Abstract
Purpose: The purpose of this study is to gain understanding on factors identified by primary care practice members as impacting sustainability of diabetes Shared Medical Appointments (SMAs) after participating in a pragmatic trial that included sustainability planning. SMAs provide diabetes self-management education and support (DSMES) in primary care, though sustainability can be challenging.
Methods: The Invested in Diabetes study was a pragmatic comparative effectiveness trial of 2 approaches to providing SMAs for adults with type 2 diabetes. Qualitative interviews at the study end explored primary care practices’ experiences with SMAs and perspectives on sustainability, analyzed using a grounded theory hermeneutic editing approach.
Results: Seventy-nine interviews were conducted in 20 participating practices. One primary finding and 3 themes on factors necessary for sustainment emerged: finding: SMAs were seen as valuable, but sustainment plans were inconsistent; theme 1) Sustainability hinges on practical factors, some not supported in current health care payment models; theme 2) Relevance and efficiency are important: future diabetes SMAs anticipated adaptations or revisions; and theme 3) Improvement in reportable practice quality measures would be an incentive to continue SMAs.
Discussion: Diabetes SMAs were perceived as beneficial, but difficult to sustain. We found that primary care teams want to provide SMAs and that changes in how primary care practices are reimbursed could support implementation and sustainment of DSMES approaches such as SMAs, leading to improved patient outcomes.
Conclusion: There is urgent need for explicit attention to policy change, health care payment innovation, and novel reimbursement models to enhance sustainability of diabetes SMAs.
- Education of Patients
- Grounded Theory
- Hermeneutics
- Practice-based Research
- Pragmatic Trials
- Self Care
- Self Management
- Shared Medical Appointments
- Type 2 Diabetes
Shared medical appointments (SMAs) are defined as “groups of patients meeting over time for comprehensive care for a defining chronic condition or health care state.”1 SMAs have been used as a method for diabetes self-management education and support (DSMES) and have been shown to improve diabetes outcomes2 and increase patient and clinician satisfaction.3,4 For example, SMAs have been shown to increase self-care behaviors, lower hemoglobin A1C measurements, and reduce clinician burnout. Despite the benefits, SMAs can be difficult to adopt, implement, and sustain in real-world primary care practices.5,6 Implementing SMAs requires new workflows and can be expensive and resource intensive. Recruiting patients to attend SMAs can also be challenging. Primary care practices often implement programs such as SMAs, only to discontinue offering them due to these and other challenges.7–9
Sustainability has been defined as “the continued delivery of an innovation or intervention, potentially after adaptation, at a sufficient level to ensure the continued health impact and benefits of the intervention.”10 Often, interventions that are effective during trials or initial implementation do not achieve sustainment (the actual continuation of a program or service). Systematic reviews indicate that up to half of all interventions are not sustained past a few years and many are significantly modified or adapted to better fit practice context.11–13 Thus, although an intervention may be effective, if it is not continued long-term, the ability to meaningfully impact one’s practice panel and public health is limited.11–13 The literature shows that factors that support successful implementation and sustainment include practice champions, leadership support, training, and financial sustainability.14,15 It is well established that diabetes SMAs experience sustainability challenges in primary care, including lack of leadership support, staffing turnover or challenges, and concern that reimbursement for the intervention will not cover the cost of implementation and delivery.14,16,17 Recommendations have been made to proactively address these challenges through training, including one-on-one clinical visits in the structure for reimbursement, to enhance sustainability.18
The Invested in Diabetes study was a pragmatic cluster-randomized, comparative effectiveness trial designed to compare 2 different models of diabetes SMAs delivered in primary care.19 Practices were randomly assigned to either a patient-driven or standardized diabetes SMA model condition. Both conditions used an adapted modular evidence-based curriculum that was originally developed for a longer intervention known as Targeted Training in Illness Management (TTIM) that provided DSMES for people with serious mental illness and diabetes.20 The adapted version consisted of 6 sessions intended to last 2 hours. Session topics included an introduction to diabetes management, personal monitoring of blood sugar and other physical symptoms, stress and mental health related to diabetes, discussing and advocating for yourself with a clinician, nutrition, and other lifestyle interventions that improve diabetes outcomes. External practice facilitators supported practice planning around implementation and sustainability of SMAs from the inception of the project, proactively addressing known barriers to SMA sustainability in primary care through training and education around such things as billing for SMAs and planning for staff turnover. Practices had flexibility in determining the schedule for the sessions but generally offered them either biweekly or monthly over a period of 3 to 6 months. Eligibility requirements for patients were that they were receiving care at the participating practice, were aged 18 or older, and had a diagnosis of type 2 diabetes.
