Table 3.

Health Home Leaders’ Perceptions of Key Factors Influencing Health Home Implementation (N=72 leaders)

Key Implementation Themes	Summary	Illustrative Quotes
Organizational fit (Mentioned by 54 of 72 leaders interviewed)	Leaders perceived the health home Program as strongly aligned with Psychiatric Rehabilitation Programs’ (PRPs) mission and experience, including their focus on addressing all aspects of clients’ wellbeing and their experience developing meaningful provider-consumer relationships and coordinating services for people with SMI. Leaders noted that the fact that many clients with SMI attend PRPs multiple times per week as a facilitator of health home implementation.	…you got to really wrap around people to give them the support that they need. And I feel like those wrap around supports are going to come from something like a PRP. You can’t wrap around a person the same way in a community mental health center.
Geographic proximity (Mentioned by 50 of 72 leaders interviewed)	Leaders consistently viewed geographic proximity of service providers involved in health home implementation as facilitating service coordination for clients with SMI. While co-location was viewed as optimal, geographic proximity more generally, e.g. in the same section of town, was also perceived as helpful. However, leaders noted that geographic proximity alone, including co-location, was insufficient to prompt effective coordination and that other communication and coordination strategies, like standing meetings and shared access to clients’ EMRs, were needed.	What’s nice about having the primary care here and the psychiatrists here is that when there is an issue we can coordinate between the two of them, and sometimes we can even get them to talk to each other.
Coordination with external providers (Mentioned by 56 of 72 leaders interviewed)	Leaders identified coordination with external providers as a key component of implementation success. They viewed this component as consistently challenging, noting difficulty engaging providers – particularly primary care providers – in the community. Leaders mentioned strategies to overcome this barrier including use of standard letters introducing the health home program to external providers and accompanying clients with SMI to appointments with community providers.	A lot of physicians don’t want to hear from you…any client who’s going to a primary physician, I have a letter that says, "So-and-so is part of our health home." And if I see that their labs need updating, I send the letter.
Health IT (Mentioned by 51 of 72 leaders interviewed)	Leaders identified Health IT as a key component of effective implementation. They viewed Maryland’s Chesapeake Regional Information System for our Patients (“CRISP”)–which sends providers alerts of hospital and ED admissions/discharges–as a facilitator of health home transitional care services. While 27 of the 46 sites had access to population health management software designed to help programs track and address unmet health needs in their population, leaders reported problems with the usability of the software; specifically, an interface many staff found challenging to use, the need to enter a lot of data by hand due to the software’s inability to connect with EMRs, and delays in Medicaid data transmissions intended to populate the software with information on services received by clients. Many sites, including those with and without the population health management software, developed their own tracking systems. Leaders also noted lack of complete access to participants’ EMRs as an implementation barriers.	We use CRISP for our notifications on a daily basis, of hospitalizations, ER visits. I have not fully understood how to use [the population health management software] for population health management. It would be different if the different health IT tools spoke to each other… there’s like triplicate data entry everywhere.
Population health management capacity (Mentioned by 60 of 72 leaders interviewed)	Leaders viewed a tension between direct clinical care and population health management as an implementation challenge. Leaders noted challenges finding nurses who were competent in and enthusiastic about conducting population health management as opposed to delivery of direct clinical care. Leaders also noted that the requirement to deliver two health home services per month to all participants, regardless of health status, prevented them from using population health management best practices related to triaging and tailoring implementation of health home services to client groups with differing levels of need.	They [nurses] do not want to simply do population health management…they want to bandage things and poke at things. I have a 24-year-old that’s healthy…why do I need to see him every month? It seems like a waste. Are we making inroads with people that really have things that are going on?
Shifting staff roles to support implementation (Mentioned by 63 of 72 leaders interviewed)	Leaders reported that shifting the roles of existing PRP staff, e.g. case managers and counselors, to include health home service delivery was a key part of health home implementation. Leaders felt this approach was necessary in order to provide the 2 required health home services per client per month.	When it comes to the majority of the actual health homes services it is the staff at the programs who do those services.