Engaging patients in population-based chronic disease management: A qualitative study of barriers and intervention opportunities

Abstract

Objective

Cardiovascular disease (CVD) continues to be a leading cause of morbidity in the U.S. Managing CVD risk factors, such as diabetes or hypertension, can be challenging for many individuals. We investigated the barriers experienced by patients who persistently struggled to reach their CVD risk factor control goals.

Methods

This qualitative study examined patient, clinician, and researcher observations of individuals’ experiences in a chronic disease management program. All participants (n=332) were enrolled in a clinical trial testing a skills-based group intervention seeking to improve healthcare engagement. Data were analyzed through a general inductive approach and resulting themes were structured along the Capability-Opportunity-Motivation-Behavior framework.

Results

Analyses identified care engagement barriers related to participants’ communication skills and activation, care team relationship processes, and emotional factors. Although most participants reported benefitting from skills training, persistent barriers included distrust of their providers, shame about health challenges, and dissatisfaction with care team interactions that were described as impersonal or unresponsive.

Conclusions and Practice Implications

Efforts to support engagement in CVD risk factor management programs should address whether patients and their care team have the necessary skills, opportunities and confidence to proactively communicate health needs and engage in non-judgmental interactions for goal-setting, rapport-building, and shared decision-making.

1. Introduction

Cardiovascular disease affects nearly half of all adults in the U.S. (over 120 million) and persists as a leading cause of mortality. The estimated direct cost of CVD to the healthcare system, $215 billion, is expected to increase for older adults in the coming decade [1]. Although the diagnosis and treatment of CVD risk factors such as diabetes mellitus, hyperlipidemia, and hypertension have seen dramatic improvements in reducing CVD-related mortality in the U.S., there remain patient populations that do not reach evidence-based risk reduction goals [2, 3, 4]. A continuing challenge for these patients includes the day-to-day burdens of managing their chronic disease, which entails complex medication regimens and lifestyle behavior changes that test an individual’s problem-solving skills, health literacy and motivation [5, 6].

To help patients manage these burdens, many health systems have implemented disease management programs to improve CVD risk factor testing and control [7, 8, 9]. A key goal of these programs is to maintain regular contact with patients through population care managers, often clinical pharmacists or nurses who support patients by reviewing care goals, promoting evidence-based tests and treatment protocols, and coordinating care with patients’ primary care physicians (PCPs) [9, 10]. Many of these population care interactions take place by telephone or secure electronic message, augmenting PCP visits.

One example of a successful, widely replicated CVD risk factor management program is Prevent Heart Attacks and Strokes Everyday (PHASE) in the Kaiser Permanente Northern California health care system [11]. Although most PHASE patients improve their CVD risk factor control, up to 15% of patients consistently struggle to reach treatment targets. With the goal of improving health care engagement and clinical outcomes for patients in PHASE that were not meeting CVD risk factor goals, our research group conducted the CREATE Wellness (Changing Results: Engage and Activate to Enhance Wellness) randomized control trial (ClinicalTrials.gov Identifier: NCT02302612) [12]. The CREATE Wellness intervention targeted patient activation (knowledge, skill and confidence) and care system interaction (e.g., participating in routine preventive care, communicating with care team) [13, 14].

Facilitated by a health educator interventionist, the group-based CREATE Wellness sessions used a combined motivational interviewing and didactic approach with a focus on empowering patients to take charge of health care decisions. Participants developed skills in creating a care plan, communicating their health goals with providers, and using the electronic patient portal to interact with providers and monitor health information. Participation in the CREATE Wellness clinical trial increased participants’ activation and engagement behaviors relative to the control group [15] but did not improve clinical CVD risk factor control outcomes.

Given the expanding use of disease management programs to deliver care to individuals with chronic health conditions, it is important to understand what barriers may interfere with successful program engagement and where a skills-focused intervention such as CREATE Wellness might fall short. Although past qualitative research has examined the day-to-day personal challenges of managing chronic health conditions [16], there is a need to identify and understand the specific factors that contribute towards effective patient engagement, which we are defining as any behavior that allows the patient to effectively communicate and interact with the health system to address their care needs.

The COM-B Model (Capability-Opportunity-Motivation-Behavior) provides a structured and trans-theoretical approach for conceptualizing a behavioral system that describes how capability, opportunity, and motivation interact with one another to generate behavior. This framework has been widely used to identify barriers and facilitators for various interventions related to CVD risk factors [17, 18, 19, 20], and provides the opportunity to explicitly link behavioral factors to intervention functions. In the current study, we conducted a thematic analysis of qualitative data collected from multiple sources and applied the COM-B model to explore the behavioral mechanisms and barriers of patients who consistently struggle to improve their health within a CVD risk factor management program.