The patient-driven condition was developed based on patient-partner input in prior research emphasizing the importance of a multidisciplinary team, peer mentors, and the ability to choose topics in order of priority.21 SMA participants in the patient-driven condition were able to select the order and emphasis of the topics covered in the SMAs. The practice team for both conditions included a health educator who facilitated the SMAs and a billing clinician who saw participants for an individual diabetes-focused clinical visit. The team for the patient-driven condition also included a behavioral health provider (BHP), who facilitated at least the 2 behavioral health-focused SMA sessions, and a peer-mentor, a patient of the practice with lived diabetes experience who attended the sessions and offered real-life problem-solving support to participants.
The Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM)22 model was used to guide evaluation of outcomes across conditions. The M in RE-AIM is for “maintenance,” which is “at the setting level, the extent to which a program or policy becomes institutionalized or part of the routine organizational practices and policies.” As in the published protocol for the Invested in Diabetes study, a secondary outcome was practice-level sustainability of the 2 models of diabetes SMAs studied.23 The specific time frame for assessment of maintenance or sustainment varies across projects.24 Results for the Reach25, Effectiveness,26 Adoption,27 and Implementation28 have been published elsewhere. The overall results showed minimal differences in patient outcomes (diabetes distress, diabetes self-care activities, or HbA1c) between patient-driven and standardized diabetes SMA models.26
In this article, we describe practice member perspectives on the perceived value and sustainability of SMAs, based on results of practice interviews on factors impacting sustainability of patient-driven and standardized SMAs using an adapted TTIM curriculum. We identify several areas important for future research and practice around implementation and policy of SMAs to enhance sustainment.
Methods
This aspect of the RE-AIM evaluation for the Invested in Diabetes study was a qualitative study. We used semistructured 1:1 key informant interviews to elicit practice members’ thoughts on whether they would continue SMAs after study end, focusing on factors that made this likely or unlikely, as well as practice member overall evaluation of the SMAs. The study protocol was reviewed and approved by the Colorado Multiple Institutional Review Board (protocol #17 to 2377). Interviewees provided verbal consent.
Setting and Participants
Twenty-two primary care practices in Colorado and Kansas were randomly assigned to implement either patient-driven or standardized diabetes SMAs. Practices were provided with training on how to implement TTIM using their assigned SMA model type. Practice facilitators from the study team provided structured practice facilitation and feedback for sessions during weekly to monthly check-ins. As a pragmatic trial, practices used existing personnel, systems, and processes for care to provide diabetes SMAs to their patients; while they received funding from the research award to support training and data collection, they were expected to use existing reimbursement and billing models to pay for delivery of care (typically billing for general office visit codes, in conjunction with prescribing clinician visits).
Qualitative Interviews and Analyses
Clinicians and practice staff from each practice who were engaged in SMA implementation and delivery were asked by practice facilitators to complete an interview with study staff within 2 months of completion of the final project-related SMA cohort, ranging from January 2021 to February 2022. Interviewees included SMA coordinators, health educators, and prescribing clinicians, who were recruited via e-mail and phone by study personnel with assistance from the practice contacts at each site. BHPs were also interviewed in both standardized and patient-driven sites, though they were only involved in patient-driven sites. In addition, practice leadership (eg, Chief Medical Officer), finance (eg, Chief Financial Officer), or practice managers were also interviewed to discuss sustainability plans and factors. Between 3 and 6 interviews were conducted per practice. Interviews lasted up to 60 minutes, were conducted by video-conference by a qualitative researcher within the study team, and were audio recorded and professionally transcribed.
