Table 3.
Additional interview quotes describing factors influencing the implementation of an intensive outpatient program within the VA’s patient-centered medical home
| CFIR Domain | Quote |
|---|---|
| Inner Setting | |
| Implementation Climate & Culture | … this is an enterprise that values innovation…[the director of the hospital] is very engaged with innovation…and is always looking at novel promotions for this facility. (Leadership) |
| … we are being pushed to see patients less frequently in [the General Medicine Clinic] and, you know, we are sort of at this conundrum of, okay, let’s push this patient out as far as we can, you know, see them only every six months, nine months, a year. And, you know, I think patients fall through the cracks. (Other Clinician) | |
| I think one of the biggest things that we learned that we needed to do with [ImPACT] is the ability to provide an intervention quickly. And in order to do that you have to have support. And what I think…[the nurse practitioner] interfaced with at the beginning [was]…an understaffed PACT, you can’t intervene quickly when there’s just not the resources there to do it.” (ImPACT Team) | |
| Structural Characteristics | I don’t think we could have done [ImPACT] except at the VA… because the VA had PACT care already. We didn’t have to invest in it, take care of it. They already had so many established professionals and expectations of professionals, you know integrated teams, social workers, nurses, physicians, working together—administrators. So that kind of culture could have taken years to develop. (Leadership) |
| I think it does fit [VA Palo Alto’s culture] but it’s a silo to a certain extent… and VA is really good about having silo programs and how do we really assure that flow, a seamless flow and all that? (Other Clinician) | |
| Networks & Communication | … [The nurse practitioner]’s been totally appropriate about level of acuity, you know in terms of what can be a co-signer [on a note], what can be an email, what, you know—let’s call her, let’s page. You know sometimes she just finds me and that works well. And it’s been medically appropriate so she’s not finding me for some refill that could have waited. I mean it’s all appropriate triage and if she is grabbing me it’s because something is up you know. (PACT Clinician) |
| [a patient] was on our service and [I] had no idea that they were an ImPACT patient. And I remember someone called me up and told me about some extra information about the patient that was helpful but I didn’t have any idea who this person [who called me] was… (Other Clinician) | |
| Characteristics of Individuals | |
| Knowledge and Beliefs about the intervention & Other personal attributes | [ImPACT offers] more and more creative ideas to help, more heads to try to figure out what to do with these patients that keep coming back to the ER that necessarily don’t adhere to the treatment, and so [ImPACT] gives me other ideas. (Other Clinician) |
| Well, like I said, and again, the people have been just amazing on this ImPACT team. I just feel like they are a great resource and they are very responsive and creative ideas and very flexible. (Other Clinician) | |
| I think [ImPACT gives] just sort of relief of having someone also worrying about [my patients] and not me having to call them and realizing that they are sort of taken care of. I don’t need to worry about them as much. (Other clinician) | |
| I’m used to this just being a mid-level provider: you are either really well-received or you’ve got to step up to the plate and prove your worth. (ImPACT Team) | |
| Intervention Characteristics | |
| Adaptability | … the ways that the PACT teams could interact with ImPACT was left a little bit open so [if one way] might not be the way that they prefer to do it…we’re also willing to work with them in other ways; either we can work with [the PACT clinician] or we can take over all of the care…giving room for roles to be defined, I think helped with acceptance. (Leadership) |
| Complexity | We failed to get those patients [with serious mental illness, pain and/or substance use disorders] because we’re not specifically geared towards them and they’re a whole unique set… And patients don’t need to have a computer to interact with ImPACT but you do have to have a phone. (ImPACT team) |
| Cost | Yeah. It’s not all plug and play. We’ve got—we don’t have second stringers who are waiting for a chance to play who are under the control of ImPACT. You know we’re essentially beholden to the largesse of people outside [ImPACT] to either provide additional support or do it as a collateral duty. (Leadership) |
| Outer Setting | |
| External networks | …our area is rich in resources, hugely rich in resources which makes my job completely easier. I can connect somebody, link someone into a community, free acupuncture, free this, free that for veterans… (ImPACT Team) |
| Process | |
| Reflecting and evaluating | When you are talking about the population of the chronically ill, you’re talking about people that have these behaviors and these poor self-management skills for 40 to 50 years of their lives and then you ask them to change in six to nine months and you evaluate them off of that small amount of time. I don’t think that’s fair. (ImPACT Team) |
CFIR: Consolidated Framework for Implementation Research; ER: Emergency room; ImPACT: Intensive Management Patient Aligned Care Team; PACT: Patient Aligned Care Teams; VA: Veteran Affairs Health Care System