense of self-worth and meaning for life.” (service provider #55, primary care)
Increase public and provider awareness of illness with stigma*	“I have a client who got better but later on her condition deteriorated. For her, coming to our setting [mental hospital] again is like ‘oh no, it’s like I am facing back’…shame and guilt…I mean to address this issue, it is all about public awareness…de-stigmatise mental illness and set up more mental wellbeing clinics in the community that are readily accessible.” (service provider #59, mental health) “I think end of life care is a bit taboo. People are not comfortable talking about it when someone has cancer because they feel it destroys hope, make people feel depressed or give up. But if they’re not aware of the options available, they don’t know the goal of the treatment that is offered.” (service provider #45, end of life care)
Harness existing community resources such as building peer supporters and volunteers	No input from participants in Phase 3
Develop a use case by engaging health and social care partners	No input from participants in Phase 3

* Newly added item.