Hospital-at-home care in Singapore: A qualitative exploration of health system partners’ state of readiness, and policy and implementation strategies essential to support scale-up

Crystal Min Siu Chua; Eward Wei Zheng Lim; Win Hon See Tho; Yuka Asada; Karen E. Peters; Yi Feng Lai

doi:10.1371/journal.pone.0323679

Peer Review History

Original SubmissionNovember 17, 2024
17 Nov 2024 Author Response https://doi.org/10.1371/journal.pone.0323679.r001
27 Nov 2024 Decision Letter - Veincent Christian Pepito, Editor PONE-D-24-50121Hospital-at-Home Care in Singapore: A Qualitative Exploration of Health System Partners’ State of Readiness, and Policy and Implementation Strategies Essential to Support Scale-UpPLOS ONE Dear Dr. chua, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 11 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following in your Competing Interests section: “NO authors have competing interests” Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. 4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Additional Editor Comments: Dear authors, thanks for the manuscript. The manuscript shows promise but can further be improved. Here are my comments: 1. "Readiness" is such an abstract term, and there are many dimensions to readiness. Therefore, (a) please operationally define this phenomenon in the context of your study and (b) clarify how you will assess readiness qualitatively. On what indicators? On what grounds? On what aspects of readiness? It will probably help if you upload a copy of your data collection instrument so that we can see how you asked your questions. 2. Why did you not interview patients and service users? They would have given candid feedback on quality of care, readiness, and give recommendations for patient-centered care. Is there still a way for you to collect data from them to complete the picture for this study? 3. The study lacks a clear theoretical framework. There are many implementation research frameworks out there that could have been used to clarify the data analysis and reporting process. I strongly suggest that you employ one and use it in the analysis and reporting of your results to give it more structure and clarity. 4. The Results partly answer the objectives but it is less clear which parts of the results answer each objectives. Probably there is a need to signpost readers through appropriate headings and subheadings that these are the parts that answer these objectives on readiness and these parts answer the objectives on strategies. Probably employing the use of an appropriate implementation research framework can help clarify the analysis and the reporting of results. 5. The Discussion is good but along with the comment of one of the reviewers on liability, I want to ask you to expand on quality of care as a discussion point. How do we measure quality of care for hospital at home services? How do we ensure that care received at home is just as good (or even better) as quality of care in hospitals? Where does liability lie? We have written a brief commentary which could help you build your discussion on quality of care and liability: https://pmc.ncbi.nlm.nih.gov/articles/PMC10599638/ 6. Please add a reflexivity and conditionality statement. 7. Please describe in more detail the MIC@home being evaluated by allotting a single subsection in the methodology explaining what this is and what is its theory of change. 8. The MIC@home, is it implemented by Singapore MOH and/or the National University of Singapore? If so, then the authors should be more transparent with their conflict-of-interest disclosure considering that the institutions writing this paper are the ones running the intervention and could be affected by the publication of the results of this study in this journal. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: - Needs more clarification on how the study participants were selected (more information about the sampling criteria. - The authors need more explanation of the inclusion and exclusion criteria. - Needs further clarification and discussion of the study theoretical framework and principles, specifically on HaH. - The manuscript could benefit from language editing (language usage). - (Figure 1) and (Figure 3a) must be revised. Reviewer #2: I find the article to be well written and comprehensive. It provides valuable insight into the set-up of a new and novel service in healthcare. As a clinician, the only gap that I found was regarding the ownership of liability when clinical incidents happen at home, as they invariably will. If the ministry or the institutions do not take ownership, then it will be a major barrier to healthcare professionals providing care at home. I am not sure if this has been addressed in any of the semi-structured interviews, but some mention can be made if it has. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy . Reviewer #1: Yes: Muhammad S. Al-Haddad Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0323679.r002
Revision 1