2. Methods

2.1. Study Setting and Recruitment

The CREATE Wellness randomized control trial was conducted in 4 medical facilities in Kaiser Permanente Northern California (KPNC) from February 2014 to October 2017 with 1 year of clinical follow-up ending September 2018. KPNC, a nonprofit integrated care delivery system, provided care for more than 3.8 million members and, at the time of the trial, had a distribution of members’ demographic and socioeconomic factors that was diverse and similar to that of the regional population [21].

Criteria for eligibility included membership in a Kaiser Permanente Health Plan, ability to provide informed consent in English, and one or more unmeasured or uncontrolled CVD risk factors (hyperlipidemia, hypertension, or type II diabetes mellitus) within two years prior to enrollment. Eligible patients were sent a letter in the mail describing the study and then screened for recruitment during a subsequent phone call to schedule an in-person recruitment visit. Informed and written consent was obtained from all study participants, and the study was reviewed and approved by the Kaiser Permanente Northern California Institutional Review Board. This current analysis focuses on data from the 332 patients randomized to the intervention arm of the CREATE Wellness study.

2.2. Qualitative Data Sources

We used multiple data sources described below (see also Table 1) to conduct a qualitative study that identified barriers to effective engagement in a CVD risk factor management program. We chose data sources that could contribute towards a multi-method, multi-reporter approach for examining the complex factors surrounding care engagement behavior, resulting in a diversity of themes.

Table 1:

Description of Data Sources and Investigators

Data Source	N	Description
Interventionist and researcher observations	332 observations	Interventionists (n=3) and researchers (n=4) maintained detailed notes for every patient that participated in the CREATE Wellness group sessions and between-session interactions (e.g., phone conversations). These were summarized post-intervention prior to analysis of trial results.
Patient secure messages to the interventionist or care providers	95 messages	Secure messages that were sent to the CREATE Wellness facilitator or their care team (PCP, APM, Wellness Coach) were documented for each patient. These were compiled by one of the interventionists for their group session participants.
Clinical visit fieldnotes from care providers	95 fieldnotes	Notes were documented in each patient’s EHR by their care team members to record health behaviors and treatment plans.
Patient interview responses	320 responses	Free response answers from patient interviews that included intervention feedback and care engagement progress. Interviews were conducted over phone and had an average duration of 10–20 minutes. Calls were not recorded and interviewers manually typed/wrote down patient responses. Out of the 12 participants lost to follow-up, 7 declined to respond and 5 were unable to be reached.

2.2.1. Interventionist and researcher observations.

The CREATE Wellness interventionist and other researchers who observed sessions (research assistants, health educators, a clinical psychologist [TR]) compiled notes about care engagement barriers discussed by participants. These observations included specific patient quotes, contextual details, and responses to various activities (Description of group session activities and topics: see Appendix A).

2.2.2. Patient secure messages.

We examined secure electronic messages sent by participants to their health providers through the online patient portal up to 3 months post-intervention. The dataset included messages sent to the group session interventionist and to providers associated with the PHASE disease management program (e.g., PCP, population manager, health education coach).

2.2.3. Provider clinical documentation.

We additionally analyzed electronic health record (EHR) notes made by PHASE providers during the study and up to 3 months post-intervention.

2.2.4. Patient Interview Responses.

We included participants’ responses to 5 open-format interview questions conducted during 6-month follow-up telephone interviews (List of open-ended questions: see Appendix B).

2.3. Analytic Approach

Using a general inductive analytic approach [22], our research team (AF, DA, EI, RG, AG, SS) read the raw data and, through discussion, identified an initial set of thematic categories related to engaging with the PHASE program (e.g., “patient-provider interactions,” “patient preferences”). These categories formed the basis of a codebook, which was used by two analysts (AF and DA) to assign text excerpts to each category using QSR International’s NVivo 12 qualitative data analysis software. During the first month of coding, the analysts coded the same sets of data and resolved disagreement through weekly meetings. After this training phase, the analysts continued coding datasets individually and met weekly to discuss text excerpts per category and any new categories that emerged during coding. The analysts recoded prior data with these emergent codes. Through regular meetings, the analysts and larger study team discussed text excerpts and developed a set of specific themes. The study team then mapped the qualitative themes onto the COM-B model to identify various categories of behavioral factors that contribute to CVD risk factor program engagement.

