Table 2.

An illustration of the domains, themes, and subthemes

Barriers	Poor System Integration	Poor Communication
		Difficulty Navigating the System
		Barriers to Information Exchange
		Lack of Consistency Throughout System
		Inconsistent Follow-Up Care
	Limited Access to Services	Policy and Funding Restraints
		Complicated Specialist Access and Referrals
		Inadequate Transportation
Facilitators	Person and Family-Focused Care	Holistic Care
		Inclusion of Informal Caregivers
	Self-Management Resources	Supportive Programs
		Education and Training
		Support Groups
	Successful Collaborative Practice	Team-Based Care Delivery
		Case Conferences
		Providers Who Enhance Patient Experience
Recommended System Improvements	Expanding and Integrating Care Teams	Incorporating Diverse Providers
		Inter-professional Collaboration
	System Navigation	Patient Advocacy
		Awareness of Community Resources
	Development of Standardized Assessments, Information Systems, and Care Pathways	Standardized Assessments
		Standardized Information Systems
		Standardized Service Delivery/Care Pathways