2 Jan 2025 Author Response COMMENT BY EDITOR:1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. RESPONSE TO EDITOR:Dear Editor, thank you for your comments. This manuscript is formatted based on PLOS One requirements. COMMENT BY EDITOR:Thank you for stating the following in your Competing Interests section: “NO authors have competing interests”. Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. RESPONSE TO EDITOR:Dear Editor, thank you for your feedback and help in making the changes. We have amended the cover letter to include the relevant information. COMMENT BY EDITOR:PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. RESPONSE TO EDITOR:Dear Editor, thank you for your feedback. We have updated the ORCID iD. COMMENT BY EDITOR:Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. RESPONSE TO EDITOR:Dear Editor, thank you for your comments. We have removed the ethics statement from other sections and only included it on page 9 in the manuscript. COMMENT BY EDITOR:Dear authors, thanks for the manuscript. The manuscript shows promise but can further be improved. Here are my comments: 1. "Readiness" is such an abstract term, and there are many dimensions to readiness. Therefore, (a) please operationally define this phenomenon in the context of your study and (b) clarify how you will assess readiness qualitatively. On what indicators? On what grounds? On what aspects of readiness? It will probably help if you upload a copy of your data collection instrument so that we can see how you asked your questions. RESPONSE TO EDITOR:Dear Editor, thank you for your insight. We agree that ‘readiness’ is an abstract term with multiple dimensions. We have added the definition on page 5. To assess readiness qualitatively, we relied on semi-structured interviews. Questions were based on prior literature with some of the following examples:- " In your opinion, are there any significant driving forces/motivators from you/your team/your organization for the scale-up to be successful?” - Share your insights on the key system-level facilitators (to have worked well) and barriers to the scale-up of MIC@Home in Singapore. For clarity, we have attached a copy of our interview guide (data collection instrument) as supplementary material (S1 Material). COMMENT BY EDITOR:2. Why did you not interview patients and service users? They would have given candid feedback on quality of care, readiness, and give recommendations for patient-centered care. Is there still a way for you to collect data from them to complete the picture for this study? RESPONSE TO EDITOR:Dear Editor, we fully agree with your insights. Prior to this study, we have interviewed patients and caregivers on their perceptions and experiences: 1. Chua, C. M. S., Ko, S. Q., Lai, Y. F., Lim, Y. W., & Shorey, S. (2022). Perceptions of stakeholders toward “hospital at home” program in Singapore: a descriptive qualitative study. Journal of Patient Safety, 18(3), e606-e612. 2. Ko, S. Q., Chua, C. M. S., Koh, S. H., Lim, Y. W., & Shorey, S. (2023). Experiences of patients and their caregivers admitted to a hospital-at-home program in Singapore: a descriptive qualitative study. Journal of General Internal Medicine, 38(3), 691-698. We have also provided references to these studies on pages 4 and 7. This study completes the picture by interviewing policymakers and organizational members, offering valuable insights into how to successfully implement the HaH model. Additionally, this study's research questions are technical and require a deep understanding of the healthcare system and service delivery models. As most patients and service users lack this level of insight, we focused our sampling on the specified groups who could provide relevant expertise (page 8). COMMENT BY EDITOR:3. The study lacks a clear theoretical framework. There are many implementation research frameworks out there that could have been used to clarify the data analysis and reporting process. I strongly suggest that you employ one and use it in the analysis and reporting of your results to give it more structure and clarity. RESPONSE TO EDITOR:Dear Editor, thank you for your insights. The themes and subthemes described in our Results were developed inductively, and as such, they may not fully align with existing frameworks. However, we recognize that applying a framework could enhance structure and clarity. To address this, we have integrated the Health Policy and Partnership Readiness Assessment Framework in our Introduction and Discussion section to better interpret and contextualize our findings (pages 2, 5 and 28-36). We seek your kind understanding. Thank you once again for your valuable input. COMMENT BY EDITOR:4. The Results partly answer the objectives but it is less clear which parts of the results answer each objectives. Probably there is a need to signpost readers through appropriate headings and subheadings that these are the parts that answer these objectives on readiness and these parts answer the objectives on strategies. Probably employing the use of an appropriate implementation research framework can help clarify