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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

From: Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation

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
  1. Source: [12]. For each CPC component where they apply, facilitators are indicated with a checkmark and barriers are indicated with an x. CPC Comprehensive Primary Care initiative, EHR electronic health record, HIE health information exchange, HIT health information technology
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Implementation Science

ISSN: 1748-5908