Skip to main content

Table 4 Thematic analysis shows the barriers and facilitators identified by the studies mapped on to their corresponding CFIR domains and constructs

From: Facilitators and barriers of implementing the chronic care model in primary care: a systematic review

Construct Domain Facilitator [reference number] Barrier [reference number]
  1. Intervention characteristic   
A. Intervention source    
B. Evidence strength & quality    “Limited guidance on prepared practice team development” [40]
C. Relative advantage   “Patient screened by staff before seeing physician ” [39], “Structured assessment in patient education” [39]  
D. Adapability   “Integrating Guided Care nurse in work flow” [36], “Processes integrated in to existing clinical operations” [43], “CCM adaption within context of daily practice” [48], “Program tailored to region needs” [50], “Adapting communication system to local context” [52], “Integrated project to routine care” [52]  
E. Trialability    
F. Complexity    “Intervention was too complex, targeted different components resulting in many priorities” [50]
G. Design quality & packaging   “Nurse training for components of intervention” [35], “Curriculum should be specific to CCM intervention” [36], “Different intervention model options were offered” [19], “Structured learning sessions and support by health collaborative” [44], “Guideline development” [50] “Intervention was too disease specific and did not address chronic care principles” [45]
H. Cost   “Low-cost program relied on community health workers, mentors and non-clinical staff” [43], “Financially viable” [48], “Sufficient funding” [37]  
  2. Outer setting   
A. Patient needs & resources   “Community health workers important in addressing patient needs” [43], “Program accessible and offered peer support” [43] “Need for patient resources” [19], “Patients uninsured or Medicare insured” [38], “Language barriers” [38], “Language and literacy issues” [44]
B. Cosmopolitanism    
C. Peer pressure    
D. External policies & incentives    “Poor organization of primary care in region” [50]
  3. Inner setting   
A. Structural characteristics   “Development of prepared practice teams” [40], “Electronic medical record (EMR) implementation and clinic remodelling” [39], “Recruitment of multilingual staff and interpreters to address language barriers” [44], “Worked with human resources to change organizational policies” [44], “Role of specialist in supporting and supervising other staff” [45], “Addition of technology system” [52], “Nurse practitioner role in implementation” [53] “Staff turnover” [19], “Large size of medical group” [40], “Unions unsupportive of staff role change” [40], “Medical director turnover” [38], “Need to expand role of provider” [44], “Staff turnover and loss meant very few staff could assume additional responsibilities” [44], “Lack of staff expertise in team approach to implementation” [48], “Lack of flexibility in reorganizing model of care” [52], “Smaller organizations had difficulty addressing barriers” [45]
C. Culture   “Support from primary care physicians” [35], “Support from physicians” [36], “Recognition of benefit of care managers” [39], “Stable work relationships” [40], “Recognition of patient role in self management” [44], “Persistence despite extra work” [44], “Organizational culture and enthusiasm for care improvement” [45], “Promoting multidisciplinary approach” [51], “Change to patient-centred care” [52], “Receiving personal recognition” [37] “Providers need for clear structure and autonomy” [19], “Organizational culture unsupportive of change” [40], “Lack of commitment or tradition of working in interdisciplinary teams” [50], “Difficulty changing provider care to patient-centered care” [52], “Rigid role expectations and thought processes” [52]
D. Implementation climate   “Clear, shared long term commitment for change” [40], “Recognized need for change” [40], “Work credit to ensure staff buy-in” [42], “Institutional commitment for change” [45], “Commitment to follow guidelines” [48], “Provider dissatisfaction with current system” [50], “Financial reimbursement for attending meetings” [51], “Organizational will to promote change and manage change” [51] “Career promotion opportunities” [37], “Incentives such as skill development” [37] “Lack of physician interest in addressing communication barriers with specialists” [39], “Disagreement on need for standardized care” [40], “Lack of commitment and interest by chief physician” [40], “Lack of committed vision” [45], “Difficult to motivate providers due to program uncertainty” [50], “Lack of provider commitment” [50]