the analysis and the reporting of results. RESPONSE TO EDITOR:Dear Editor, thank you for your feedback. We agree that the Results can be clearer in answering the objectives and have added more in-text signposting for each of the themes on pages 11, 16 and 24. COMMENT BY EDITOR:5. The Discussion is good but along with the comment of one of the reviewers on liability, I want to ask you to expand on quality of care as a discussion point. How do we measure quality of care for hospital at home services? How do we ensure that care received at home is just as good (or even better) as quality of care in hospitals? Where does liability lie? We have written a brief commentary which could help you build your discussion on quality of care and liability: https://pmc.ncbi.nlm.nih.gov/articles /PMC10599638/ RESPONSE TO EDITOR: Dear Editor, thank you for your insights. We have added the reference on page 34. We would also like to clarify that this study was not designed to assess quality, safety, equity, or liability issues, which have been well covered in the literature. For instance, two relevant Cochrane Reviews provide comprehensive analyses on these topics: 1. Edgar K, Ilić S, Doll HA, Clarke MJ, Gonçalves-Bradley DC, Wong E, et al. Admission avoidance hospital at home. Cochrane Database of Systematic Reviews 2024, Issue 3. Art. No.: CD007491. 2. Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E, et al. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews 2024, Issue 3. Art. No.: CD014765. With clinical effectiveness well represented in the literature, this study aims to highlight strategies that are necessary for the successful scaling of hospital at home programs. Thank you for your understanding. COMMENT BY EDITOR:6. Please add a reflexivity and conditionality statement. RESPONSE TO EDITOR:Dear Editor, thank you for your suggestion. We have added reflexivity and conditionality statements on page 9. COMMENT BY EDITOR:7. Please describe in more detail the MIC@home being evaluated by allotting a single subsection in the methodology explaining what this is and what is its theory of change. RESPONSE TO EDITOR:Dear Editor, thank you for your comment. We have provided more context on MIC@Home with its theory of change under Settings (pages 7 and 8) and in S1 Material. COMMENT BY EDITOR:8. The MIC@home, is it implemented by Singapore MOH and/or the National University of Singapore? If so, then the authors should be more transparent with their conflict-of-interest disclosure considering that the institutions writing this paper are the ones running the intervention and could be affected by the publication of the results of this study in this journal. RESPONSE TO EDITOR:Dear Editor, thank you for your question. MIC@Home is implemented by the hospitals of Singapore. MOH Office for Healthcare Transformation and the National University of Singapore have no direct influence over implementation of MIC@Home. Therefore, we have declared no competing interest on page 40. COMMENT BY REVIEWER 1:- Needs more clarification on how the study participants were selected (more information about the sampling criteria. - The authors need more explanation of the inclusion and exclusion criteria. RESPONSE TO REVIEWER 1:Dear Reviewer, thank you for your feedback. The participants were purposefully sampled based on their insights to MIC@Home. Furthermore, this study's research questions are technical and require a deep understanding of the healthcare system and service delivery models. As most patients and service users lack this level of insight, we focused our sampling on the specified groups who could provide relevant expertise We have added more explanation to the patient eligibility criteria on pages 6 and 7. COMMENT BY REVIEWER 1:- Needs further clarification and discussion of the study theoretical framework and principles, specifically on HaH. RESPONSE TO REVIEWER 1:Dear Reviewer, thank you for your insight, we have given our Discussion more structure with references to the Readiness Assessment Framework. This can be found on pages 2, 5 and 28-36. COMMENT BY REVIEWER 1: - The manuscript could benefit from language editing (language usage). RESPONSE TO REVIEWER 1:Dear Reviewer, thank you for your feedback. We have reviewed our manuscript and completed language editing. COMMENT BY REVIEWER 1:- (Figure 1) and (Figure 3a) must be revised. RESPONSE TO REVIEWER 1:Thank you for your feedback. Figure 1 and Figure 3a represent detailed themes and subthemes that were inductively derived from our data. Instead of revising these figures, we have now incorporated the Readiness Assessment Framework to guide the Discussion section based on our results. This approach will provide greater clarity and highlight actionable insights moving forward. We kindly seek your understanding and appreciate your valuable input. COMMENT BY REVIEWER 2:Reviewer #2: I find the article to be well written and comprehensive. It provides valuable insight into the set-up of a new and novel service in healthcare. RESPONSE TO REVIEWER 2:Dear Reviewer, thank