Table 2.

Measures, data sources and data collection timeline by RE-AIM dimension and assessment level

Assessment level(s)	Measures	Data sources	Timeline
Reach
Individual	▸ Eligibility criteria	▸ Patient-recruitment tracking system	▸ Ongoing
	▸ Demographic information	▸ Survey items	▸ HEALD-PCN specific:  baseline, 3–6 months ▸ TeamCare-PCN specific: baseline, 612 months
	▸ Identified facilitators and barriers to recruitment ▸ Identified recommendations for improvement	▸ Interview data (PCN staff and ABCD team)	▸ Baseline and midpoint
	▸ Patient characteristics (participants vs population)	▸ PCNs’ patient registry ▸ AH/ADSS data	▸ Post-intervention
Organisation	▸ Ability to estimate and identify targeted patient populations	▸ Document review (standardised checklist)	▸ Baseline
	▸ Registry development and maintenance process issues, including identified facilitators and barriers ▸ Identified recommendations for improvement	▸ Interview data (PCN staff and ABCD team)	▸ Baseline and midpoint
		▸ Document review (field notes)	▸ Ongoing
Effectiveness
Individual	Primary outcomes: A1c, blood pressure, total cholesterol, & BMI ▸ HEALD-PCN specific: total # of steps ▸ TeamCare-PCN specific: Composite of PHQ-9 Secondary outcomes: self-reported quality of life, quality of care, self-efficacy, & satisfaction with care ▸ HEALD-PCN specific: nutritional behaviours & satisfaction with intervention ▸ TeamCare-PCN specific: process care indictors including: # of visits with healthcare providers, referrals, psychotherapy sessions, medication adjustments, and adherence to treatment	▸ Clinical assessment recorded in patient outcome tracking systems ▸ Survey items	▸ Ongoing ▸ HEALD-PCN specific: baseline, 3–6 months ▸ TeamCare-PCN specific:  baseline, 6–12-months
	▸ Perceptions of impact/ consequences (positive or negative)	▸ Interview data (PCN staff)	▸ Baseline, midpoint, and post-intervention
Adoption
Individual	▸ Total number of member physicians participating in ABCD project	▸ Document review (PCN and ABCD project documents)	▸ Post-intervention
Organisation	▸ Criteria for PCN participation in ABCD Project ▸ PCN Board agreement to participate ▸ Features of participating PCNs ▸ Comparison of characteristics between participating and  non-participating PCNs, as possible ▸ Description of usual care in the focus areas ▸ Perception of extent to which ABCD Project has been adopted by PCNs and modified to fit their context(s) ▸ Identified facilitators, barriers, and recommendations at  organisational level	▸ Document review (project and PCI/PCN documents –websites and business plans, availability of secondary data e.g., PCI evaluation) ▸ Standardised checklist ▸ Interview data (PCN staff)	▸ Baseline, midpoint, and post-intervention
Implementaton
Individual	▸ HEALD-PCN specific: # of steps in log and  self-reported physical activity ▸ TeamCare-PCN specific: adherence to treatment  plan, including medications and behavioural modifications	▸ Patient outcome tracking systems ▸ Survey items	▸ Post-intervention
Organisation	Development of: ▸ Project materials: job descriptions for intervention staff,  recruitment and data collection protocols and forms ▸ Training and resource materials: project binders, algorithms,  patient resources ▸ Systems/processes: patient registries, patient recruitment &  outcome tracking systems	▸ Document review (PCN and ABCD Project  documents)	▸ Baseline
	▸ # and type of intervention staff hired by PCNs, including  turnover	▸ Document review (eg, contracts)	▸ Ongoing
	▸ Provision of and quality of training in ABCD Project and  interventions: # and type of staff trained, detailing sessions, and training materials provided; attendance in training sessions; assessment of change in knowledge and satisfaction	▸ Document review (ABCD Project documents) ▸ Presurvey /postsurvey items ▸ Interviews with PCN intervention staff	▸ Baseline, midpoint, and  post-intervention
	Service delivery: ▸ HEALD-PCN specific: # and type of group meetings and  patient resources distributed; level of attendance ▸ TeamCare-PCN specific: # and type of screenings,  assessments, patient management plans, follow-up sessions, specialist consultations; time of service delivery; and QI assessment through monthly teleconferences	▸ Document review:(class attendance lists) ▸ Patient outcome tracking systems	▸ Ongoing and post-intervention
	▸ Perceptions of implementation as intended ▸ Identified facilitators and barriers to implementation ▸ Identified recommendations for improvement	▸ Interviews with PCN staff	▸ Baseline, midpoint, and  post-intervention
		▸ Document review (field notes, communications,  meeting minutes)	▸ Ongoing
	▸ Economic Evaluation: Decrease in # of family physician and  ER visits; reduction in complications, co-morbidities, and  mortality; reduction in direct medical costs; and reduction in projected future healthcare costs	▸ Document review (budget and invoices) ▸ AH/ADSS data	▸ Post-intervention
Maintenance
Individual	▸ Sustained awareness, knowledge, and management of type  2 diabetes and depression or lifestyle behaviours	▸ Survey items (ABCD Cohort Study) regarding  health behaviours and self-care	▸ Post-intervention & ongoing  (minimum 4-year follow-up)
		▸ Interviews with HEALD-PCN intervention group  participants	▸ Post-intervention
Organisation	▸ PCN level: integration of aspects of the model into usual  care; and/or incorporation of models into future business planning	▸ Interviews with PCN staff	▸ Post-intervention
	▸ More appropriate healthcare utilisation: decrease in # of  family physician and ER visits; reduction in complications, comorbidities, and mortality; reduction in direct medical costs; and reduction in projected future health care costs	▸ AH data	▸ Post-intervention