Barriers and facilitators to implementing pharmacist-provided comprehensive medication management in primary care transformation

Abstract

Purpose

How to effectively integrate pharmacists into team-based models of care to maximize the benefit they bring to patients and care teams, especially during times of primary care transformation (PCT), remains unknown. The objective of this study was to identify barriers and facilitators when integrating pharmacist-provided comprehensive medication management (CMM) services into a health system’s team-based PCT using the Consolidated Framework for Implementation Research (CFIR).

Methods

Semistructured qualitative interviews were carried out with 22 care team members regarding their perceptions of the implementation of CMM in the PCT. Transcripts were coded to identify CMM implementation barriers and facilitators, and resulting codes were mapped to corresponding CFIR domains and constructs.

Results

Fifteen codes emerged that were labeled as either a barrier or a facilitator to implementing CMM in the PCT. Facilitators were the perception of CMM as an invaluable resource, precharting, tailored appointment lengths, insurance coverage, increased pharmacy presence, enhanced team-based care, location of CMM, and identification of CMM advocates. Barriers included limited clinic leadership involvement, a need for additional resources, CMM pharmacists not always feeling part of the core team, understanding of and training around CMM’s role in the PCT, changing mindsets to utilize resources such as CMM more frequently, underutilization of CMM, and CMM scheduling.

Conclusion

Clinical pharmacists providing CMM represent a valuable interdisciplinary care team member who can help improve healthcare quality and access to primary care. Identifying and addressing implementation barriers and facilitators early during PCT rollout is critical to the success of team-based services such as CMM and becoming a learning health system.

Key Points

• Many healthcare systems are undergoing primary care transformation and adopting new models of care to be more team based.

• Frameworks from implementation science, such as the Consolidated Framework for Implementation Research, can be used to guide successful implementation of pharmacist-delivered comprehensive medication management services during transformation efforts.

• Identifying and addressing implementation barriers and facilitators early during primary care transformation rollout is critical to the success of team-based services, such as comprehensive medication management.

Primary care is the cornerstone for achieving high-quality, accessible, and efficient healthcare.^1,2 However, given the demands placed on primary care teams and the complex needs of some primary care patients,^3,4 primary care transformation (PCT) is essential to achieving the quadruple aim of improving quality of care, decreasing healthcare costs, and improving patient and provider experiences.⁵ An important component of PCT is enhancing team-based care,^6-8 and previous literature has advocated for an increased role for pharmacists as part of primary care teams.^9,10 Given their expertise in optimizing medications and medication-related outcomes, pharmacists can have a significant role in helping to achieve quality goals and increasing patient access to care. In fact, pharmacists providing patient care in primary care settings have been demonstrated to have a positive impact on all aspects of the quadruple aim.^11-15 Thus, as practices undergo PCT and adopt new care models, it is important to evaluate the implementation of key team members, such as pharmacists, in these models of care.

To date, many PCT efforts have focused on adopting the patient-centered medical home (PCMH) model.^16-18 Research has demonstrated better patient outcomes when pharmacists have been integrated into PCMH practices.^19-21 Nevertheless, inclusion of pharmacists in PCMH practices has been sporadic, despite key features of the model including comprehensive and coordinated care that maximizes quality and safety. As a result, it remains unclear how pharmacists can be successfully implemented and integrated in novel team-based primary care models.

Research in implementation science has demonstrated that effective interventions and services do not always translate into meaningful patient outcomes in different contexts.²² Therefore, it is important to assess barriers and facilitators that may impact successful implementation of pharmacy services early in the PCT process. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive framework of 39 constructs that outlines implementation determinants.²² These constructs are organized under 5 domains: (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) characteristics of individuals, and (5) process (Box 1). Intervention characteristics relate to characteristics of the service or program that is being implemented that could affect implementation success. Outer setting refers to the economic, political, and social context of the implementing organization, while the inner setting is made up of the structural and cultural contexts within the organization. Characteristics of individuals represents the knowledge and beliefs individuals working within an organization have toward the intervention being implemented, as well as these individuals’ feelings about the organization and self-efficacy. Finally, process refers to organizational change components that present during the process of implementation.²²

Box 1. Consolidated Framework for Implementation Research Domains and Constructs²².

