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. Author manuscript; available in PMC: 2024 May 3.
Published in final edited form as: J Healthc Qual. 2023 Dec 14;46(3):137–149. doi: 10.1097/JHQ.0000000000000419

Table 2.

Site-Specific Barriers and Facilitators through Updated CFIR Lens

Site Descriptives* Innovation Inner Setting Individuals Outer Setting Process
Site 1

  • Beds: 0–299

  • City population: ~286,000

  • Urban status: Urban

  • Region: Southeast

  • Cost (1 FTE) (+)

  • Complexity (N/A)

  • Offerings: PHI/PHP, Free classes, GeroFit wellness program partnership (+);

  • Accessibility: Self- or PCP referral to pathway classes (e.g., Taking charge of my health and my life, Coaching) (+); Virtual classes (+)

  • Relational connections and communication: Siloed Services (−)

  • Compatibility: Partnered with GeroFit program (+)

  • Structure and resources: WH staff (+), Limited infrastructure (staffing, funding) (−)

  • Learning centeredness: Need for engagement metrics (−)

  • -Information and knowledge access: Need for updated list of services and how to connect (−)

  • Innovation deliverers: PCP (+)

  • Innovation recipients: N/A

  • Implementation leaders and team: 1 FTE (+); Interdisciplinary WH steering committee (+)

  • Capability: Lack of Veteran and staff WH engagement knowledge (−)

  • Opportunity: N/A

  • Motivation: N/A

  • Partnerships: community partnerships (planning phase) (+)

  • Critical Incidents: COVID-19 interrupted in-person classes (−)

  • Doing: N/A

  • Reflecting and evaluating: Limited metrics; Only measuring course attendance (+/−); GeroFit visits tracked in CPRS (+); Potential metrics include Veteran/Employee engagement survey, environmental resource survey (+/−)
Site 2

  • Beds: 600+

  • City population: ~368,000

  • Urban status: Urban

  • Region: Mid-west

  • Cost (2 FTEs) (+)

  • Complexity: (N/A)

  • Offerings: PHI/PHP, Main campus free classes (+/−), numerous classes (+); Virtual engagement options (+); classes varied by location (+/−)

  • Accessibility: Peer/Physician referral (+/−); Provider referral required for classes (+/−); rural Veterans limited access to in-person offerings (−)

  • Relational connections and communication: WH marketing by VA (+)

  • Compatibility: Insufficient staff for WH education (−)

  • Structure and resources: Limited WH education staff (−)

  • Learning centeredness: Need for engagement metrics (−)

  • Information and knowledge access: N/A

  • Innovation deliverers: Healthcare staff/providers (+/−)

  • Innovation recipients: Steps needed to engage Veterans (−)

  • Implementation leaders and team: Team is 1 WH director and 1 coach (+/−); Need for more innovation drivers (−); 2 FTE (+)

  • Capability: Barriers to provider and Veteran WH awareness and knowledge (−); referral limited by unclear role (mental health vs. PCP) (−)

  • Opportunity: N/A

  • Motivation: Highly motivated Veterans (+)

  • Partnerships: Cost of third-party services used to price offerings (e.g., acupuncture) (+)

  • Critical Incidents: COVID-19 interrupted in-person classes (−)

  • Doing: N/A

  • Reflecting and evaluating: WH team tracks referral rate and source (PCP vs. Mental Health) (+), but not engagement, continuation of program, % of referrals that attend WH classes (−); No QOL or pre-post metrics used for classes (−); Lack of provider WH knowledge assessment (−)
Site 3

  • Beds: 0–299

  • City population: ~693,000

  • Urban status: Urban

  • Region: Southeast

  • Cost (> 65 FTEs) (+)

  • Complexity (N/A)

  • Offerings: PHI/PHP, 1 coach/PACT, Free online/in-person classes CIH clinic rural location (+/−)

  • Accessibility: Self-referral to well-being programs/PHI, HCP referral to CIH clinic (+/−); VVC connection options (+)

  • Relational connections and communication: Coach/PACT; local marketing (e.g., radio); website information (+), lack of PACT team communication

  • Compatibility: WH coach-PACT team integration needed (+/−)

  • Structure and resources: Assigned WH coaches and leadership (+), No CIH clinic staff at main campus (−), transport provided to rural CIH clinic (+/−)

  • Learning centeredness: Need for engagement metrics (−)

  • Information and knowledge access: PACT coaches serve as information source (+), Provider conferences and training (+); Nationally replicated coach training program (+)

  • Innovation deliverers: Peer-to-peer coach model (e.g., Veteran as coach) (+), but heterogenous background/style results in variable approaches and PACT team integration (+/−)

  • Innovation recipients: N/A

  • Implementation leaders and team: ≥65 FTE (+); Interdisciplinary WH initiative leadership team driving change (+)

  • Capability: PACT WH coaches equipped with knowledge (+); PCP unsure of current WH provider list; inappropriate CIH referrals due to unclear criteria

  • Opportunity: N/A

  • Motivation: N/A

  • Partnerships: WH has community partnerships for referral if rural CIH visit is not feasible for Veteran (+)

  • Critical Incidents: COVID-19 interrupted in-person classes (−)

  • Doing: Challenges with affecting culture change (−)

  • Reflecting and evaluating: WH leadership team tracks unique CIH clinic service encounters to track for health improvement, i.e., Veteran requires less appointments (+); plan to track PROMIS-10 for baseline Veteran assessment by coach (+/−); engagement evaluation hampered by lack of integration among three computer systems (−)
Site 4

  • Beds: 600+

  • City population: ~425,000

  • Urban status: Urban

  • Region: Mid-west

  • Cost (0 FTE)

  • Complexity: Menu with too many options, but multiple consultation pathways (+/−)

  • Offerings: Introductory courses (+)

  • Accessibility: Provider referral required; IHH department triages consultation (+); CPRS consult menu (+) but no general consult and too many options (−); VVC connection options (+); Lack of mechanisms for Veteran engagement (lack of self-referral?)