Semistructured interview guides (supplemental material) were created by the study team and covered practice perceptions of the value and sustainability (burden, complexity, and potential for widespread uptake) of their assigned diabetes SMA model. Implementation challenges were also explored, especially regarding virtual SMAs and other adaptations and challenges due to the COVID-19 pandemic and group meeting restrictions.
Analysis
The qualitative team, comprising the qualitative lead (JSH), physician researcher (AN), study manager (DG) and qualitative analyst (JR) all have extensive experience collecting and analyzing qualitative data. Interview transcripts were cleaned and entered in the ATLAS.ti qualitative software program (ATLAS.ti version 9, Scientific Software Development GmbH). For all analyses, we began with a grounded theory hermeneutic editing approach to the data.29 This approach allows identification of themes that are “grounded” or developed from an interpretation of the data. The analyst team read through 20% of interviews together to discuss and determine the key themes and the associated definitions and labels (“codes”). These codes were determined inductively to capture new findings that were not considered before analysis. In additional, a priori codes were established using the implementation framework, RE-AIM with each RE-AIM domain considered a code. The team identified codes using a collaborative process, identifying a code of “sustainability,” which was defined as any discussion of plans to continue offering SMAs after study end, whether using the Invested in Diabetes approach or a modified approach (ie, different curriculum or format). Code books were finalized iteratively and vetted with the larger study team. After initial codes were established, the analysts coded – first together, then independently – the data using a coding and editing approach as outlined by Addison,29 and compared and reconciled coding until achieving a high degree of conceptual inter-rater reliability.
Once coding was complete, a full thematic analysis was conducted. Analysts separated interviews by study condition (standardized vs patient-driven) and practice type (Federally Qualified Health Center (FQHC) vs non-FQHC) when reviewing the data, as we believed there could be some categorical differences in perceptions of sustainability by study condition or practice type. Coded segments of data were reviewed within and between the groupings.
Results
We completed 79 interviews with practice members from 20 practices; 2 practices ended engagement with the study before data collection (Table 1). We identified 1 primary finding and 3 themes regarding factors that influence sustainability of SMAs. We did not observe any meaningful differences in sustainability themes by study condition (ie, no differences between patient-driven or standardized SMAs) or by practice type (ie, no differences between FQHCs and non-FQHCs).
Practice and Interviewee Breakdown
Primary Finding: SMAs Were Seen as Valuable and Beneficial to Practices and Patients, but Sustainment Plans Were Inconsistent Across Practices
Interview participants representing all clinic roles endorsed benefits of SMAs to patients, although these tended to be qualitatively described as relational and motivational, such as camaraderie, group support, patient education and empowerment, rather than in stating quantitative outcomes such as lower A1C measurements. Practices had not received clinical outcomes study data at the time of interviews so while they could have monitored clinical outcomes on their own, most had not. They also reported benefits to the practice, such as more effective patient education processes and giving clinicians a good option for DSMES outside of one-on-one clinic visits. Participants also mentioned that clinicians often do not know how to provide effective DSMES to patients and diabetes SMAs filled that gap. Interviewees reported a paucity of DSMES options for patients, and noted that by offering or continuing SMAs, they were providing an important service.
Despite identification of benefits and study team efforts to help practices consider sustainability, in many cases interviewees hadn’t really thought about sustaining SMAs and/or did not have a plan for how to do it after study completion. Interviewees from the same practice sometimes had differing perspectives on whether they would be continuing SMAs. Often, interviewees were not aware of or included in discussions on sustaining SMAs even though they were involved in conducting SMAs for this project. Among interviewees who knew about or had been involved in their practice’s plans for sustaining SMAs, some reported that while they were interested in providing SMAs, they were not planning to offer SMAs at this time, frequently citing challenges to funding and staffing. Interview data also revealed that decision making typically was the purview of high-level administration and it seemed the whole team had rarely been included in planning the future of SMAs at their practices.