Intervention characteristics	Outer setting	Inner setting	Characteristics of individuals	Process
◦ Intervention source ◦ Evidence strength and quality ◦ Relative advantage ◦ Adaptability ◦ Trialability ◦ Complexity ◦ Design quality and packaging ◦ Cost	◦ Patient needs and resources ◦ Cosmopolitanism ◦ Peer pressure ◦ External policy and incentives	◦ Structural characteristics ◦ Networks and communications ◦ Culture ◦ Implementation climatea ◦ Readiness for implementationb	◦ Knowledge and belief about the intervention ◦ Self-efficacy ◦ Individual stage of change ◦ Individual identification with organization ◦ Other personal attributes	◦ Planning ◦ Engagingc ◦ Executing ◦ Reflecting and evaluating

^aImplementation climate has the additional subthemes of tension for change, compatibility, relative priority, organizational incentives and rewards, goals and feedback, and learning climate.

^bReadiness for implementation has the additional subthemes of leadership engagement, available resources, and access to knowledge and information.

^cEngaging has the additional subthemes of opinion leaders, formally appointed internal implementation leaders, champions, and external change agents.

Having already adopted the PCMH model, a health system in Minnesota is now building on this model and undergoing a team-based PCT with a focus on population health. The objective of this study, therefore, was to identify barriers and facilitators to implementing comprehensive medication management (CMM) in this novel PCT using the CFIR.

Methods

Setting and PCT model.

M Health Fairview is an academic health system partnered with the University of Minnesota comprising 8 hospitals and 40 primary care clinics across Minnesota. In May 2019, M Health Fairview began their PCT in 2 clinics, with plans to continue to implement the PCT in all primary care clinics over the coming years. The 2 initial clinics were selected because they had previously participated in care innovation work and were located in the same geographic region, facilitating leadership and oversight of initial PCT efforts. As part of the transformation, all M Health Fairview primary care patients were placed into 1 of 5 different strata, called “service bundles,” based on their complexity of care; services and appointment lengths were then tailored to each service bundle. For example, patients in service bundle 5, which included the most complex patients, received 60-minute primary care visits. There were also changes in care team roles. For example, every patient was assigned a patient advocate and liaison (PAL) to serve as the patient’s point of contact with the care team. For many patients, this is a nurse, but PALs also include clinic health guides and team coordinators.

CMM program.

Clinical pharmacists have been providing CMM within M Health Fairview since 1997, and the team has grown to include 45 pharmacist full-time equivalents (FTEs) practicing in 52 locations (including the initial PCT clinic sites) with over 28,000 CMM patient encounters in 2020. CMM pharmacists are embedded into primary care teams where they meet with patients individually to assess all of their medications and ensure that each one is appropriate, effective, and safe and that the patient is adherent. If any medication-related problems are identified, the pharmacist works with the patient and the rest of the care team to develop an individualized care plan and follows up with the patient to assess whether they are meeting desired outcomes.²³ In the clinic, pharmacists generally sit in the specialty provider workspace, which is shared by specialists such as endocrinologists, podiatrists, etc. One exception is the office dedicated to the service bundle 5 team. The pharmacist working with this team generally sits in this office space during activities other than patient care. Pharmacists at M Health Fairview have measured and reported on numerous outcomes demonstrating the effectiveness of their program over the years.^11,15,24

Patients are identified for CMM through several mechanisms, including pharmacist identification, patient self-referral, transitions of care, payer referral, and, most commonly, provider referral. This is true for the PCT model as well; however, there have been some modifications, such as pharmacists being included in all initial service bundle 5 visits. The demographics of the patients seen by CMM pharmacists throughout the PCT are available elsewhere.²⁵ To enhance the integration and availability of CMM, the number of pharmacist FTEs was increased from 1.2 to 2.8 between the 2 pilot clinics as part of the PCT.

Study design.

This was a formative evaluation using qualitative methods and grounded in the principles of learning health systems. Formative evaluations are designed to provide insights into what is and is not working during program rollout for potential program improvement.²⁶ Formative evaluations are useful in the context of learning health systems, because a learning health system is one in which data are collected from practice, knowledge is gleaned from the data, and that knowledge is then implemented back into practice to improve care delivery.²⁷ The University of Minnesota institutional review board determined that this study did not involve human subjects and, therefore, did not require formal review and approval.

Participants and data collection.

