Table 3.

Context, mechanisms and outcomes configurations underpinning the adoption and adaptation of the Esther Network (EN) model in SingHealth

Context	Mechanisms	Outcomes
Macrosystem
(1) Need for understanding of an effective model of PCC	Ministerial visit to EN Sweden signalled nation’s priority to adopt a PCC model perceived as relevant and transformative by policy makers and healthcare operators	Spread of EN nationally to two out of three healthcare clusters
(2) The need for order and hierarchical structures in local culture	Public endorsement from leaders affirmed staff about their participation in EN * Involvement of coaches’ supervisors as sponsors enabled coaches to initiate changes Leaders recognised the role of doctors as coaches to lead in change management*	All SingHealth institutions (n=13) have Esther coaches 171 project sponsors with low attrition rate of 0.03% 9% of coaches were doctors, with 16% of projects led by them
Mesosystem
(3) Insufficient understanding of PCC	Coach and advocate training centred the Esther story brought like-minded people together*	271 coaches and 379 advocates trained
(4) The need for order and hierarchical structures in the local context	A head coordinator, an organisation structure with formal roles and responsibilities put in place increased coaches’ ownership * An innovation unit to support coaches enabled them to scale person-centred projects that reached more Esthers*	Expansion of network 25 out of 85 (>30%) projects upscaled across settings
(5) EN was a new concept in the SingHealth local setting	Communication efforts through official launch, newspaper articles and yearbooks were intentional and increased understanding of EN and Esther stories	Increased participation and interest in EN
(6) Professionals worked in silos and health-social engagements tended to be superficial and short-lived	Prerequisites in selection of coaches resulted in synergy among multi-professionals; the common passion in improvement work sustained the continuing participation of coaches EN provided a long-term platform for health and community practitioners to meet and leverage on existing efforts to codrive socialhealth integration and improvements	Active coaches reflect the workforce distribution– 9% doctors, 11% administrative, 18% allied health, 27% nurses, 35% community practitioners 59 (>70%) community practitioners in the region joined the network with 76% projects on social-health improvements
Microsystem
(7) Patient or citizen involvement was an unfamiliar concept	Esther’s story was a driving force to bring people together; the idea of coproduction between providers and users fostered trust and strengthened relationships	The relatedness and sense of being valued motivated Esthers to continue participation
(8) Reductionist approach in patient care	Coaches saw the healthcare system as it was through Esther Café and shadowing of Esthers; the approach to start with what mattered to Esthers energised them Coaches who cared routinely for Esthers recognised they were well-placed to engage Esthers and make improvements in various areas (more examples in table 4)	100% Esther projects were coproduced with services users and 83% of coaches had completed an Esther project 85 person-centred improvement projects in 5 years: 22% made process improvements; 23% resulted in service innovations; 35% improved clinical outcomes; 35% increased services users’ empowerment in self-management

*Denotes the mechanisms that facilitated the adaptations made in EN Singapore.

PCC, person-centred care.