Table 6.

Example determinants, theoretical methods, and implementation strategies.

Implementation outcome:Health care provider makes referrals of patients with prediabetes to the National DPP.
Determinants	Methods (Theory)	Implementation strategies
Perception and awareness Outcome expectations	Modeling (Social cognitive theory; diffusion of innovations theory) Framing (Protection motivation theory) Tailoring (communication-persuasion matrix) Discussion (elaboration likelihood model) Goal-setting (Goal-setting theory) Feedback (Theories of learning; social cognitive theory). Guided practice (Social cognitive theory)	Develop and distribute tailored materials Educational materials include salient, gain-framed messages highlighted: National DPP eligibility criteria and policies. EHR referral pathways Models of clinics implementing National DPP highlighted: National DPP providers discussing the importance of submitting patient referrals. How other clinics prioritize National DPP referrals and integrate the process in their current workflows. Testimonials from health care provider about the impact of the National DPP. Thank you notes to providers including a message of support for their referral's effort and the number of referrals made each quarter. Training materials included: Walkthrough presentations and handouts illustrate proper identification of patients to promote diabetes prevention and referral submission Reminder materials included: Flyer with diabetes risk factors, eligibility criteria, and program details. The flyers also included the National DPPs contact information and a message about the National DPP benefits from a participant's point of view and a gain-framed message (“Refer patients at risk of diabetes to the National DPP to reduce their risk of developing type 2 diabetes.”). Monthly meetings between the clinic staff (e.g., leadership, administration, and program champion), National DPP and the UTHealth team to share knowledge and relay clinical data to providers. Presentations and discussions to: Describe how to conduct referrals, including the use of decision support tools and benefits on patient outcomes. Discuss clinics’ diabetes prevention efforts, number of referrals made. Review patient records and referral numbers to identify opportunities for improvement. Provider-to-provider mentoring Meetings to give feedback on the progress of the providers' goals and referrals.
Interorganizational relationships	Discussion (Elaboration likelihood model) Participatory problem solving (Organizational development theories; social capital theory; models of community organization). Enhancing network linkages (Social networks and social support theory)	Monthly meetings included the National DPP, the clinic staff (e.g., leadership, administration, and program champion), and the UTHealth Team. Regular interaction between the National DPP, the clinic staff (e.g., leadership, administration, and program champion), and the UTHealth Team facilitated: Rapport and linkage building between teams. Troubleshooting as adoption or implementation barriers occurred. Change clinic records systems to include EHR-based referral system between clinics and partner National DPP. Updates/changes made to the clinics and National DPP EHR included: Connecting the health center EHR and the National DPP into the same network. Establishing direct messaging between the clinic and the National DPP to facilitate the referral process. Integrating lab results into the clinics EHR. Promote network weaving by partnering the clinic with local food bank. Facilitate integration of food bank services with the National DPP and clinics.
Feedback and reinforcement	Technical Assistance (TA) (Organizational development theories; diffusion of innovations theory; social capital theory; models of community organization)	Centralized monthly technical assistance meetings with the National DPP, the clinic staff (e.g., leadership, administration, and program champion), and the UTHealth team. Monthly meetings included: Training on how to use EHR-based referral system, benefits of using CDS to facilitate referrals Support and troubleshooting for EHR-based referral system Assistance with EHR/CDS optimization and workflows Discussions about the importance of reviewing and interpreting data trends on a continuous basis.

This table shows a sample of the methods and practical applications for environmental outcomes for clinics.

CDS, clinical decision support; EHR, Electronic Health Records; National DPP, National Diabetes Prevention Program; TA, Technical Assistance.