Table 4.

Respondents’ illustrative quotes describing implementation barriers or facilitators organized by the HEIF

HEIF Domain	Clinician-Reported Implementation Barriers and Facilitators	Patient-Reported Implementation Barriers and Facilitators
Characteristics of the Innovation	“I think part of that reason is- for me, it all depends on when, at which point, of the meeting I do the PRAPARE. If I do it towards the beginning and there’s really no rapport that has been built between me and the patient, they’re not going to be as open or as talkative. They’re not going to be as detailed with their answers. They may just give me “yes” or “no.” Or one word answers. But, because they don’t really know me, they don’t feel as comfortable. But, if I talk with them a little bit more or a little bit longer or if I’ve had previous visits with them and we have that rapport built already or even just a little bit of it, then, yeah, they’re going to open up with me more, and therefore I’m able to find out more details and needs that they have.” (African American female MSW, LCAS-A Case Manager with 4.5 years of practice experience; Facilitator) “For me, I guess I wanna know- I know how it’s [PRAPARE] helping patients identify barriers, life stressors, concerns, but what other way is it helping, really? Besides showing you, “Hey, this issue is here. We may be able to refer you out to a resource,” but it just feels like extra work. There’s no definite end for it. Like, how is it helping the patient, besides identifying that there is a problem?” (African American female MSW Case Manager with 14 years of practice experience; Barrier)	“I was just so grateful. I didn’t know I could get that kind of service the same day.” (62 year old African American female patient; Facilitator) “Another thing that <care manager name> told me was if I took the bus, that they could help with bus pass. <care manager name> was saying things like that. You know, she just threw out everything that could to help me.” (62 year old African American female patient; Facilitator) “I was like, very, very happy about that because sometimes—you know, I’ve been an independent person all my life. I never asked for help. I don’t like to ask when I can because somebody else is worse than me. And for her to go into what I was going through, for her to bring it out of me, to just say it—I was very grateful.” (62 year old African American female patient; Facilitator) “It was good because the food they gave me, it was something I could use. Like some pantries give you things and you really can’t use them, but they gave me things that I wouldn’t buy for myself like squash, zucchini. Sometimes I can’t really afford it, but they gave it to me.” (52 year old African American male patient; Facilitator)
Clinical Encounter	“So, I’ve come across a lot where, you know, a person may go through almost the whole entire PRAPARE with me, and they’re not identifying that they have any needs. But then, just kind of trying to talk to them and not administer the paperwork and just talking to them from a human being to a human being: that’s when Pandora’s Box gets opened up. And then we went from “no real needs” to “I need food. I need clothing. I’m trying to find a job. I don’t have internet.” (White/Caucasian female MSW, LCSW, LCAS-A Case Manager with 4 years of practice experience; Facilitator)	“…she took her time. I would say it was closer to eight. Maybe around eight to 10 min, something like that. She stood there. She took her time.” (52 year old African American male patient; Facilitator) “I was really impressed because she says, ‘Well, I left a message.’ She says, ‘If they don’t get back to you, call me and let me know.’ So, it just really impressed me. A lot of people say, ‘Oh, I’ll make a phone call. Somebody will get back to you.’ They never get—you know.” (52 year old African American male patient; Facilitator) “…I was surprised that she [clinician case manager] would even supply that kind of help, or just even tell me that I could get a little bit of help. She kept asking me, ‘After you got sick and went back to work, do you have food? Do you have money?’ She kept asking me those kind of questions now and I’m like, how did she even think about those kinds of things, because usually you go to your doctor and they would just treat you and you leave, but she was just awesome.” (62 year old African American female patient; Facilitator) “That’s what really just, you know, really just got to me. You know, I was telling you know the other clients, the other people that was sitting there, you know, about how well they helped, how quick—I mean they just—it really shocked me how quickly— They jumped in to help you.” (64 year old African American female patient; Facilitator)
Patient Factors	“I don’t know if it’s cultural-wise or not, but I think, with the Latinos, they don’t really often see another person like them screening and asking them, “Hey, do you need help?” So, when they do find someone, they’re going to open up and tell you, “Yeah, I need this and this and this.” Versus, maybe an American, who seems used to having multiple resources and people who speak their language – they can easily access it – versus a non-English speaker.” (Hispanic female MSW, LMHC Case Manager with 4 years of practice experience; Facilitator)	“Because a lot of people don’t realize how much help is out there. You know, unless you ask, you never know. And I’ve never dreamed of asking anybody at (FQHC name) that until she approached me that day. So, it really helped me, you know?” (58 year old African American male patient; Barrier) “For one, it shows that it’s not just about seeing a patient, getting them in and out, that they actually care about the patients. I’ve been going to (FQHC name) off and on for many years and I know that the majority of the patients, including myself, are low-income. So, knowing that there are other resources out that can help with different things, that’s real helpful.” (48 year old African American female patient; Facilitator) “No, I didn’t have any concerns about my privacy, because I felt like they was there to help, and you know, the only way for them to help me is to give them the information that they need to help me. If I beat around the bush, then it’ll take longer, because I’m not really giving them the straight information. So no, I really wasn’t concerned about, you know, my privacy.” (64 year old African American female patient; Facilitator)