  • Relational connections and communication: Town Hall meeting; Word of mouth; IHH department relationship building (+)

  • Compatibility: WH added to general workflow duties (+/−), Duplicative CPRS charting (−); IHH department (+)

  • Structure and resources: Assigned WH staff (+); WH duties added to regular staff duties (−) but lack of monetary incentive (−)

  • Learning centeredness: Need for staff and Veteran needs assessment (−)

  • Information and knowledge access: WH TMS training (+); mandatory training (+/−), staff well-being and wellness retreat (+), Direct care training (+)

  • Innovation deliverers: General healthcare staff (+/−); IHH department handles specialty referrals (+)

  • Innovation recipients: N/A

  • Implementation leaders and team: IHH department took lead (+); WH coordinator (+); Few and unclear champions working in siloes (−)

  • Capability: N/A

  • Opportunity: WH delivery limited by competing workflow priorities (−)

  • Motivation: Providers view WH as a philosophy of care that can be applied without formal referral (+/−)

  • Partnerships: N/A

  • Critical Incidents: COVID-19 (−)

  • Doing: Implementation process viewed as “bursts of involvement,” with a lack of consistent implementation (fire up and fizzle) (−)

  • Reflecting and evaluating: Referral rates and source (e.g., department); staff and volunteer counts; interdisciplinary involvement counts (+); Timed health assessments based on National metrics (i.e.., baseline, 3, 6, 12 months) for consults (+)
Site 5

  • Beds: 600+

  • City population: ~25,000

  • Urban status: Small city

  • Region: Southeast

  • Cost (17 FTE budgeted, 11 FTE filled) (+)

  • Complexity: lengthy consultation menu (+/−)

  • Offerings: N/A

  • Accessibility: Self, peer, champion, and HCP referral (WH 101, must complete to be “enrolled” in WH); No class offerings outside business hours for Veterans with typical work schedules (−)

  • Relational connections and communication: Online, paper, and word-of-mouth local marketing (+)

  • Compatibility: Difficult to manage in Primary Care (−); Lack of CPRS integration (no consult reminder) (−)

  • Structure and resources: WH duties added to regular staff duties (−), but lack of protected time incentives (−)

  • Learning centeredness: Need for engagement metrics (−)

  • Information and knowledge access: Complex order menu (−)

  • Innovation deliverers: General healthcare staff (+/−)

  • Innovation recipients: Working Veterans can’t attend classes due to schedule conflicts (−)

  • Implementation leaders and team: Assigned WH staff (11 FTE) (+); Unclear champions working in siloes (−)

  • Capability: Veterans and Primary Care staff have limited WH knowledge; unable to explain WH to Veterans (−)

  • Opportunity: Veterans work schedule conflicts with WH classes; WH delivery limited by competing workflow priorities (−)

  • Motivation: N/A

  • Partnerships: N/A

  • Critical Incidents: COVID-19 (−)

  • Doing: N/A

  • Reflecting and evaluating: Veteran referral source (i.e., PCP) and appointment attendance rate (+); Intro to WH class attendance and completion (+); lack of ability to capture who attends a la carte WH classes; no tracking of self vs. HCP referrals, QOL pre-post assessment, staff/Veteran satisfaction, lack of between-group comparison of Veteran pain outcomes for those using pain medications vs. WH services, etc. (−)
Site 6

  • Beds: 0–299

  • City population: ~286,000

  • Urban status: Urban-suburban

  • Region: Mid-west

  • Cost (8 FTEs) (+)

  • Complexity: N/A

  • Offerings: N/A

  • Accessibility: Limited, but easy self-referral (classes/specialty clinic) (+/−); CPRS consult menu (+)

  • Relational connections and communication: Word-of-mouth

  • Compatibility: Low buy-in to overall WH with regular care (−)

  • Structure and resources: N/A

  • Learning centeredness: N/A

  • Information and knowledge access: Consultation process confusing to staff (−)

  • Innovation deliverers: N/A

  • Innovation recipients: N/A

  • Implementation leaders and team: Eight WH program members; 8 FTEs (+); 1 Veteran peer mentor/champion (+)

  • Capability: Providers lack knowledge of CPRS self-referral process and WH engagement (−)

  • Opportunity: Some Veterans lack internet access (−)

  • Motivation: Providers view WH as a philosophy of care that can be applied without formal specialty referral (+/−); lack of buy-in (−)

  • Partnerships: Limited time for outreach (−)

  • Critical Incidents: COVID-19

  • Doing: N/A

  • Reflecting and evaluating: No systematic or defined metrics collected for “engagement”
*

Site descriptives provide ranges of facility bed and rounded population estimates. WH=Whole Health; PHI=Personal Health Inventory, PHP=Personal Health Plan; FTE=Full Time Equivalent(s); PHP=Personal Health Plan; PHI=Personal Health Inventory; N/A=Not applicable or missing information; HCP=Healthcare Professional; CIH=Complimentary Integrative Health; IHH=Integrative Health and Healing; PCP=Primary Care Provider; CPRS=Computerized Patient Record System; TMS=Talent Management System (Staff Education Portal); QOL=Quality of Life; VVC=VA Video Connect