Table 1.

Relationships between elements of the CCM and themes from informant interviews.

CCM elements	Representative themes	Representative quotes
Health-care organization: Create a culture, organization and mechanisms that promote safe, high-quality care (includes leadership, organizational values/goals and reimbursing/purchasing environment)	Theme 1: Care approaches are complex	“I am almost never taking care of somebody where heart failure is their primary or sole problem. It is heart failure, but pneumonia plus diabetes plus dementia. Where heart failure is prioritized on the list depends on where the other things are.” (General internist—P4) “I’m sure I want to know how frail my patient is, as that will eventually help me decide which way we should go, since some older patients are so frail that they need more palliative [versus] invasive intervention.” (Cardiologist—P15)
	Theme 3: A standardized protocol of care would improve care delivery	“…I think for the academic doctors, we are probably following the guidelines but the non-academic or community doctors probably follow the guidelines very little. We just did a trial to look at the peripheral heart failure clinic [and] there are a very low number patients following the guidelines of the recommended dose of therapy.” (Cardiologist—P13)
	Theme 4: Interdisciplinary approaches to care are missing	“I think in general, it does take a team to manage someone who is more complex than just presenting with failure.” (Family Doctor—P10) “When they have multiple morbidities, we either need someone who is capable of managing the morbidities or very good communication between the doctors who are managing the morbidities because there is so much conflict between the treatment modalities and the expectations of the different specialists when someone has multiple comorbidities.” (Cardiologist/Manager—P1)
Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support (includes practice design and labour/personnel)	Theme 2: Barriers to optimal care include non-medical factors	“I think that for people who are marginalized, it is very tough. I think in general, it does take a team to manage someone who is more complex than just presenting with failure.” (Family doctor—P10)
	Theme 4: Interdisciplinary approaches to care are missing	“I think the first thing is you would have a strong primary care system where the primary care doctor would be the quarterback. You need to have good access to cardiology and multi-disciplinary cardiac teams to deal with some of the complications and the other related issues to heart failure.” (Cardiologist—P12) “I think one of the challenges we face is real-time transparent communication between members of the health care system in the primary family practice unit or health care group. I think that this is one of the biggest challenges for us. We can see a patient, and then they see a nephrologist who may not be at this institute and we have to try to make sure our communication gets to them and theirs gets to us. Because they may want to adjust a medication that I don’t want to adjust and vice versa…how do we ensure that we are not actually hindering patient’s care by our differential approach?” (Cardiologist/Heart failure specialist—P7)
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences (includes the use of guidelines and educational sessions)	Theme 1: Care approaches are complex	“…you can’t just deal with their heart failure because so many other things are interfacing with it and you may not have the knowledge, skills and resources to deal with that problem that is related to, or aggravating, their heart failure. How to work through that is difficult.” (Nurse manager/Heart failure specialist—P11) “…there is [an] issue [with] comorbidities and polypharmacy. They are going to be on multiple medications, [and have] confusion with […] timing [and] dosage adjustments…this often [necessitates] supervision…[If] and when they do have heart failure, medications can be changed […] frequently as you are adjusting to the volume status, which can be complicated and difficult for a caregiver if they don’t have a medical background or are elderly and frail themselves….” (Cardiologist/Manager—P1) “We know cardiac rehab is very effective for heart failure patients with multiple comorbidities. Do we want to […] get them into a cardiac rehab program if they are also frail? Immobility will worsen their prognosis.” (Cardiologist—P12)
	Theme 3: A standardized protocol of care would improve care delivery	“I think an ideal system would have an evidence-based standardized protocol that was shared and became commonplace; in other words, the whole circle of care used it. The specialists, the family physicians and the patients [would know] this protocol and the patients [would be] engaged in co-managing it….” (Family Doctor—P10)
Clinical information systems: Organize patient and population data to facilitate efficient and effective care, and ensure compliance with practice guidelines (includes reminder systems, feedback tools and registries)	Theme 3: A standardized protocol of care would improve care delivery	“I would love to see seamless electronic integration happening so that community, institutional and primary care are able to coordinate care a whole lot better. I think that would go a long way. Clinicians would have richer information; patients if they could access it, could have a better understanding of what was happening, […] and people at the regional level would understand what was happening from a performance measurement perspective and look for variations, justified [or] unjustified.” (Administrator—P9)
	Theme 4: Interdisciplinary approaches to care are missing	“I think that using technology to help us is kind of a given. […] We are putting a lot of work into [a virtual clinic environment in the home environment] using Bluetooth enabled technology […] that home environment is being monitored for their weight, blood pressure, heart rate and all […] this information gets pushed to all members of the team in real-time so all members can communicate….” (Cardiologist/heart failure Specialist—P7)
Self-management support: Empower and prepare patients to manage their health and health care	Theme 2: Barriers to optimal care include non-medical factors	“…‘I don’t think they are getting it, I just don’t think it’s connecting,’ and so […] cognitive function is a huge issue in communication strategies.” (Nurse manager/Heart failure specialist—P11) “…the most important thing that we don’t do as clinicians enough is to ask patients what their preferences are—not in terms of what diseases they want treated, but what they want to be able to do, or how would they like to be able to feel.” (Rheumatologist—P5)
	Theme 5: Improved care pathways are needed	“Another important issue is recurrent hospitalizations which is super disruptive and tough to manage. For patients who have very little support, coming into the hospital is almost a routine thing. And keeping patients out of the hospital is also really challenging.” (Cardiologist/Manager—P14) “…the other thing that goes with frailty is that you often think of older patients and you often think of geriatricians [who] are like gold bars. They are very hard to find [and] are wonderful when you can find them. To […] do a patient justice and take the time it takes to manage the problems related to frailty and aging, you need a lot of expertise and access. If you could embed geriatricians or people with an interest in care of the elderly in your care plan, that would be an important component….” (Cardiologist/heart failure specialist—P3)
The community: Mobilize community resources to meet needs of patients	Theme 5: Improved care pathways are needed	“…ensuring you have the integration between home and community care supports, [and] the different organizations; so hospital x is different from the community care access centre, which is different from the primary care practice…All of these are different organizational entities that aren’t necessary streamlined, so that fragmentation of the system needs to be corrected.” (Cardiologist—P12) “…geriatrics and palliative care […] is probably something that just has to be explicitly built in as a pathway. Because […] there are some people, in fact all people, [who] ultimately end up in that same place, and I think we sometimes neglect it….” (General Internist—P4)

CCM: Chronic Care Model.