Table 1.

Barriers to implementation and potential solutions

CFIR Domain	CFIR Construct	Specific Element	Potential Solutions	Status of Solution
Intervention Characteristics	Adaptability	Perceived portability issues with pillbox	Educate patient that pills may be removed early in the day (i.e., before going out)	Adopted, with moderate success
		Pillbox connectivity: poor signal in some locations	Planned pillbox enhancements	Not adopted during trial
			Optimize location of the pillbox within the home	Adopted, need to balance with accessibility of box, ability to hear alarms
		Pillbox threshold for detecting removal of small pills	Group medications for each dose if possible	Adopted, with moderate success
			Planned pillbox enhancements to detect one small pill	Not adopted during trial
	Complexity	Time required to dispense medications and enter information into pillbox application	Develop pillbox software interface compatible with hospital EHR system	Not adopted during trial
Outer Setting	External Policies and Incentives	Lack of insurance coverage for early prescription refills	Plan to engage insurance companies to allow for early refills	Not adopted during trial
			Grant paid for recently dispensed medications	Adopted, successful (but not sustainable)
		Regulations that prohibit pharmacists from repackaging previously dispensed medications	Plan to work with state agencies re: whether filling a pillbox counts as repackaging	Not adopted during trial
		Potential for copayments to increase for monthly fills	Emphasize to patients that benefits of the intervention may be worth the copay increase	Adopted, with limited success
			Engage insurance companies to waive co-payment increase for smart pillboxes	Not adopted during trial
Inner Setting	Implementation Climate: Compatibility	Too many medications dispensed outside of the pillbox	Text reminders for non-pillbox medications	Adopted, with moderate success
			Patient education re: using pillbox under different situations	Adopted, with moderate success
		Turn-around time: pharmacy often received prescriptions < 2 h before anticipated discharge	Encouraged clinicians to provide prescriptions as early as possible	Adopted, with limited success
			Facilitated early communication between pharmacist and clinician	Adopted, with limited success
		Outpatient pharmacy closed on weekends	Developed protocol for patients discharged over the weekend to return on Monday to receive pillbox	Adopted, with limited success (patients often did not come back)
		Difficulty obtaining prescription refills from providers, esp. if multiple prescribers per patient	Procedures for obtaining refills from each practice and documenting usual prescriber for each medication	Adopted, with moderate success
Characteristics of Individuals	Individual state of change	Patient denial of previous problems with adherence	Scripts to reduce stigma of accepting the intervention	Adopted, with limited success
			Engagement of patient’s caregivers and providers	Adopted, with limited success
	Other personal attributes	Difficulty reaching patients to confirm refills	Attempt to reach patients through multiple methods in addition to phone calls	Adopted, with limited success