Table 4.

Descriptions of Themes and Representative Quotes

Theme	Description	Representative quote
Workforce changes	Staff hiring, staff training, changing roles/responsibilities	“We initially hired +1 FTE chronic care manager for the process that has since retired but we are actively recruiting for a new one. However, we reengineered the practice model to accommodate for workflow changes that happened secondary to transformation.”—Practice A
Outcomes measurement	Data collection and reporting, patient/disease registries, quality indicators, risk stratification/tracking	“Yes, we created reports to identify target populations. We rely on payers to send us paper notifications about thirty-day readmissions, patients not taking meds, no-shows, and eligibility issues.”—Practice G
EMR integration	EMR adoption, EMR use for data collection and reporting, creation of patient/disease registries, patient portals	“Helps create patient registries, reminder systems for patients, enhance reporting and recall ability, and clinical decision-making prompts.”—Practice B
Patient engagement	Patient feedback, patient surveys, shared decision making, patient education/outreach, self-management	“We offer many educational materials and self-care tools, including the health action plan and the health progress report mentioned above.”—Practice C
Care coordination and communication	Communication and coordination with outside hospitals/providers and patients, referrals	“Community coordinator that calls into the nurse. Also the nurse helps coordinate with the hospice and home care sites.”—Practice F
Implementation barriers	Time constraints, financial constraints	“If we had more revenue available we would hire someone, but this has been a struggle with bare-bones funds.”—Practice A
Enhanced access	Extended hours, open access scheduling, increased visit numbers, patient portals	“We opened evening hours for 2 days weekly. We are now using our EMR's patient portal, which allows easy access for patients. Our providers e-mail back and forth to patients, they can access their test results, send requests for referrals, prescriptions, appointments, etc.”—Practice C
Enhanced continuity	Patient stays with same primary care provider/team, patient visit mapping, routine follow-up	“Identify the PCP in EMR real time, which helped sorting out patients to switch between the inpatient team and outpatient team. For example, a call may go to a physician-specific nurse, which helps improve continuity and identification. We have an automated e-mail system that e-mails PCPs when their patients are in the hospital or ER”—Practice H
Medical management	Medical reconciliation, renewal policies	“Medication reconciliation occurs at each visit and within 24 to 48 hours of a patient's discharge from the hospital. We use ePrescribing and have configured alerts within the ePrescribing module of the EMR”—Practice D
Outside resources	Financial support, CCI, Transformed, training resources	“We are planning on continuing with CCI. No, we needed the leverage to move forward with our staff and practice. It gave us the reasonable goods and resources to force us to look at what we've been doing and how we can get better.”—Practices I–K
No change	No change after transformation, No change to assessing patient/family experience	“No we have not changed the way we assess patient/family experience”—Practice H

CCI, chronic care initiative; EMR, electronic medical record; ER, emergency room; PCP, primary care provider.