To hear from a range of stakeholders about barriers and facilitators, different leadership and care team roles were identified at the 2 initial PCT clinics. Identified individuals included clinic administrators, medical assistants, patient care representatives (ie, care team members who schedule patient visits and check patients in for visits), all 4 CMM pharmacists who were part of the PCT, providers (ie, physicians, nurse practitioners, and physician assistants), and nurses and health guides who were working in the newly developed PAL role, along with a team coordinator (the care team member who works at a team station to help coordinate appointments and patient visits) and the home care nurse who was part of the service bundle 5 team. These individuals were either purposefully or randomly selected for participation. For example, clinic administrators were purposefully selected, whereas individuals in other roles, such as providers, were randomly selected using staff lists and a random number generator. Clinic administrators and pharmacists were purposefully selected because they were the only individuals in those roles. For other roles, such as providers, individuals were randomly selected because we wanted to capture their perspectives while also minimizing bias in the selection process. Leadership and care team members who were selected for interviews were sent an email requesting their participation in a 30-minute semistructured interview about their perceptions of the PCT and the integration of CMM into the PCT. Individuals were offered an incentive of lunch for agreeing to participate.

All interviews (Appendix A) took place in person in January through March of 2020 and were conducted by a learning health system researcher embedded in the M Health Fairview system as part of a K12 career development award.²⁸ Interviews were recorded and transcribed verbatim. In addition, the lead investigator regularly visited both clinics from September 2019 through March 2020 and took field notes during this time.

Analysis.

To identify barriers and facilitators to implementing CMM in the PCT using the CFIR, transcripts were coded by one author through a both deductive and inductive process using NVivo 12 (QSR International, Doncaster, Australia). First, data were deductively coded into 1 of the 5 CFIR domains. Then, to develop codes and definitions that were relevant to the PCT and system stakeholders, the data within each CFIR domain were inductively coded to create PCT-specific codes and definitions. These codes were then mapped to corresponding CFIR constructs. Finally, the codes that emerged were labeled as a perceived barrier or facilitator in a second-cycle magnitude coding process.²⁹ Magnitude coding consists of adding a subcode indicating the direction or evaluative content (eg, positive or negative) of an existing code.²⁹ To enhance the validity of the findings, peer review and debriefing occurred between 2 authors experienced in qualitative data analysis throughout the coding process. In this process, the researcher seeks an external check by someone familiar with the research, much the same as with interrater reliability in quantitative research.³⁰

Results

Eleven care team members from each clinic participated in interviews for a total of 22 participants (Table 1). Fifteen codes emerged from the data, and Appendix B illustrates the mapping of the codes to CFIR domains and constructs, along with illustrative quotations for each code. Table 2 provides an excerpt from Appendix B illustrating the mapping of PCT codes to the CFIR domain and constructs within intervention characteristics. Below is a description of the CFIR codes that emerged. Codes are presented under the corresponding CFIR domain, and each code is marked as being perceived as a facilitator (+) or barrier (–) or having aspects of both (+/–).

Table 1.

Interview Participants’ Clinic Roles

Role	No. of interviewees
Administrator	2
Home care nurse	1
Medical assistant	2
PAL (nurses and clinic health guides)	5
Patient care representative	2
CMM pharmacist	4
Provider (ie, physicians, nurse practitioners, physician assistants)	5
Team coordinator	1
Total	22

Abbreviations: CMM, comprehensive medication management; PAL, patient advocate and liaison.

Table 2.

Mapping of Primary Care Transformation Codes to the Consolidated Framework for Implementation Research Domain and Constructs for Intervention Characteristics