Some were planning to return to the diabetes education activities they had been doing before this study, while others wanted to continue or build on the work they had done as part of the study. These individuals cited improved patient metrics or care, financial motivators (ie, grants or quality metrics), or supportive leadership as motivators for sustainment. Other practice members reported thinking of new ways to offer these services to patients such as online recorded sessions or bringing a Certified Diabetes Care and Education Specialist onto their staff to increase convenience and accessibility or reimbursement options. Supporting quotes are found in Table 2.
Quotes Supporting Primary Finding: SMAs Were Seen as Valuable and Beneficial to Practices and Patients, but Sustainment Plans Were Inconsistent Across Practices. Collected January 2021–February 2022 in Participating Practices in Colorado and Kansas
The following 3 themes all reflect factors that emerged as important to practices’ ability and interest in sustaining SMAs.
Theme 1: Sustainability Hinges on Practical Factors, Many of Which Are Not Supported in Current Health Care Payment Models
The primary concern that interviewees had regarding SMA sustainment was how to cover the costs to avoid a financial burden on the practice. Many were frustrated that it was a challenge to get reimbursed fairly for their time and effort, especially because DSMES is recommended in primary care diabetes guidelines. In an effort to minimize the financial impact, some talked about using money from capitated plans to support SMAs in the future but were not currently able to do that.
Many participants said SMAs did not have to generate revenue, but needed to at least be financially neutral. While the intervention was designed to include prescribing clinician visits as a way to cover costs, participants noted this did not always work well; sometimes there was no need for a visit at the time of the SMAs, patients objected to paying copays that would come with having an individual visit during the group time, or hadn’t met their deductible so had to pay the full visit charge. These data shed light on how difficult it is to conduct SMAs in a fee-for-service system where the primary income generator is clinician time spent with patients or procedures, and there are not generally robust reimbursement mechanisms for services provided by other team members.
The other practical factor that was mentioned as a barrier to sustainment was the demands on staff with regards to the time and effort to coordinate the SMAs. Scheduling, training, and recruitment all take time and that adds to the hassle and expense as there is currently no method to recoup these costs. Supporting quotes for theme 1 are found in Table 3.
Quotes Supporting Theme 1: Sustainability Hinges on Practical Factors, Many of Which Are Not Supported in Current Health Care Payment Models. Collected January 2021–February 2022 in Participating Practices in Colorado and Kansas
Theme 2: Relevance and Efficiency Are Important: Future Classes Anticipate Including Some Elements of the Invested Program, but with Adaptations or Revisions
Many respondents reported that they would use the TTIM curriculum, but likely would modify it to meet their practice needs and context. Additional nutrition content was most commonly suggested, with respondents noting that patients really wanted to learn more about dietary approaches for managing diabetes and wanted more resources (eg, recipes to try at home). There was general agreement that mental health is an important component of DSMES, although some mentioned that they would either reduce the behavioral health content or present it in a different way. It was generally felt that shorter classes and reducing the number of sessions would improve patient attendance and thus be easier to sustain. Supporting quotes for theme 2 are found in Table 4.
Quotes Supporting Theme 2: Relevance and Efficiency Are Important: future Classes Anticipate Including Some Elements of the Invested Program, but with Adaptations or Revisions. Collected January 2021–February 2022 in Participating Practices in Colorado and Kansas
Theme 3: Improvement in Quality Reporting Measures Would Be an Incentive to Continue SMAs
Many mentioned that improving quality measures around diabetes (eg, lower A1C, improved blood pressure readings) is important both for patient health outcomes and also for practice financial reimbursement. If SMAs contributed to improvement, they would be more likely to continue offering them. Further, if SMAs could be shown to be related to improvement in these measures, some interviewees were open to taking a financial loss knowing it would pay off later in higher reimbursement related to improved quality metrics. Respondents also mentioned that they did receive some incentive payments related to quality of care and that SMAs could be helpful for increasing quality and thus incentive payments in the future. Supporting quotes for theme 3 are found in Table 5.