E. Readiness for implementation   1. “Used pre-existing available resources: information system and education program” [34], “Buy-in from senior management” [19], “Previous implementation of structured assessment in EMR” [39], “Importance of project leaders” [52], “Sufficient staff personnel” [37] “Low staff and space resources” [43], “Lack of reimbursement strategy” [45], “Lack of financial resources” [50], “Software builder did not meet goals” [52], “Limited financial resource” [34], “Hidden and unexpected implementation expenditures” [52]
  4. Individual characteristics   
A. Knowledge & beliefs about intervention   “Increase awareness and education about program to providers” [41], “Observation of program processes by providers” [42], “Patient registry received interest in providers” [44], “Clinical assessment tool accepted and endorsed” [45], “Information campaign to increase awareness and knowledge” [50], “Education about project goals & process” [51], “Demonstration of project benefit to physicians” [51], “Staff morale and burnout reduction associated with reports of improved care outcomes” [37] “Needed more information on structured assessment” [39], “Unconvinced of usefulness of structured assessment for diagnoses” [39], “Lack of program information from providers that were not full time” [41], “Physician buy-in and adoption of intervention was not uniform” [47], “Fear of losing patient control to education program” [50], “Time needed for provider trust in program” [50], “Clinicians sensitive to workload and time commitment” [45]
B. Self-efficacy    “Fatigue and apathy from pace of change” [40], “Decreased staff participation in intervention results in low morale” [37]
C. Individual identification with organization    
D. Personal attributes    
  5. Process   
A. Planning   “Realistic expectations for measureable results” [40], “Consultation with focus groups for change process priorities” [50], “Physician involvement in planning” [51], “Utilized patient and physician experience in project development” [51], “Goals of QI as drivers of planning ” [52] “Lack of details on care change goals & outcomes” [40], “Too many priorities and uncoordinated change processes” [40],“Need for stronger program goals delineation” [41], “Lack of clear program aim at the start of campaign” [50]
B. Engaging   “Supportive administration and intervention champion” [19], “Strong physician leadership” [40], “Supervisor support” [40],“Strong registered nurse leadership” [40], “Clear goals by leaders” [40], “Strong supportive leader” [45], “Commitment & support of senior leaders” [50], “Recruitment of physician champion” [51], “Engaging champions with physicians” [51], “Presence of strong champion” [37] “Need for more senior management support” [19], “Need for intervention champion” [19], “Lack of accountability by leadership” [40], “Leaders face multiple uncertainties and distractions” [40], “Champion provider had limited time with patients” [44], “Change difficult without leadership endorsement” [44], “Lack of active provider champion” [44]
C. Executing   “Coordination of program components” [41], “Target screening of at risk patients” [39], “Pre-visit screening by staff before seeing physicians” [39], “Pre-visit by nurse and clerical staff” [40], “Approached patient as a team” [44], “Health care organizations part of collaborative had high CCM fidelity and moderate intensity” [46], “Flexible meeting times and locations” [51], “Fair distribution of tasks” [37] “Inadequate time to work on intervention” [19], “Difficulty with patient registry” [19], “Need for technical support” [19], “Competing demand of simultaneous EMR implementation” [40], “Physicians not engaged in change processes” [40], “Patient registry lacked IT support” [44], “Difficult to implement all CCM elements at high intensity in 12 months” [46], “Screening all patients time was consuming” [39], “Time constraints in appropriate assessment” [48], “Buy-in from staff not sufficient to sustain program” [48], “Increase in administrative burden” [50], “Patient involvement in own care was difficult” [52]
D. Reflecting & evaluating   “Periodic reviews and feedback of performance” [36], “Staff provided feedback on process design” [41], “Continuous assessment and revisions of program” [41], “Support from monthly feedback and learning sessions” [44] “Insufficient time to measure change” [40], “Lack of useful measure of change” [40], “Lack of EMR and billing codes were barriers for measurement of processes and outcomes” [48], “Implementing and measurement was labour intensive” [48]