Table 1 Interview guidelines

1. Inter-entity organization and management

(1) How to work with different local government departments, which support medical care and social care?

(2) How to arrange cases, how to assign cases among the tier ABC? And how to allocate the overall service hours among the tier ABC?

(3) LTC Plan 2.0 emphasizes the integration of resources. What are the most challenging difficulties for the agency so far? (e.g., Agency role, Human resources, Service delivery, Coordination of different departments and agencies, Resource development), and any strategy to deal with the challenges?

2. Coordination of care

(1) How to coordinate recipients’ needs between Tier A and (government) care managers?

(2) What are the difficulties between Tier A and (government) care managers when doing case management?

(3) Any difficulty in developing service plans?

(4) Any difficulty in implementing service plans, especially when services are provided by different agencies (e.g., gate-keeping, caseload)

3. Integrated information systems

(1) How to pass clients’ personal information and service plans among Tier ABC teams?

(2) Possible solutions

4. Integrated financing

(1) What is the present payment mechanism?

(2) What was the financial impact for the agency when the LTC Plan 2.0 policies started?

(3) What are the difficulties for integrated financing?