Intervention characteristics construct22	PCT codea	Example quote
Relative advantage: stakeholders’ perception of the advantage of implementing the intervention vs an alternative solution	Invaluable resource (+). Feelings that CMM pharmacists are a useful resource for the care team in addressing questions, collaborating on patient care tasks, and improving patient care. In addition, the presence of CMM helps providers to be more efficient.	Provider: “[MTM] has been invaluable honestly. I mean, we love MTM. It’s huge. I’ve been here 20 years, and 20 years ago you did not have pharmacists at your use. For instance, if you are having a hard time getting a diabetic under control, the MTM can just sort of take over these folks and help them. It is amazing, it’s really remarkable. So, MTM has really been good. It was a very helpful set-up before PCT, and now it’s even better. We have been a big fan of MTM.”b
Design quality and packaging: perceived excellence in how the intervention is bundled, presented, and assembled	Precharting (+). One of the changes that occurred with the PCT was pharmacists’ ability to prechart (ie, begin documenting visits for patients who have not yet arrived and to pend orders). This was commented on as being very helpful for providing efficient care and saving the pharmacist time documenting after a visit.	Pharmacist: “The prechart has been super helpful. I would say, before precharting, I spent more time documenting than I do now.”
	Appointment length (+). As part of the PCT, CMM visit lengths were revised based on the patient’s service bundle and visit lengths were adjusted to incorporate time for the pharmacist to document at the end of the visit. This added time was seen as a positive to complete documentation in a timely manner.	Pharmacist: “If you have a 35-minute visit, the concept is to see the patient for 25 minutes, give them a follow-up appointment, then after-visit summary, you document for 5 or 8 minutes and you have your chart closed. You go on to the next patient. Then, by the time you come to the end of the day, you don’t have that 2 hours of charting that you typically had.”

Abbreviations: CMM, comprehensive medication management; PCT, primary care transformation.

^aA perceived facilitator is indicated by a plus sign.

^bWithin M Health Fairview, the CMM program is referred to as medication therapy management (MTM).

Domain 1: Intervention characteristics.

Relative advantage (+). A number of different care team members, including providers, PALs, and a medical assistant, spoke about the benefits of having a pharmacist providing CMM on the care team. Providers mentioned that CMM helps in achieving and maintaining quality metrics and is a beneficial resource for patients and the care team. Other care team members, such as PALs and a medical assistant, also mentioned that they felt that having a CMM pharmacist helped to provide more efficient care.

Design quality and packaging (+).

Design quality and packaging refers to how the intervention (in this case, CMM delivered in the PCT) is designed and delivered.²² As part of the PCT, there were 2 design changes made to CMM that were both seen as beneficial by the pharmacists. One change was introduction of the ability to prechart (ie, start documentation for patients before their arrival and to pend orders). Previously, pharmacists did not have this capability; therefore, being able to prechart was commented on as being very helpful for providing efficient care and timely completion of documentation.

In addition, CMM appointment lengths were adjusted as part of the PCT to include time for the pharmacist to perform documentation at the end of the visit. This added time was also seen as a positive by pharmacists for completion of documentation in a timely manner.

Domain 2: Outer setting.

External policy and incentives (+). External policy and incentives is a broad construct that includes external strategies to spread interventions, such as payment incentives.²² In Minnesota, not all insurance plans include CMM as a covered benefit. This was a barrier for the care team because it was a challenge staying up to date on which patients could be seen by CMM to know who could be referred. However, to test this new population health model, if a patient’s insurance did not cover CMM, the service was funded by the health system. Multiple members of the care team, including a pharmacist, a provider, and a nurse, mentioned that, because insurance coverage was no longer a barrier for who could receive CMM, this was “one of the biggest wins of the PCT,” as one provider put it.

Domain 3: Inner setting.

Leadership engagement (–). Given the organizational structure of the health system, local clinic leadership was not closely tied to the design of CMM into the PCT. This presented a challenge if there were PCT barriers the pharmacists faced or if there were any clinic-level CMM issues that needed to be addressed.

Available resources (+/–).

One of the benefits of the PCT that 8 interviewees, including pharmacists, clinic administrators, and providers, spoke of was the increase in pharmacist FTEs that occurred at the PCT clinics. Interviewees commented that having more pharmacy presence led to increased availability of CMM, which, in turn, led to CMM being used more frequently. Some providers also spoke of the benefit of being able to offer CMM to certain patients if the provider had limited availability, which is something they might not have been able to do previously with limited CMM availability.

However, a barrier that was brought up by both pharmacists and other members of the care team was the need for additional CMM resources to support efficient CMM delivery. For example, certain resources, such as a designated exam room and support staff for rooming patients, were not always available to pharmacists, which may have minimized their efficiency and therefore the benefits of CMM.

Culture (+/–).

When speaking of clinic culture, 11 interviewees expressed that they felt they were providing more team-based care in the PCT with more integration of CMM. However, the clinics are made up of 3 to 5 different care team stations, and, because the pharmacists cover all providers in a clinic and are often not able to make daily team huddles, the pharmacists expressed that a barrier was not always feeling part of a core clinic team.

Networks and communication (+).

