Barriers to Integration of Primary Care into Emergency Care: Experiences in Germany

PRIMARY OUTCOMES	SECONDARY OUTCOMES
Time from presentation to treatment Duration within department Admitted versus discharged	Investigations Therapy Further specialistreferral Onward care Subsequent use of Notaufnahme or Primary Care Cost-effectiveness Adverse events

Table 2

Intended Mixed-Method Data Collection.

QUANTITATIVE DATA
CLINICAL LEVEL			COMMENTS
Patient Questionnaires	Pre- and Post-Intervention (i.e. PCP-Streaming)	Pre-consultation: demographic data and circumstances of attendance	The questionnaire was designed using the Hamburg study’s questionnaire as a template [15] and augmented as per the Tübingen context and study focus.
Patient Questionnaires	Pre- and Post-Intervention (i.e. PCP-Streaming)	Post-treatment: patient’s experience and satisfaction, care received/ recommended
ORGANISATIONAL LEVEL
Hospital Clinical Software	Pseudo-anonymised data	Patient journey, resource use and cost of care (to the public body)*	Outcome was acknowledged to be a likely increase in resource use and cost of care because many self-referrers were previously sign-posted to alternative healthcare access points (e.g. outpatient clinic, primary care practice).
QUALITATIVE DATA
Interviews with ED staff	Pre- and Post-Intervention (i.e. PCP-Streaming)	Experiences pre- and post-intervention	The interviews were planned to take place at the 6-month point, however the project did not reach this stage.
First person experiences of study PCP

[i] * We were to reassess and focus on cost comparisons in the broader roll out of the project in the second phase, but the project was terminated early. A recent meta-analysis serves as a useful guide in the cost analysis of integrated care projects [19].

**(A)** Standard Patient Flow. **(B)** Patient Flow in PCP Streaming.

Conceptual framework for integrated care based on the integrative functions of primary care [22].

Table 3

The Key Features of Normative Integration (Adapted from ‘Taxonomy of 59 Key Features’) [23].

KEY FEATURES	DESCRIPTION
Collective attitude	Collective attitude within the collaboration towards open communication, sincerity and respect at operational, tactical and strategic levels.
Sense of urgency	Awareness regarding the need and purpose to collaborate at the operational, tactical and strategic levels.
Reliable behaviour	The extent to which the agreements and promises within the collaboration are fulfilled at operational, tactical and strategic levels
Conflict management	The ability to effectively manage interpersonal conflicts within the collaboration.
Visionary leadership	Leadership based on a personal vision that inspires and mobilizes people.
Shared vision	A collectively shared long-term vision within the collaboration at the operational, tactical and strategic levels.
Quality features of the informal collaboration	Effectiveness and efficiency of the informal collaboration at the operational, tactical and strategic levels (e.g. group dynamics and attention to the undercurrent).
Linking cultures	Linking cultures (e.g. values and norms) with different ideological values within the collaboration at the operational, tactical and strategic levels.
Reputation	Individual reputation of those people involved in the collaboration.
Transcending domain perceptions	The ability to transcend one’s own professional domain within the collaboration at the operational, tactical and strategic levels
Trust	The extent to which those involved in the collaboration at operational, tactical and strategic levels trust each other.