you for your kind encouragement. COMMENT BY REVIEWER 2:As a clinician, the only gap that I found was regarding the ownership of liability when clinical incidents happen at home, as they invariably will. If the ministry or the institutions do not take ownership, then it will be a major barrier to healthcare professionals providing care at home. I am not sure if this has been addressed in any of the semi-structured interviews, but some mention can be made if it has. RESPONSE TO REVIEWER 2:Dear Reviewer, thank you for your insight, we fully agree with you that patient safety is important. We would like to stress that hospitals remain liable for MIC@Home’s patient clinical outcomes, and that supporting policies, regulations and guidelines are crucial for ensuring quality and safety of patient care (pages 33, 35-36). Attachments Attachment Submitted filename: Response to reviewer_020125.docx https://doi.org/10.1371/journal.pone.0323679.r003
25 Feb 2025 Decision Letter - Veincent Christian Pepito, Editor PONE-D-24-50121R1Hospital-at-Home Care in Singapore: A Qualitative Exploration of Health System Partners’ State of Readiness, and Policy and Implementation Strategies Essential to Support Scale-UpPLOS ONE Dear Dr. chua, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Apr 11 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Veincent Christian Pepito Academic Editor PLOS ONE Additional Editor Comments: Dear authors, Thanks for your revision. The reviewers have advised acceptance, but I still have a few comments: 1. The abstract needs to be re-written. The framework used should be in the Background/Methods part, and not in the Results. This should be fixed. 2. A brief description of the framework used should be put in the Introduction, also explaining why that particular framework was used. Also, please improve the integration of the framework with the rest of the article. As it stands, the framework does not appear to be well-integrated with the methods and results. The framework should in some sense, guide the questions asked, the analysis, and the presentation of the results. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy . Reviewer #1: Yes: Muhammad S. Al-Haddad ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0323679.r004
Revision 2
8 Apr 2025 Author Response All relevant data are within the manuscript and its Supporting Information files as Supplementary Files 1, 2, and 3. We would like to confirm that our minimal data set is present. I confirm that the manuscript and supporting files (S1 Material.jpg, S2 Interview Guide.docx, and S3 Material.pdf) include the minimal data set as defined by PLOS ONE. No further data uploads are required. I mistakenly selected the assistance checkbox at submission, but do not require additional support. Reviewer comments: Dear authors, Thanks for your revision. The reviewers have advised acceptance, but I still have a few comments: 1. The abstract needs to be re-written. The framework used should be in the Background/Methods part, and not in the Results. This should be fixed. Response to reviewer: Dear Editor, thank you for reviewing our manuscript, and your comments. We have reorganized the abstract accordingly on page 2. Reviewer comments: 2. A brief description of the framework used should be put in the Introduction, also explaining why that particular framework was used. Also, please improve the integration of the framework with the rest of the article. As it stands, the framework does not appear to be well-integrated with the methods and results. The framework should in some sense, guide the questions asked, the analysis, and the presentation of the results. Response to reviewer: Dear Editor, thank you for your feedback. We have added some context about the framework on pages 5 and 6. Furthermore, we have integrated the framework more thoroughly within the Methods section (page 9) and the Results section (pages 12, 13, 17, and 27). This ensures consistency with its use in guiding the Discussion segment, as previously outlined. With this addition, the framework now would have been integrated to guide our research questions, analysis in methods, and presentation of results. Thank you. Attachments Attachment Submitted filename: Response to reviewer_130325.docx https://doi.org/10.1371/journal.pone.0323679.r005
14 Apr 2025 Decision Letter - Veincent Christian Pepito, Editor Hospital-at-Home Care in Singapore: A Qualitative Exploration of Health System Partners’ State of Readiness, and Policy and Implementation Strategies Essential to Support Scale-Up PONE-D-24-50121R2 Dear Dr. chua, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Veincent Christian Pepito Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0323679.r006
Formally Accepted
Acceptance Letter - Veincent Christian Pepito, Editor PONE-D-24-50121R2 PLOS ONE Dear Dr. Chua, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Mr Veincent Christian Pepito Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0323679.r007

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