Networks and communication refers to social networks and the nature and quality of communication within an organization.²² At both pilot clinics, the pharmacists’ workspace was at the work station for specialty providers (eg, endocrinologists, podiatrists). However, with the increase in the number of pharmacist FTEs that occurred with the PCT, a pharmacist at one of the pilot clinics began sitting at different internal medicine/pediatrics workstations. A couple of interviewees, including a provider, expressed that having CMM located at provider stations led to increased awareness of CMM and, in turn, higher use of CMM.

Access to knowledge and information (–).

The CFIR defines this construct as “access to digestible information and knowledge about the intervention and how to incorporate it into work tasks.” ²² In the context of implementing CMM in the PCT, this presented as other care team members’ understanding of and training around CMM’s role in the PCT. This was determined to be a barrier as almost half of the interviewees spoke of either their own or other care team members’ limited understanding or awareness of aspects of CMM and the role of the pharmacist. Some interviewees suggested increased education around when and how to engage CMM to overcome this barrier.

Domain 4: Characteristics of individuals.

Knowledge and beliefs about the intervention (–). While a focus of the PCT was to enhance team-based care and better integrate services such as CMM, 6 different participants mentioned the challenge of changing care team members’, particularly providers’, mindsets to engage CMM more frequently. Both providers and other interviewees discussed how providers are used to managing medications on their own and that there needs to be a shift in mindsets to maximize use of resources such as CMM.

Domain 5: Process.

Executing and engaging (+/–). According to the CFIR, executing is carrying out an intervention as intended while engaging is involving the appropriate individuals in the implementation and use of the intervention.²² In the CFIR, these are 2 distinct constructs; however, in this study, 2 barriers emerged that related to both executing and engaging. The first was CMM scheduling. Pharmacists, administration, and other team members brought up different aspects of scheduling that posed a barrier to CMM. Pharmacists mentioned that, although appointment lengths were modified as part of the PCT, the appointment lengths did not always match the time needed to complete a CMM visit and the necessary documentation. There was also a lack of awareness from some care team members, such as PALs, on how to schedule CMM visits appropriately in the PCT. Additionally, there was some confusion regarding which care team members had the authority to schedule a CMM visit.

Another barrier was the perception that CMM was not being utilized as much as it potentially could be. Six different interviewees, including a clinic manager, providers, PALs, and pharmacists, cited possible reasons for this, including other positions not being fully staffed at the beginning of the PCT, resulting in fewer people to refer patients to CMM. Another potential reason that was mentioned was that CMM may be “out of sight, out of mind.” Given that there are significantly more providers in a clinic than there are pharmacists, it was suggested that providers may not always remember that CMM is a resource.

Finally, a component of engaging is the presence of champions. For CMM in the PCT, these were care team members other than pharmacists, such as providers and PALs. Two of the pharmacists discussed how the PALs have emerged as champions of CMM and the benefit this has provided to be included in additional patient visits. Other care team members, such as a provider and PALs, also spoke of how they frequently advocate for CMM to increase the buy-in for CMM among patients and providers.

Discussion

This study illustrated the distinct barriers and facilitators that emerged during implementation of CMM services in a new PCT. Many of the barriers and facilitators that presented were specific to the PCT, such as the benefits from increased appointment lengths that occurred as part of the PCT or the challenge of limited clinic leadership involvement in the design of CMM. However, a number of barriers and facilitators likely existed previously, such as the need for additional CMM resources, but became more apparent during the PCT. The CFIR can be applied during many phases of implementation. When the CFIR is used before implementation, it serves to guide capacity and/or needs assessments; when it is applied during implementation, it can identify unanticipated influences on implemenation.²² Because this study was conducted in the early phases of implementation with the first 2 PCT clinics, the results likely represent a mixture of programmatic needs and influences on this specific implementation.

Understanding and addressing barriers and maximizing facilitators early in the process of PCT is vital to successful implementation of CMM services and core to the principles of learning health system research. An example of how this could be applied to this project would be addressing the barrier of a lack of understanding of who could schedule CMM visits. In this barrier, if a care team member encountered a patient who they felt would benefit from CMM, they were unsure whether they could schedule a CMM visit or if that could only be done by the provider. This is important to know so that, as the PCT is rolled out to more clinics, greater emphasis can be placed on care team members’ roles as well as when and how to engage other members of the care team. Similarly, facilitators should continue to be leveraged. A positive influence on implementing CMM in the PCT was the presence of CMM champions. Knowing this, as the PCT expands to include more clinics, targeted efforts should be made to identify similar individuals early in the implementation process to foster the uptake and success of CMM.