Quotes Supporting Theme 3: Improvement in Quality Reporting Measures Would Be an Incentive to Continue SMAs. Collected January 2021–February 2022 in Participating Practices in Colorado and Kansas
Discussion
We found that staff and clinicians from practices that participated in Invested in Diabetes believed that diabetes SMAs are beneficial for their patients, and should be offered and sustained in primary care. However, we also found that many practice teams either had not discussed sustaining SMAs or had decided not to continue to offer SMAs after the study. The identified qualitative themes help to elucidate this contradiction as they indicate that sustainment is a challenge in primary care practices due to financial and personnel issues, but could be better supported if there were better mechanisms for DSMES billing (for health education) in primary care settings or improved quality metrics leading to higher reimbursement. While there were some varying views on sustainability, there were no substantive differences between the experiences of interviewees from practices implementing the standardized versus patient-driven SMA model, or those in FQHC versus non-FQHC practices. This is also an important finding as the literature suggests that a team approach may be more sustainable,18 which was not true in this study.
While our results were consistent with established evidence on important factors in sustainability of clinical programs and services, we believe that these are important as this project was designed and implemented with an emphasis on sustainability.13,30 As described in the Integrated Sustainability Framework, sustainability is a function of outer context and policy environment factors (eg, reimbursement models), inner context and organizational factors (eg, resources, internal funding, leadership support, champions), implementation processes (eg, staff training, sustainability planning), characteristics of interventions (eg, adaptability), and characteristics of implementers (eg, motivation, skills) and patient populations (eg, health literacy, health priorities).13 While many of the practices were most vocal about sustainability challenges pertaining to the outer context and policy environment, these were not the only issues identified. For instance, within the implementation process domain, a key theme reflected lack of sustainability planning within the Invested in Diabetes practices despite dedicated work by practice facilitators encouraging practices to consider sustainability (ie, respondents noted there had not been explicit discussions about continuing to offer SMAs). While we had undertaken significant efforts to help adapt the diabetes SMAs to fit practice context at every stage of the project,31–33 there might still have been features of the diabetes SMAs tested in this study that were not a good fit for practices. For instance, the prescribing clinician visit – an important element of billing for SMAs – was not a good fit for many practices given the complexity of scheduling and resource allocation decisions made at the organizational level. Offering assistance around navigating both inner and outer contextual challenges by dedicated practice facilitators was not enough to alleviate the barriers to sustainability experienced.
Despite perceived value of SMAs and work to ensure sustainability, sustainment in our sample ultimately came down to finances and resources, as challenges were related to the current reimbursement system. Guidelines recommend DSMES, but it is scarce and generally underfunded or not reimbursed in primary care settings.34 Given improvement in diabetes self-management is a goal within the United States health care system, interventions that allow skill development, such as SMAs need to be feasible to conduct and widely available. SMAs may not be the only way to do this in primary care, or in communities more broadly, but they are effective, generally acceptable to patients, and allow primary care practices to provide a level of care that is satisfying and rewarding to staff and patients alike. This sense that a different reimbursement approach or system might allow for more successful SMAs is reflected in participant observations that SMAs might be more suitable in a capitated reimbursement structure. While movement toward capitated pay-for-performance is occurring, it is not clear that these approaches will allow practices to support interventions such as SMAs or DSMES.
An additional and related challenge for practices seems to be evaluating the practice-specific return on investment. While many reported that improvements in quality metrics and patient outcomes are factors that drive SMA sustainment, sometimes at the expense of revenue, most practice members interviewed were generally not aware of patient clinical outcomes, which may have been a result of their knowing they would get these data from study participation. However, it indicates that they did not have existing processes for these results in place within their own systems. Since completion of these interviews, practices were provided with outcomes data, and overall a reduction in A1C was seen in patients participating in Invested in Diabetes. However, these results came after many practices had already made decisions regarding continuation of SMAs. Practices could use an efficient and timely way to evaluate programs like SMAs, both from financial and outcomes standpoints. This is an area for future research and reflection on current quality measures - could practice-friendly measures support sustainment by giving a clear reason to continue?