3. Results

3.1. Patient Characteristics

We conducted observations for 332 patients in 40 different group session cohorts, collected 95 secure messages and clinical visit notes, and recorded 320 interview responses. The sample was diverse in race/ethnicity (32.6% white, 26.3% Latino, 21.2% Asian, 11.4% black), 55.8% were women, and the average age was 60 ± 9.2 years (Table 2). Of the 332 participants, 40.4% were not at goal for hyperlipidemia control, 40.1% of patients for hypertension control, and 73.2% of patients for diabetes control.

Table 2:

Patient Characteristics (N = 332)

Characteristic	Number (%)
Age and Gender
Age, mean ± SD, y	59.7 ± 8.9
Women	180 (54.2)
Race/Ethnicity
Hispanic	91 (27.4)
Asian	71 (21.4)
Black	39 (11.8)
Native American	12 (3.6)
Other race/ethnicity	11 (3.3)
Other Characteristics
Unemployed or disabled	35 (10.6)
Household income ≤ $50,000	100 (30.1)
College graduate	129 (38.9)
Low health literacy	76 (23.0)
% of Patients At Goal for CVD Risk Factors
Hyperlipidemia (At goal)	193 (59.6)
Hypertension (At goal)	199 (59.9)
Diabetes mellitus (At goal)	83 (26.8)

3.2. Barriers to Engagement in a Chronic Disease Management Program

Our qualitative analysis revealed barriers in six categories of behavioral factors related to effective chronic disease program engagement (Table 3). Based on the COM-B mapping, barriers were categorized as relating to participants’ skills and confidence (capability domain), care team relationship processes (opportunity domain), and emotional factors (motivation domain).

Table 3:

Barriers to effective engagement in a chronic disease management program for patients who struggle to reach their CVD risk factor goals.

Themes	Example Barrier(s)	COM-B Domain
Patients valued having the knowledge and skills to effectively communicate with their care team	• Having limited technological literacy for communicating online with care team. • Lacking confidence of knowing when to bring up certain health concerns or questions.	Capability
Patients shared ambivalence about taking a proactive role in their care.	• Only engaging with their care team about their chronic disease if experiencing symptoms. • Lacking the ability to navigate cultural or social barriers that discourage assertive behaviors.
Patients felt their care team was dismissive or inflexible to health concerns and preferences.	• Having health needs ignored, especially around medication use and lifestyle changes. • Lacking transparent opportunities for securing alternative medical options.	Opportunity
Patients wanted engaged and non-judgmental support from their care team.	• Receiving care that felt impersonal, insensitive and judgmental. • Lacking enough time or opportunities to build rapport with their care team.
Trust in providers or health system had a major role in care engagement.	• Having distrust from reinforcement of past negative experiences with the health system or lack of patient preference alignment.	Motivation
Patients avoided their care from feelings of guilt, shame, or hopelessness.	• Avoiding care team when unable to follow care recommendations due to socioeconomic barriers. • Having fatalistic beliefs or feelings of hopelessness in not being able to make changes and improve their health.

Below, we provide participant examples across different data sources and note how a skills-based intervention (CREATE Wellness) potentially addressed or failed to address these barriers.

3.2.1. Patients valued having the knowledge and skills to effectively communicate with their care team (capability)

Coming into the intervention, many participants did not have the knowledge, skill and confidence to facilitate productive interactions with their care team and did not know that they could be assertive with their providers when making health decisions.

“Patient shared that testing 4x a day is challenging and painful. I asked him if he had ever talked to his doctor to see if he could reduce the testing. He looked at me in shock and said, “no”. Then the patient next to him said “I didn’t know we could do that.” (Interventionist Observation)

During the intervention, participants often used their training to assertively communicate their care preferences for making lifestyle changes instead taking medication for their chronic disease management.

“I finally stood up for myself and told my physician that I didn’t want to take anymore medication and that I wanted to try and improve my numbers by working out and eating healthier.” (Participant Interview)

Reflecting on their experiences interacting with their care team, participants recalled that helpful strategies for communication included bringing a list of questions, a care plan created during their group session, or other health information handouts to their care team.

“The class helped me talk to the docs and tell them what I feel. I can expect a good answer. Took class handouts to my doctors.” (Participant Interview)

Participants also expressed the benefits of learning how to use online platforms to have productive conversations with their care team (i.e. electronic patient portal, secure message). Especially for participants who felt in-person visits were too rushed or short, sending messages online was especially helpful in communicating their needs.