The health system is now making adjustments to the PCT and how it is rolled out based on some of the findings from this study. For example, an implementation barrier that arose in this work was that care team members may not always consider CMM as a patient care resource. To facilitate the uptake and use of CMM among PCT sites, the system is now piloting criteria to proactively identify patients who may be in the most need of CMM. In addition, there is a workgroup to establish criteria to determine when a patient with diabetes would benefit from seeing a CMM pharmacist vs a certified diabetes educator (CDE), and such patients are being proactively scheduled to meet with a pharmacist or CDE in an effort to enhance interdisciplinary care and improve patient outcomes.

Pharmacists can have a pivotal role in helping to address some of the longstanding obstacles primary care has faced. For example, a shortage of primary care providers and difficulties in achieving rapid access to primary care have been widely cited in the literature.^31,32 In Minnesota, as well as many other states, pharmacists have the ability to prescribe medications under a collaborative practice agreement. Therefore, if a patient is seeking primary care to manage a chronic condition or several chronic conditions (eg, diabetes, hypertension, heart failure), that patient could potentially be seen by a pharmacist. This, in turn, would allow medical providers to see patients in need of medical or acute care, as opposed to pharmaceutical care. Similarly, increased integration and utilization of the pharmacist within healthcare teams can improve quality outcomes, decrease the mental exhaustion providers face when working with complex patients, and provide a valuable skill set and resource to the team.¹³ The results of this study illustrate that providers and care team members view CMM pharmacists as an invaluable resource, yet there were still several barriers impeding the successful integration and implementation of CMM into the PCT. Therefore, as health systems undergo PCT and strive to provide team-based care, it is important to begin by understanding implementation barriers and facilitators. Understanding and addressing these determinants of implementation success is key to learning health system research and fostering the spread of CMM services.

Limitations.

A limitation of this study was that data were collected from 2 clinics in a single geographic region. It is possible, therefore, that clinics of differing sizes and with more or less exposure to CMM may perceive different barriers and facilitators. Additionally, this was meant to capture early-stage implementation barriers and facilitators. For that reason, as the PCT progresses, it is possible that additional barriers and facilitators critical to sustaining CMM may emerge. Lastly, not every CFIR construct emerged in the results. Interview questions were intentionally broad (eg, “What do you feel is going well with CMM and what do you feel could be improved?”) to capture what interviewees felt were the most salient implementation barriers and facilitators. While it likely would not have been feasible to probe on every one of the 39 CFIR constructs, additional constructs may have emerged had they been intentionally probed.

Conclusion

PCT is critical to providing high-quality and efficient primary care, and many PCT efforts emphasize adoption of team-based care models. Clinical pharmacists providing CMM are a valuable interdisciplinary care team member who can help improve healthcare quality and access to primary care. The results of this study illustrate the early-stage barriers and facilitators experienced by care team members implementing CMM within a team-based, population health–focused PCT. Using an implementation science framework, such as the CFIR, provides a theoretical framework to illustrate where barriers and facilitators exist (eg, with individuals vs the intervention vs the process). Identifying and addressing implementation barriers and facilitators early during PCT rollout is critical to the success of team-based services such as CMM and becoming a learning health system.

Appendix A—Interview guide

Opening/warm-up questions

• The primary care transformation (PCT) has been in operation for about ___ months now, how do you feel it is going?

• What is going well?

• What could be improved?

Main questions

• Now thinking about comprehensive medication management (CMM) in the PCT, how do you feel CMM in the PCT is going?

  • [Interviewer probe/ask follow-ups on any items that they state]

• With regards to CMM, what do you feel is going well?

  • [Interviewer probe on what is going well we these items, what has changed now with the PCT compared to before, etc]

• What could be improved with CMM in the PCT?

  • [Interviewer probe on items that they state to understand why these are barriers, the effect of these barriers, etc]

Wrap-up question

• Is there anything that we did not talk about that you wanted to mention?

