Table 2 Final thematic coding categories, with examples

Team Design

 Structure

It’s a free for all sister!

 Development

We’re at a cross, it seems like, between hierarchy and collaboration. And trying to find middle ground.

Aspirations

I think certainly reducing some of the bureaucracy or the logistical complications of getting patients the care that in our medical decision-making they need to have.

Organizational Context

 Barriers

Financing. And space. Money and space. Cause right now, like we, if we had the money for a social worker, I wouldn’t have anywhere to put them.

 Facilitators

Critical for me to have professional, capable, nursing staff and ancillary people to help me to make each patient visit the most efficient I possibly can.

 Culture

You know, there’s two wars going on. Some providers are like, “I don’t want to see anymore [patients].” And then the administration is like, “But we gotta make money.”

 Values

We really do try to put the patients first.

Social & Policy Context

 Structure

We have a lot of blueberry fields... so we have a lot of, they’re migrants, they go to Florida in Spring, they come here for the summer, they go to Michigan for the winter then turn right back around.

 Barriers

You’re focused on getting a patient in and out and taking care of it in a, in a highly effective way … but all of a sudden it doesn’t matter cause they can’t afford it, or you know they’re living on the street or something like that.

 Facilitators

There’s the Practice Transformation Network, you probably are familiar with that, is also driving some of our change. It’s not necessarily the impetus, but it’s helping give us some structure.