“Before CREATE, he was mostly communicating with his doctor face to face, but now he is emailing more which he feels saves time and is a way to get doctor’s undivided attention” (Interventionist Observation).

3.2.2. Patients shared ambivalence about taking a proactive role in their care (capability)

Several participants initially took a more passive role in their care management and did not engage in shared decision making with their care team. While some still preferred this role, several shifted towards more proactive behaviors after the intervention. Specifically, participants expressed feeling enabled after receiving “permission” from CREATE Wellness which often resulted in finding new providers to better meet their care needs.

“[CREATE Wellness] opened my eyes to how to take care of myself with chronic illness. I need to participate in my care. Got a new diabetes nurse who really cares” (Participant Interview).

Other helpful strategies included a more personalized approach towards building rapport with their provider, such as sharing about their unique interests, passions and strengths during clinical visits.

“You need to go in, tell a little story so they remember you. Tell them something unique about self; you’ll be remembered” (Participant Interview).

More persistent factors that negatively affected patient proactiveness included difficulties navigating cultural or social barriers related to assertiveness and questioning authority figures.

“[The patient] has been conflicted with sharing frustration over medications because of how he was raised and his cultural values of showing respect, honor, and not expressing frustration” (Interventionist Observation).

Some participants still struggled with building the confidence to use these strategies with their care team. This barrier was often attributed to the intervention format, as some described needing more continuous support to actively practice these behavioral changes.

“3 sessions are not enough to set down goals and begin changing practices in your life. Some in class just found out new things; more time needed to digest and make changes.” (Participant Interview)

3.2.3. Patients felt their care team was dismissive or inflexible to health concerns and preferences (opportunity).

While the skills-based intervention helped participants learn various communication and engagement strategies (i.e. how to build rapport with their care team, messaging through the online health portal), some expressed that their care environment was not conducive for getting their health concerns and preferences effectively addressed. If participants felt their care team was dismissive, they were often left feeling unsupported, disengaged, or with decreased trust in the health system. Specifically, some felt that they were being treated like a “child” or ignored when it came to making care decisions.

“I was asking [my doctor] for a treatment, but he was pretty much ignoring it. But when my husband asked, the doctor reacted right away and gave it to me. Does he ignore me more because I am a woman? Sometimes I’m afraid to mention to doctor how I’m feeling” (Interventionist field note of participant quote).

Several participants also felt that their care management had a “cookie cutter” approach and expressed wanting more flexible, personalized, and transparent care options.

“‘Was wondering if there are procedures for securing second medical opinions. The primary physician seems to be the gatekeeper for all medical options” (Secure message from participant to interventionist).

Participants also felt frustrated when their care team dismissed their concerns around medication use and wanted more advice, coaching or active practice for alternative care strategies that focused on lifestyle changes (i.e. diet, exercise).

“My doctor, though being very patient, has mentioned several times that I may have to start taking insulin. I have been 100% against it and keep saying give me more time to lose weight” (Secure message from participant to interventionist).

3.2.4. Patients wanted engaged and non-judgmental support from their care team (opportunity)

Participants expressed the importance of having personable, positive interactions with their care team that recognized their strengths or accomplishments. For example, several participants reported missed opportunities to receive positive reinforcement for successful health changes and felt unsupported when only acknowledged for their problems or setbacks.

“When I successfully lowered BGs on own, no one on care team gave me kudos or showed appreciation. The doctor just wanted to look at numbers and only give me attention when numbers were high. Wouldn’t talk to me about my success and what was working at the time, total disregard” (Interventionist fieldnote of participant quote).

Additionally, when their interactions were described as overly critical, participants struggled to engage with their care team. This included participants who felt that their care team used fear tactics or that they were scolded and shamed for being non-compliant.

“I understand that it’s my responsibility, but I don’t like how they just give you paperwork, followed by the blaming that you get when something goes wrong. Life sometimes gets in the way” (Interventionist field note of participant quote).

Participants also described having difficulties with bringing up questions or concerns when care interactions felt rushed, robotic, or lacking humanized connection.

“I often feel rushed. You’re talking to his back, then he starts looking at the computer. So, I feel like I have to get to the point and if I want to ask more questions, I feel like I can’t” (Researcher field note of participant quote).

Some also struggled to have designated providers to communicate with and wanted more opportunities to build rapport with their care team. This included frustrations with having limited time to build rapport in-person, a lack of consistent responses, or feeling their care team was too busy with other patients.

