Table 4.

Quotes Illustrating Factors Influencing the Implementation of the Four Transitional Care Interventions (TCIs)

Theme	CFIR (domain/factor)	Quotesa
Significant barriers at the organizational level	Inner setting:
	Structural characteristics	(1) “So, in practice, you only see it being rolled out in the centers that are indeed capable of it and those are really the larger centers … who are big enough, the cardiologists who are willing to do that, and who can convince the hospital that it is important.” (HCP, Case D)
	Networks and communications	(2) “Yes, in terms of stumbling blocks. I think it is really just communication with GPs that is the biggest issue, but … they are looking for a digital solution.” (HCP, Case D)
	Readiness for implementation―available resources	(3) “The obstacle in the implementation is that I personally have to be able to do it within my time.” (HCP, Case D) (4) “Things that discourage are the administrative burden, things that have to be done extra, lack of time, all the care providers simply have an impossible amount of work and they are always short of time.” (Project Coordinator, Case C) (5) “That is the biggest challenge and in terms of barrier, that means lack of funding for staff, for interventions, well for everything.” (Project Coordinator, Case D) (6) “… when you say about the difficulties of financing, yes … the funny thing was that there was actually rarely a budget for the nurse coordinator in the intermediate care center.” (HCP, Case A)
	Health information technology systems resources	(7) “So, communication by electronic means is the most difficult … but the big problem remains finding a platform where first, second, and third can communicate.” (HCP, Case C)
	Information continuity	(8) “What we have noticed and continue to notice that data sharing just doesn’t work, because you have different platforms.” (HCP, Case A)
	Outer setting:
	External policy and incentives	(9) “I think what is blocking us most of all is the fact that the supra-local policy is not so well coordinated; the federal health policy and the Flemish welfare policy.” (HCP, Case C) (10) “The way primary care is currently financed is not always very conducive to integrated care, because it actually keeps the partitions in place, and partitioning is difficult if the financing model doesn’t change.” (Project Coordinator, Case A)
Power of committed individuals―“the key triggers and facilitators”	Intervention characteristics:
	Intervention source	(11) “A very important one has been the neighborhood teams; these are teams of care providers in the first line. GPs, pharmacists, nurses, physiotherapists, psychologists, etc. who work together at neighborhood level on chronic patients and they implement the care programs … that is actually how it came about from the bottom up, because the initiators of those neighborhood teams were the GPs.” (Project Coordinator, Case A)
	Outer setting:
	Cosmopolitanism	(12) “We are very lucky to have a chronic care project in this region, because, yeah, healthcare providers they kind of know each other … and that is like very beneficial or very facilitating for this cooperation.” (Project Coordinator, Case A)
	Community resources	(13) “I think the fact that we have community centers and local service centers in Leuven is a good thing, yes, anchor points for a caring neighborhood.” (HCP, Case C)
	Characteristics of individuals (health care providers and implementers):
	Knowledge and beliefs about the intervention	(14) “In addition, what certainly plays a role is that, as I said at the beginning, there is a motivator for more quality care, so a facilitator or motivator, achieving support and shared responsibility are all things that motivate.” (Project Coordinator, Case C)
	Other personal attributes	(15) “There is a lot of commitment, there is a lot of enthusiasm, there is a lot of goodwill and openness to try things not only to that heart failure project, but also to the broader project. So that is positive, but actually implementing it then yes, that also depends on how much personal affinity people or carers have with it. That varies greatly, but the basis is that there is a lot of goodwill … it was our own motivation and commitment.” (Project Coordinator, Case D)
	Process–Engaging:
	Champions	(16) “What was good about facilitating us was the people (TCIs team) themselves. They really took the initiative to set up meetings with the community team because otherwise, I think, it would never have happened so quickly.” (HCP, Case C) (17) “And (person name from TCIs team) was kind of more a backup … that was very good because she is like the face of (TCIs), so this really helps for this kind of work; and I think this really works for the motivation of the pharmacists, the healthcare providers, in general.” (Project Coordinator, Case A)
	Key stakeholders	(18) “… but (person name from TCIs team) yes, she also works at hospital for her other job. So that was also a gateway to making it easier to contact other people within the hospital.” “Yes, the pharmacists within (TCIs team) and (person name) are the representatives of the pharmacists. So, in the meantime you have good contact with most pharmacists, so that also helps to motivate them”; “So I think in this way they were the most important triggers for this action.” (Project Coordinator, Case B)
	Innovation participants	(19) “The fact that citizens are also involved means that they also see that yes, we can play a role in this.” (HCP, Case C)
	Engaging organizations, external context	(20) “That there are a number of strong players involved, two large GPs practices that are both committed … a number of institutions are also involved.” (HCP, Case C)
Imperfect fit between interventions’ components and older adults’ profile	Intervention characteristics:
	Design quality and packaging	(21) “So those bottlenecks were initially the design of the envelope which was not clear enough for the older population, and something that clearly needed to be addressed was raising awareness among patients and nurses in any case, and also among pharmacists.” (Project Coordinator, Case B)
	Targeted groups	(22) “… the problems are mainly related to identifying the right patient, and a second problem is once the patients are identified to get them to the right person, and that is something that is not quite running smoothly yet.” (HCP, Case C) (23) “Being confronted once again with the complexity of the patient group that is indeed at risk, and the complexity is in the medical … but also in the social, psychological, element that is really crucial, and that complicates a number of things, such as early care planning.” (HCP, Case D)
	Characteristics of individuals (older adults):
	Knowledge and beliefs about the intervention	(24) “We have also had a patient before who said I have had a lot of explanations, but I didn’t understand a thing, so could you please do it again?” (HCP, Case B)
	Other personal attributes	(25) “Asking an 85-year-old to log into an app on his own. That is still difficult … there will always be a generation gap with every modernization.” (HCP, Case D)
Disruption of implementation by COVID-19	Outer setting–miscellaneous:	(26) “But we have never actually been able to sit together in real life with all the people from the neighborhood team, which made communication a bit more difficult in the beginning.” (HCP, Case C) (27) “So yes, that was difficult because of COVID, that not everyone’s role was equally clear … who can I talk to and who is here.” (Project Coordinator, Case A) (28) “That was a real disaster, wasn’t it? You saw that within the care program not only on cardiac consultation simply. I think we had a time when 30% of the patients did not show up without calling. If necessary, I would say give the people a tablet so that I can give them their education via the computer, but the people all refused. That really was a period of time; I think it was more than two months that I couldn’t include anyone.” (HCP, Case D) (29) “I think very strongly. On the one hand, there are many bottom-up initiatives. I think much more than in other times. Neighbors helping each other out … A lot has been set up. There are also, I think, a lot of agreements with hospitals … their discharge policy. I know that the pharmacists have also taken very nice actions with home delivery of medication; so many things have been accelerated. So that has been very nice.” (HCP, Case C)

Notes: CFIR = Consolidated Framework for Implementation Research; HCP = health care professional; GP = general practitioner; TCI = transitional care intervention; covid-19 = coronavirus disease 2019.

^aThe presented quotes are representative of and can be generalizable across the cases.