Table 4 Facilitators and barriers to implementation across the five CPC components, as commonly reported or observed in deep-dive practice interviews and visits conducted in 2013
CFIR domain | CPC component | ||||
|---|---|---|---|---|---|
Access and continuity | Planned care for chronic conditions and population health | Risk-stratified care management | Patient and caregiver engagement | Coordination of care | |
Characteristics of the CPC initiative | |||||
Facilitators | |||||
Adequate resources for new capacities (both financial and time) | ✓ | ✓ | ✓ | ✓ | ✓ |
Compatibility with care improvement objectives | ✓ | ||||
Barriers | |||||
Insufficient resources for new capacities (tools, financial, time) | x | x | |||
Complex or unclear requirements | x | x | |||
External environment and context | |||||
Facilitators | |||||
Effective local electronic HIE | ✓ | ✓ | ✓ | ||
HIT “meaningful use” incentives | ✓ | ||||
Regional history of patient-centered medical home programs | ✓ | ✓ | ✓ | ✓ | ✓ |
Barriers | |||||
Lack of direct electronic access to health information from other care settings | x | x | x | ||
Delays in access to patient survey results | x | ||||
Gaps in electronic information available through HIE | x | x | x | ||
Complexity of needs in patient population | x | ||||
Internal context and setting of the practice | |||||
Facilitators | |||||
Prior experience with quality improvement efforts | ✓ | ✓ | ✓ | ✓ | ✓ |
Organizational commitment to population health approaches to care | ✓ | ✓ | |||
Independent practices could make rapid change | ✓ | ✓ | ✓ | ✓ | ✓ |
System-affiliated practices had support for management, HIT, quality improvement | ✓ | ✓ | ✓ | ||
Integration of new work with existing work processes | ✓ | ||||
EHR technology integrated with disease registries and patient reminder systems | ✓ | ✓ | |||
Prior use of shared decision-making tools | ✓ | ✓ | |||
Existing staff trained in patient self-management approaches | ✓ | ||||
Barriers | |||||
Organizational commitment to traditional office visit-driven model of care | x | x | |||
Independent practices lacked support for management, HIT, and quality improvement | x | ||||
System-affiliated practices had limited local authority to make change | x | x | x | x | x |
Lack of a practice-level quality improvement infrastructure | x | x | x | x | x |
Lack of population management systems and sufficient care management staffing | x | ||||
Lack of knowledge of available shared decision-making tools | x | x | |||
Preventive health and chronic illness-related data entered into EHRs as unstructured data | x | x | |||
EHRs had to be modified to integrate new work | x | x | |||
Characteristics and attitudes of practice staff and clinicians | |||||
Facilitators | |||||
Shared staff and clinician commitment to population health approaches to care | ✓ | ✓ | |||
Barriers | |||||
Clinician skepticism regarding the value of CPC requirements | x | x | |||
Shared staff and clinician commitment to office visit-driven model of care | x | ||||
CPC implementation process within the practice | |||||
Facilitators | |||||
Use of established quality improvement processes | ✓ | ✓ | ✓ | ✓ | ✓ |
Use of pilot testing before making practice-wide changes | ✓ | ✓ | ✓ | ✓ | ✓ |
Tailored assistance from regional learning faculty | ✓ | ||||
Standardization of implementation processes across system-affiliated practices | ✓ | ✓ | ✓ | ✓ | ✓ |
Dedicated CPC implementation meetings | ✓ | ✓ | ✓ | ✓ | ✓ |
Barriers | |||||
Implementation limited to some (not all) clinicians or care teams, creating multiple workflows for the same processes | x | x | x | x | |
Knowledge of CPC requirements unevenly shared across practice members | x | x | x | x | |