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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