Appendix B—Mapping primary care transformation codes to Consolidated Framework for Implementation Research constructs

CFIR domain/construct and definition22	PCT code and definitiona	Example quote
Intervention characteristics
Relative advantage: stakeholders’ perception of the advantage of implementing the intervention vs an alternative solution	Invaluable resource (+). Feeling that CMM pharmacists are a useful resource for the care team in addressing questions, collaborating on patient care tasks, and improving patient care. In addition, the presence of CMM helps providers to be more efficient.	Provider: “[MTM] has been invaluable honestly. I mean, we love MTM. It’s huge. I’ve been here 20 years, and 20 years ago you did not have pharmacists at your use. For instance, if you are having a hard time getting a diabetic under control, the MTM can just sort of take over these folks and help them. It is amazing, it’s really remarkable. So, MTM has really been good. It was a very helpful set-up before PCT, and now it’s even better. We have been a big fan of MTM.”b
Design quality and packaging: perceived excellence in how the intervention is bundled, presented, and assembled	Precharting (+). One of the changes that occurred with the PCT was pharmacists’ ability to prechart (ie, begin documenting visits for patients who have not yet arrived and to pend orders). This was commented on as being very helpful for providing efficient care and saving the pharmacist time documenting after a visit.	Pharmacist: “The prechart has been super helpful. I would say, before precharting, I spent more time documenting than I do now.”
	Appointment length (+). As part of the PCT, CMM visit lengths were revised based on the patient’s service bundle and visit lengths were adjusted to incorporate time for the pharmacist to document at the end of the visit. This added time was seen as a positive to complete documentation in a timely manner.	Pharmacist: “If you have a 35-minute visit, the concept is to see the patient for 25 minutes, give them a follow-up appointment, then after-visit summary, you document for 5 or 8 minutes and you have your chart closed. You go on to the next patient. Then by the time you come to the end of the day, you don’t have that 2 hours of charting that you typically had.”
Outer setting
External policy and incentives: a broad construct that includes external strategies to spread interventions, including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting	Insurance coverage (+). Before the PCT, not all patients’ insurance would cover CMM. As part of the PCT, the system provided CMM as a covered service for all patients, which was seen as a great benefit.	Provider: “In the past, there was a limitation as to who [MTM] could see and all that. That’s the great thing. I think that is one of the biggest wins of PCT that anyone can see MTM . . . . Being able to add them to the care team has been great, without having to worry about if you can actually do that, because the insurance doesn’t cover it. I think that is the greatest thing.”
Inner setting
Leadership engagement: commitment, involvement, and accountability of leaders and managers with the implementation	Clinic leadership involvement (–). Clinic-level leadership was not as closely tied to the design of CMM in the PCT, which created a challenge for addressing CMM issues if they occurred.	Clinic administrator:“In all truthfulness, I’m not as closely tied to [MTM in the PCT].”
Available resources: the level of resources dedicated for implementation and ongoing operations, including money, training, education, physical space, and time	Need for additional resources (–). CMM does not always have certain resources (eg, designated exam room, support staff), which was considered a barrier for efficient care delivery and maximizing their skill set.	Pharmacist: “Then having an MA would help quite a bit . . . . That would be extremely helpful. Not only for time, but what I have found is that a patient who needs a vaccine . . . I have to go find someone and it is very hard to do that. Then I just have to send the patient to the pharmacy and it’s hard to say if the patient goes to the pharmacy or not to get the vaccine. That’s hard. There are a lot of things like that . . . outreach to patients, letters, phone calls. We do all of it. Again, if we are maximizing our clinical skills and time, someone else could help out with them and we could be doing other things that are more clinical based.”
	Increased pharmacy presence (+). The increase in pharmacist FTEs as part of the PCT increased the availability of CMM and, therefore, the use of CMM. It also allowed providers to offer CMM to certain patients if the provider had limited availability.	Provider: “[We have been referring] MTM for a lot more things than we did before—even depression, weight loss medications, and a lot more with asthma, which is something that I’ve historically always done on my own, but the pharmacist is spectacular at it. If there are patients that can’t get in to see me, it’s such a great expert offshoot to use.”
Culture: norms, values, and basic assumptions of a given organization	Enhanced team-based care (+). Feeling among care team members that more team-based care is being provided in the PCT and the benefits of collaborating with CMM.	Clinic administrator: “I still feel like we have a little ways to go, but I feel like [CMM pharmacists] are more integrated as part of the team.”
