Table 2.

Factors influencing the implementation of intensive outpatient programs within patient-centered medical homes

CFIR domain	Implementation factors identified in literature review	Implementation factors identified in qualitative analysis
Inner Setting
Implementation Climate & Culture	-Defining the roles for new models of care (e.g., who will provide health coaching) [3, 19] -Proper pay scale for care managers/coaches given that they are often classified as medical assistants, but require more skills/pay [3]*	-Tension for change -Culture of innovation
Structural Characteristics	-Availability and effectiveness of health information technology [18, 17, 3, 19] -Healthcare system financing structure (e.g., capitated) [3]*	-Established health information technology and existing PCMH
Networks & Communication	-Communication, coordination, and collaboration within and between intensive outpatient team, other clinicians, and patients [23, 17, 3, 18, 21] -Information overload and inefficient patient management, including multiple clinicians managing the same issue [19]	-Collocation of intensive outpatient team and PCMH, proximity to key specialists (e.g., mental health care) -Access to information about the intervention -Clarity of roles and responsibilities
Leadership Engagement	-Level of leadership support [18, 3, 19]	-Leadership engagement
Characteristics of Individuals
Knowledge and Beliefs about the intervention & Other personal attributes	-Clinicians’ medical, cultural, language, problem-solving, and interpersonal skills, especially with complex patients [23, 3] -Managing psychological strain of treating complex patients [22, 18, 17]* -Non-intensive management clinicians’ interest in new approaches to care [3, 19, 18] -Staff perseverance and proactive approach to care [20] -Willingness to provide non-traditional care in the absence of evidence about efficacy [3, 21, 19]	-Positive beliefs about the intervention and intervention staff, including staff’s clinical and interpersonal expertise -Team cohesion -Proactive approach to care
Intervention Characteristics
Adaptability	-Flexibility of follow-up timeline [18] -Flexibility of care plan procedures (no single approach for all patients) [21, 19, 17] -Degree to which health coaches are encouraged to employ unique strengths [3] -Degree to which teams can grow and change to meet patients’ needs [19]	-Feasibility of adapting intervention to meet the needs of patients and PCMH clinicians
Complexity	-Flexible team boundaries when providing care [18, 20, 21] -Staff retention [18] -Patient-clinician ratio [17, 3] -Presence of mental health and pharmacy clinicians [23, 3, 21] -Availability, relevance, and quality of training [3, 22, 19, 18]	-Multidimensional roles of staff -Shortage of relevant training for novel intervention
Cost	-Intervention costs [3, 17]	-Limited staff and insecure employment
Outer Setting
External networks	-Shared mission and trust* among all outside partners, including clinician buy-in [18, 22, 21] -Integration and collaboration with community resources [18, 20, 19] -Partners access to health information technology [19]* -Community partners’ approach to patients with multiple conditions [20]*	-Connection to community programs through recreation therapy
Process
Reflecting and evaluating	-Clinician referrals [19] -Length of follow-up periods and the ability to see changes within that period [23] -Finding cost data from outside systems [17, 24]* -Detailed mental health assessments to track changes in mental health [24]* -Time between participants expressing interest and intake assessments [23]* -Staff availability in patient recruitment [24]*	-Importance of involving staff from the beginning of the development process -Time pressure to show results

*Not mentioned by ImPACT staff

CFIR: Consolidated Framework for Implementation Research [23]; PCMH: Patient-centered medical home

Note: Dorr and colleagues [19] provide additional information on Intermountain Healthcare. [31] Lessler and colleagues[18] provide additional information on King County Care Partners. [23] Okin and colleagues [20] provide additional information on the program described by Shumway and colleagues. [24]