Table 2 Examples of key themes at the intersection of Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) constructs and Collaborative Chronic Care Model (CCM) implementation, for CCM implementation overall and for core CCM elements

CCM implementation overall

• Empowers providers to better navigate the system to help meet patient needs

• Needs more clarity around what care delivery processes embody CCM principles

• Are familiar with patient-centered and recovery-focused care

• Do not always have the authority to design care processes

• Balancing implementation alongside concurrent change initiatives is challenging

• CCM being a national recommendation serves as an impetus for local implementation

• External facilitators help set reasonable expectations and are responsive to inquiries

• Internal facilitators’ experience with quality improvement and team/process skills is valuable

CCM element: work role redesign

• Better allows multidisciplinary input

• Brings about more efficient workflow for referrals

• Leverage autonomy where possible to implement CCM

• Grow together as a team and build trust in playing synergistic roles

• Frequent staff transitions are challenging

• Existing adjacent site-specific processes may or may not fit with CCM

• External facilitator provides overall CCM knowledge

• Internal facilitator leads redesign of specific team roles

CCM element: patient self-management support

• Better enables step-down in care intensity for patients

• Makes an interdisciplinary team of providers available to patients

• Are aware of having group treatment plans

• Explain to patients the new team-based mode of care delivery

• Provider experience with actively involving patients in their care is helpful

• Use of evidence-based therapies that involve self-management support is helpful

• Internal facilitator discusses with team how to strategically plan supportive maintenance for medically improved patients

CCM element: provider decision support

• Enhances the frequency with which cases are discussed

• Fosters a shared understanding of different expertise

• Consult team members from different disciplines

• Consult expertise outside the team

• Collocation of providers helps CCM

• Existing capability to assign additional signers to patient notes is used for CCM

n/a

CCM element: clinical information systems

• Is a useful reminder to more routinely deliver evidence-based care

• Makes panel-based case management difficult without adequate information systems

n/a

n/a

• Both external and internal facilitator support increasing shared caseloads and creating shared panels across team

CCM element: linkages to community resources

n/a

• Share resources in team meetings and through pamphlets

• Rely particularly on social work team members for knowledge

• Existing collections of available resources are helpful

• Communicating effectively with community organizations is challenging

n/a

CCM element: organizational/leadership support

• Is met with resistance from leadership

• Is not clear on the extent to which teams can design their own processes

• Use professional networks to solicit input from leadership

• Need support to attend trainings to increase CCM-related skills

• Leadership does not always solicit input from providers in making CCM-related decisions

• Leadership is not always aware of being non-inclusive

• Many sites had positive experiences with implementation facilitation

• Isolated cases of mishandled communication or being from outside the service threatened team trust in facilitators