Provider Factors	“I felt like, again, being clinically trained to be able to kind of recognize body language, if we came across a tough one like intimate partner violence one or- I could kind of see a change in their body language when I asked a question. Then that triggered me to kind of normalize what was going on and I found that that was a little bit more helpful for patients.” (White/Caucasian female MSW, LCSW, LCAS-A Case Manager with 4 years of practice experience; Facilitator) “…one of our main purposes in general, as far as the type of work we do, is to be able to see how the different parts of a person’s life impacts them because a lot of times one area influences the other. Like, if they’re having challenges emotionally with depression or stress or whatever it may be, it may be the fact that they don’t have income or the fact they don’t have a job or they don’t have housing- is contributing to their stress or their depression or anxiety, or whatever it may be that they may be having challenges with. I would say because of that, PRAPARE is definitely in line with that because it impacts the overall, I guess, challenges with that patient. That’s what I’ve been seeing.” (African American female MSW, LCAS-A Case Manager with 4.5 years of practice experience; Facilitator)	“Yeah…when you have people that actually listen—that was another thing about the social worker, she actually listened to me.” (26 year old African American male patient; Facilitator) “Yeah, I was comfortable because of their approach. You know, some people have a hard approach, you know, to you, to your situation—you know, why this happen, why that happen? But they didn’t go into that. They didn’t go into, “What did you do with every penny?” You know, because I told her, I said, “Look, I only get so much a month, I only get SSI, and I have a high gas, high electric.” So she was like, “Don’t worry about that. This is what you need.” You know?” (64 year old African American female patient; Facilitator)
Inner and Outer Context	“Honestly, I think that’s a double-edged sword because we’re not dealing with patients – and I hate to say it, I’m not trying to be biased – but we’re not dealing with <local health system> patients. All of our patients, pretty much, are coming with complex case management needs. And, it’s gotten worse with COVID. There are 40,000+ patients at <FQHC name>, who have these complex case management needs. And, there’s four case managers. So, how do you expect the limited number of people to be able to give these patients the quality that they deserve to address those needs?” (White/Caucasian female MSW, LCSW, LCAS-A Case Manager with 4 years of practice experience; Barrier)	“The Housing Authority is failing the tenants. They are. They really are. And I’m like, I just don’t get it. I don’t get it.” (64 year old African American female patient; Barrier) “I set an appointment, I cancelled an appointment, and I feel that they don’t want to treat me. I don’t know why. I cancelled the last appointment because I have fever. It’s very difficult to go to the dentist with fever. I don’t know why they are not flexible. And as I told you before, they are dealing with patients, they are not dealing with machines or robots.” (43 year old Hispanic male patient; Barrier) “I had to go to the social service department and provide proof. It was just such a long process and they didn’t need an appointment, but I was there for like hours and it was so draining. I’m like, if I had known this, I would have just made an appointment, maybe it would have been faster. I sat in the lobby for a long time, probably like a good hour waiting to see someone… Do you know what I’m saying? I didn’t want to spend half of my day sitting there waiting to get assistance with a bill.” (48 year old African American female patient; Barrier)
Societal Influence	“…I can administer the paperwork. I can give people the resources. But, if resources aren’t there, then to me that diminishes the effectiveness of the PRAPARE because now, “Great, I got all this information. Guess what? I really don’t have much I can help you with,” specifically housing-wise or for the individuals that need help paying utilities but the system is not set up to help them, whether they’re not eligible for it or they can’t get the help because the bill is in somebody else’s name or… So, it’s effective to get the information, but where the resources aren’t, then it makes it ineffective. Where the resources are, it makes it very effective.” (White/Caucasian female MSW, LCSW, LCAS-A Case Manager with 4 years of practice experience; Barrier) “Yeah, I see it a lot, and then I don’t know if they- Because I have a lot of patients where they come in and they say, “I don’t wanna ask for anything because I don’t want them to think I’m trying to use the government and I’m trying to fix my papers, and if I use this then it’s gonna stop me from doing this. I don’t wanna use this.” And so, they automatically think that asking for food or asking for anything is gonna mess up that aspect.” (Hispanic female MSW, LCSW-A Case Manager with 3 years of practice experience; Barrier)	“I’ve always done everything for myself. So, when you’re done everything for yourself it is so embarrassing to beg. Not beg, but it’s—… Because you’re used to doing those things for yourself. So, because you’re not used to it, so it’s hard to just get up and start asking people and things like that. So, it was a little difficult to ask about it.” (62 year old African American female patient; Barrier) [Did you find that anything else, just like in your background, your culture, that made it difficult to ask those questions or reach out for help?] “Yes. Because, like my culture—when we come, and you travel, you travel to be strong. You don’t travel to be weak, because we are stronger like 10 times more because that’s why we came here. We didn’t come to be a liability, you see? So, these are some of the things that you think about, too. You didn’t come to be a liability, and so we work like 10 times harder.” (62 year old African American female patient; Barrier) “The problem—let me be honest with you. We are in the process with the United States Citizenship and Immigration Service, and I told the person, I remember the—probably she was a social worker or something like that. I told the person that we can’t receive any, any help from the government right now because we are in the process with the United States Citizenship and Immigration Service. I talked with my lawyer. He told me that it’s not the time—it’s not good for us to receive any government help right now.” (43 year old Hispanic male patient; Barrier) “Sometimes, when you’re applying for a job, or when you are filling out a form, sometimes I feel that it’s like discriminatory. Discriminatory because if, for example, if I say ________, “He’s Hispanic, he’s American Indian,” probably you don’t get that job, or you don’t get—or probably, sometimes—I think sometimes that you don’t—you’re going to be treated fairly or something like that because it’s a barrier.” (43 year old Hispanic male patient; Barrier) “People judge. You know, “Why do you need help? What did you do with—aren’t you working?” Things like that. Because people tend to judge. If you’re in need and they figure it’s something you didn’t do right or it’s something you did wrong, whereas that may not necessarily be the situation.” (48 year old African American female patient; Barrier) “Well, social needs, financial needs, I don’t discuss with anybody because ain’t nobody going to listen to you. The people that I normally talk to, they don’t have no more than I have, so there’s no one else to talk to because don’t nobody else want to listen. That’s how I look at it. Like the mayor. We talk and talk and talk and talk, and he just does what he wants to do.” (62 year old African American female patient; Barrier)