“I think I did wellness coaching too, but I didn’t feel like I was getting enough support so I gave up. We were supposed to have ongoing phone sessions, but she never called back” (Interventionist field note of participant quote).

3.2.5. Trust in providers and the health system had a major role in care engagement (motivation)

These frustrations of having dismissive, judgmental or time-limited care often resulted in participants developing feelings of distrust in sharing health goals or concerns with their care team, where several participants further specified that they did not see themselves discussing these goals outside of CREATE Wellness.

“Feels he is his own support, doesn’t divulge things to others like coworkers and has ‘trepidation’ with care team as well. Feels he needs someone who he trusts to contact about private issues.” (Interventionist observation).

During prompted discussions about interacting with the health system, various participants expressed having difficulty trusting the recommendations of their care team after having previous negative experiences. They viewed the patient-physician relationship as adversarial, with the patient responsible for steering decisions. When physicians did not appear to listen to their concerns, this adversarial dynamic appeared to deepen.

“Decided after stent placement that he is in the driver seat and will make all decisions for his health after feeling his concerns dismissed, changed doctors. Doctor is there to make suggestions and provide advice but he will be in control of choices. Feels doctors need to learn to “sit and listen” and not behave as if they know everything” (Interventionist observation).

Some participants were able to build trust with their care team after learning communication and engagement strategies. For example, one participant initially refused to trust the health system as a whole after believing that following medical advice had caused the death of a family member with diabetes. However, after changing to a new provider that was perceived as more attentive to their preferences, this increased the participant’s openness to their recommendations.

“[My physician] listened...addressed all of my concerns...looked at and remarked on my X-rays that I brought in! Laughed at my cynical jokes and gave me sound advice. I feel I can trust their advice, so started on a new high blood pressure med with good results already!” (Secure Message from Participant to Interventionist)

3.2.6. Patients avoided engaging with their care team from feelings of guilt, shame or hopelessness (motivation)

While some were able to develop a more trusting relationship with the care team, this was difficult for participants that expressed facing various emotional challenges when interacting with their care providers. For example, participants reported that they would often make progress in their care but disengage after experiencing setbacks or feelings of fear, guilt, and shame from not meeting CVD risk factor goals.

“I used to have a wellness coach, which went well, but then I was always required to set a goal which I don’t like because it makes me feel like a failure, so I stopped going” (Interventionist field note of participant quote).

These negative emotions often stemmed from economic challenges where many of these participants were unable to afford certain recommendations such as lab tests and medications. This resulted in avoidance of their care team which continuously prevented their providers from having the opportunity to address their challenges.

“Patient recently went to pick up insulin but doctor didn’t approve because she had not done labs. Reported feeling ashamed from not being able to do labs because of increase in co-pay and told doctor it was too much” (Interventionist observation).

There were also participants who felt overwhelmed and doubtful of their ability to manage their chronic condition. These participants were left feeling disempowered, wanting to give up, or avoiding their care team from feelings of denial or fear.

“I don’t expect the doctor to understand this and do anything about it. I don’t even expect myself to understand all this stuff. I am confident I am not going to be able to do anything about anything!” (Researcher field note of participant quote).

4. Discussion

To define and provide a framework for the mechanisms behind patient engagement in CVD risk factor disease management programs [23], we developed a map of the behavioral factors that were crucial for effective care engagement among this patient population (Figure 1). Engagement behaviors were characterized as (1) being able to find a provider that addresses their care needs, (2) actively expressing health concerns and preferences for shared decision-making, (3) building rapport with their care team for emotional support, and (4) using strategies and tools to communicate with their care team. These are further specified by capability, opportunity, and motivational factors that correspond to barriers that prevented patients from effectively interacting with the health system.

Figure 1.

Relationship between engagement factors and behaviors mapped onto the COM-B Framework

From CREATE Wellness, participants were able to gain knowledge, skills and confidence to engage in the various behaviors outlined in Figure 1. However, despite increased autonomy and activation, participants faced several persistent emotional and environmental CVD risk factor disease management barriers that require the consideration of more targeted or systemic intervention approaches beyond traditional chronic disease care. Most significantly, we found that this patient population especially struggled with clinical interactions that felt dismissive, judgmental, and lacking of emotional support.