	CMM not always feeling part of the core team (–). Feeling that CMM is still frequently viewed as an optional resource rather than an integrated member of the care team.	Pharmacist: “I think huddles could be helpful if we were consistently at a station . . . that’s why sometimes it is hard for me to go to a huddle because I don’t feel necessarily a part of that team.”
Networks and communication: the nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization	Location of CMM (+). Perception that having CMM collocated at a provider station increases awareness of CMM and leads to higher use of CMM.	Provider: “Having MTM in the same workspace has been helpful for [integrating MTM into the PCT]. For instance, when [MTM] sits at our station, then they are just right there and I’m like, ‘Oh, this patient . . .’ Or ‘what do you think?’ . . . Having not such a siloed workspace has been really great for that.”
Access to knowledge and information: ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks	Understanding of and training around CMM’s role in the PCT (–). Limited understanding of CMM among some care team members and patients. Limited training for pharmacists as well about what their role would be in the PCT.	Pharmacist: “I think it’s been a huge learning curve for a lot of the staff, even for staff members who have been here for a long time, to better understand what MTM does. I think that is what I have learned the most is now that there are more of us and we are more present in the clinic, that we’ve had more face time with other staff members and explaining our role more and what kind of patients we might be able to see.”
Characteristics of individuals
Knowledge and beliefs: individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention	Changing mindsets (–). Belief that there needs to be a change in mindset among providers and other care team members to utilize resources such as CMM more.	Provider: “We really need to get providers and especially team members, like triage RNs, MAs, people on the phone, thinking of other options for the patient other than just seeing [providers]. . . . There has to be sometimes where like ‘What are you coming in for? Oh, you have a medication concern. Guess what? You can see MTM. They can see you tomorrow instead of waiting [to see a provider]’. That’s what we need to get to. That’s a culture shift for our system. That’s a culture shift for our patients.”
Process
Executing/engaging: Executing: carrying out or accomplishing the implementation according to plan Engaging: attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities	Identifying CMM advocates (+). Having nonpharmacist care team members advocate for CMM can help to increase buy-in with patients and utilization among providers.	Pharmacist: “We have been working really hard at advocating for ourselves, which is great. However, like I’ve mentioned, establishing those relationships with PALs and providers I found has made the biggest difference. Having them as our advocates to the patient helps the patient understand that we are part of the care team vs an optional resource.”
	Underutilizing CMM (–). Feeling that CMM is not utilized as much as it could be and therefore the pharmacists are not consistently busy. This could be due to other positions not being fully staffed at the beginning of the PCT. It was also commented that, given the provider/pharmacist ratio, providers may not remember CMM if CMM is working with other providers’ patients.	PAL: “I don’t think [CMM pharmacists are] being utilized nearly as much as they should be.”
	Scheduling (–). CMM appointment lengths were revised as part of the PCT; however, new appointment lengths may not always match the time needed to see the patient and complete documentation. CMM scheduling issues and a lack of awareness from staff on how to schedule CMM visits appropriately in the PCT also presented a barrier. There was also some confusion from staff regarding who had the ability/authority to refer patients to CMM. Finally, not having automated referral criteria for CMM was seen as a barrier.	Provider: “If the providers were OK with having some sort of automatic referral [for CMM] for certain criteria, I think that would be helpful … where the provider doesn’t have to be the middle person [to refer]. It just automatically happens. I don’t think anyone at this clinic would be opposed to it, more MTM involvement.”

Abbreviations: CFIR, Consolidated Framework for Implementation Research; CMM, comprehensive medication management; FTEs, full-time equivalents; MA, medical assistant; PAL, patient advocate and liaison; PCT, primary care transformation; RN, registered nurse.

^aA perceived barrier or challenge is indicated by a minus sign, while a perceived facilitator is indicated by a plus sign.

^bWithin M Health Fairview, the CMM program is referred to as medication therapy management (MTM).

Disclosures

This research was supported by the Agency for Healthcare Research and Quality (AHRQ) and Patient-Centered Outcomes Research Institute (PCORI), grant K12HS026379, and by the National Institutes of Health’s National Center for Advancing Translational Sciences, grant KL2TR002492. Additional support for the Minnesota Learning Health System Mentored Career Development Program (MN-LHS) scholars is offered by the University of Minnesota Office of Academic Clinical Affairs and the Division of Health Policy and Management, University of Minnesota School of Public Health. The authors have declared no potential conflicts of interest.

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The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, PCORI, or MN-LHS.