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Two researchers, using an inductive-deductive framework for thematic analysis, initially built upon previous work. The JSON schema structure outputs a list of sentences, augmented with emergent subthemes. A total of 28 patients, 29 healthcare providers, and 8 managers from four primary care practices, were supplemented by 16 representatives from community-based services and 10 representatives from geriatric clinics. Participants observed several factors impacting the