Table 5. Findings of phase 4—research priorities, themes and potential research questions.

Research priorities	Rationale for the choice by participants	Themes	Potential research questions to be answered
Theme 1: Empower residents/patients to take charge of their health	• Need for moving towards new models of care with patient-centred approach • Patient perspectives and needs overlooked • Empowerment improves chronic disease management	• Health education for members of community • Care needs of residents/patients • Avoiding medicalisation of social problems	• What behavioural modification interventions are effective for different segments of patients/residents? • How can we increase public awareness of personal responsibility for health? How effective are the existing education programmes on self-management? • How can we empower patients with usable tools, personal coaching and virtual care? • What are patients’ expectations and concerns? How to dispel misconceptions and misinformation? • What are the patient’s self-management goals and how do we support them?
Theme 2: Improve care transition and management through relationship building and communication	• Concerns about duplication and fragmentation of services • Limited understanding of one another’s missions and agendas across community partners • Reported challenges regarding the use of the national information system and competing IT platforms	• Sharing of patients’ information across care continuum • Communication involving all parties	• How can the various community partners work together more effectively? • Is there a role for common electronic platforms/apps to create an interactive network for community partners and related parties? Could these devices be used support patients and clients? • What are the barriers to utilising existing electronic information system such as NEHR (National Electronic Health Record) across the care pathways?
Theme 3: Enhance health-social care interface	• Disconnect in services between health and social care • Lack of information sharing due to absence of shared system	• Integrated health care and social services platform • Impact of social aspects of life and related support issues on health outcomes	• What is the core and targeted information needed by care providers involved in community health and social care? • How can we evaluate the performance towards the integrated health and social care system? (structure, function and outcomes and benefits for those who use services)
Theme 4: Improve respite care services for long-term caregivers	• Perceived shortage of available respite services • Lack of awareness of respite services • Need for support for caregiver wellbeing	• Caregiver training and resilience • Public awareness of illness with potential stigma (e.g. dementia, end of life) • Impact on family and others (caregiver depression and fatigue)	• How can we improve the resilience of long-term caregivers? What training is needed? • What are some available resources in the community to help manage the long-term caregivers? How can we effectively disseminate the information on community resources? • What is the effectiveness and cost-effectiveness of respite care programmes in supporting informal caregivers? • How do we facilitate the capacity of volunteers?
Theme 5: Develop primary care as a driving force for care integration	• Importance of primary care for population health • High patient load in public primary care • Limited involvement of private GPs in population health • Disconnect between primary care and community partners	• Care coordination • Continuity of care • Management of patients with complex care needs in primary care	• How do we evaluate factors that influence general practitioner’s decision to (or not to) refer patients to specialist care and community care? • What is the prevalence of primary care patients lost to follow-up in the system? What are the risk factors associated with loss to follow-up? • How can we streamline the prevention efforts in primary care? (e.g. diabetic and eye screening within one centre) • What are the challenges primary care providers face in managing complex patients in the community? What resources are required?
Theme 6: Capacity building for service providers	• Community care providers as central to population health • Perceived gaps in skill sets, knowledge and capabilities amongst community partners • Pre-eminence and appeal of specialist care & tertiary healthcare institution	• Awareness of community care services among specialists in acute hospitals • Upskilling of community care providers through training and education	• What are the perception, knowledge and awareness of community health and social care resources and mechanism among specialists in restructured hospitals? • Does training and upskilling of community care providers (e.g. nursing home health workers, community mental health workers) lead to improved care outcomes?