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. |