Some participants were also influenced by feelings of shame or hopelessness when trying to meet their care team’s expectations. Considering research literature that examines how feelings of shame, failure or stigma can negatively affect care participation and self-management for CVD risk factor goals [24, 25, 26, 27], it becomes especially crucial to address these negative emotions for this subset of patients that struggle with health system interactions. These findings support the importance of shared decision-making [28] and contribute to a growing body of literature that investigates this disconnect between patient autonomy and clinicians struggling to empower patients without leaving them feeling overwhelmed or unsupported [29, 30]. Subsequently, these challenges often resulted in patients having distrust of their care providers, being reluctant to disclose health information, and not wanting to follow clinical recommendations. This finding suggests that patient distrust is especially important to address for CVD risk factor support and can be potentially mitigated by demonstrated interpersonal effectiveness, consistent communication, and acceptance of each other’s roles in shared decision making [31, 32].

4.1. Limitations

Generalizability of study findings may be limited given that participants were enrolled in a clinical trial, which demanded some degree of engagement in a health care intervention. However, given that the majority of these participants were engaged and activated enough to participate in the group sessions and set health goals, this analysis provides a unique opportunity to understand what behavioral determinants beyond patient activation are potentially important for productive care team interactions. Another potential limitation was the use of session observations, which may have emphasized the perspectives of participants who spoke more often. Some data sources, such as the secure messages and clinical visit notes, were also not available for all participants. We attempted to mediate this through the triangulation of additional data sources (e.g. secure messages, individual interviews) to strengthen the validity our findings [33]. A strength of the session-based data was that it was collected as part of a supportive group discussion, facilitated by an interventionist trained in motivational interviewing which encouraged all participants to share openly about their health care challenges.

4.2. Conclusion

These findings underscore the complexity of behavioral factors that describe how and why patients struggle to interact with the health system for chronic disease care. While participants saw improved capability (communicating with their providers and acting proactively), some still faced persistent psychosocial and environmental barriers that discouraged effective engagement with a CVD risk factor disease management program.

4.3. Practice Implications

Future research should continue to systematically explore the various barriers we identified in this paper and develop interventions that can successfully enable patients who struggle to reach their CVD risk factor goals within a disease management program. Specifically, upon consideration of the COM-B model [17] and our qualitative findings, we recommend that key opportunities for improving patient engagement in CVD risk factor disease management include:

• Developing and improving systems that can enable patients to easily change or find new care providers for their specific chronic health needs.

• Encouraging patients to engage in shared-decision making by setting and discussing practical health goals for CVD risk factor management in collaboration with one’s care team.

• Reinforcing patient strengths and successes through positive or personalized feedback before acknowledging any problems or setbacks in care goals.

• Providing comprehensive resources, opportunities, and encouragement for both patients and their providers to build rapport and have open conversations about feelings of distrust, avoidance, or low emotional support.

Highlights.

• Patients who struggle with CVD risk factor control report a range of barriers to healthcare engagement

• These barriers include feelings of shame and distrust that can reduce motivation to engage with their healthcare providers

• Patients report that personalized and non-judgmental care is important for increasing patient activation

• Patients value pragmatic support with goal-setting, rapport-building and shared decision-making

Appendix A:

Description of Group Session Activities and Topics

Session 1: Navigating the System to Meet my Needs	Session 2: Engage in Wellness	Session 3: Establish a Plan: Preparing, Communicating, and Participating in Your Care
• Overview of program • Group introductions • Review of online health portal • Troubleshoot individual barriers to accessing care (ex: resetting passwords) • Knowledge and skill to navigate online health resources (live demonstrations) • Smartphone assistance to download KP apps • Use motivational interviewing to help set realistic health goals • Encouragement to gain skills and knowledge to practice behaviors for overall well-being • Teach to normalize failures and setbacks • Learn about lifestyle tools for managing chronic conditions	• Share health goals; what’s working and not working • Discussion of experience being active online • Share barriers to medication management; strategies for barriers; address disbelief in efficacy • Empathy and change talk • Crucial role of readiness	• Opportunity to identify concerns for discussion with provider • Fill out care plan and health goals and personal preferences • Practice discussing medical concerns and personal experiences in relation to overall health goals • Encourage to send care plan to care team • Roleplay of effective communication • Address cultural norms and social barriers

Appendix B:

List of Open-ended Questions

1.	What would you say are the most useful skills you learned from the program?
2.	In what ways (if any) has the program changed how you take care of your health?
3.	How did the CREATE Wellness program change your relationship with your care team?
4.	What parts of the program did you find not helpful or that you did not like?
5.	Do you have any additional comment or suggestions for how to improve our CREATE Wellness program?