One method to encourage sustainment of interventions like SMAs beyond the initial project period is to incorporate business and marketing approaches into the research process.35 For instance, incorporating cost effectiveness analysis, return on investment, or business model generation techniques may be helpful to encourage decision makers to allocate resources for sustainment. There are opportunities to explore which diabetes SMA models are most cost-effective – that is, staffing models (staffing types or resource centralization models), duration and frequency (eg, SMAs with fewer sessions per patient), and/or use of virtual or hybrid modalities.
Strengths and Limitations of the Study
This study leveraged the experience of 20 primary practices from a range of clinical settings and organizations which may not be representative of other practices, especially those not interested enough in diabetes SMAs to participate in a research study on it. More work is needed to demonstrate viable business models for diabetes SMA services. The consistent message from practices that SMA sustainability is limited by current reimbursement and billing models suggests an urgent need for payer policy change. Limitations include perspectives on diabetes SMA sustainability relevant only to the 2 SMA models tested in the Invested in Diabetes study. While qualitative methods are highly valuable in research, there are also a number of more structured quantitative measures of sustainability that were not used in this study. There are tools available (the program sustainability assessment tool and the clinical sustainability assessment tool) to help systematically assess sustainability from the perspective of practices.11,36 These tools can help pinpoint where additional support may be needed to enhance sustainability. Advances in measurement of sustainability have the potential to inform research as well.36
Conclusions
Diabetes SMAs have benefits beyond improvement in clinical diabetes outcomes. However, until SMAs are adequately supported and promoted, it will be difficult for real-world primary care practices to routinely offer these services to patients outside of specific research projects that receive support beyond reimbursement. While sustainability was addressed from the onset in Invested in Diabetes via practice-specific adaptations and dedicated practice facilitation, it is possible that continued efforts to 1) plan for sustainability from the outset of program planning; 2) make iterative adaptations; 3) study the impact of different types of staff diabetes SMA facilitators or other ways to reduce costs; or 4) redesign workflows, could increase probability of sustainment. Notably, policy and reimbursement structure changes (such as pay for performance or requirements to report on patient-centered outcomes) are likely necessary to make SMAs sustainable for many primary care practices and according to our results, would be welcomed.
Acknowledgments
The authors thank the entire Invested in Diabetes project team, dedicated patient partners, and engaged practices for participating in the study.
Appendix
Invested in Diabetes Primary Care Practice Interview Guide – Patient Driven Condition Practice Members
Prior to Interview –
**Review practice information from the summary matrix as well as coach notes for this practice, including whether practices conducted virtual SMAs and interviewee role.
End Point Check in (3rd INTERVIEW)
Intro: Hello, my name is________________, and I am a researcher with the University of Colorado. The purpose of our meeting today is for me to learn from your perspective on the Invested in Diabetes Project and your practice’s implementation and plans for the future of diabetes shared medical appointments. I am not associated with the intervention, but instead am part of the project evaluation team. OR Today I am here in the role of a member of the evaluation team. This means that what you share with me will be confidential and you can feel free to be honest about your true impressions.
First, I would like to share this consent form with you keep and outline a few important points.
This interview is voluntary. You may choose to answer or not answer any questions.
All information you provide is confidential and will not be shared outside of the study team.
I will be audio taping this session for the purposes of having it transcribed for analysis. All names will be removed and your answers will not be identified as belonging to you. The only individuals who will hear your answers are myself and other researchers involved with this project. May I have your permission to record?
This discussion should last approximately 45 minutes. If you are ready we will get started with the questions.
This project was reviewed and approved by the Colorado Multiple Institutional Review Board. The protocol number is 17-2377. The Principal Investigators are Dr. Bethany Kwan and Jeanette Waxmonsky.
Participant Role
[Note to interviewer: brief, <2 min]
Briefly, please confirm your role in the practice with regards to delivery of diabetes care in general. I have that you are a [ROLE]. Is that correct?
Also, would you please confirm with me your role in this practice regarding the delivery of diabetes shared medical appointments? I have that you are a [ROLE] (e.g., SMA coordinator, SMA facilitator such as health educator, behavioral health provider, etc, prescribing provider, practice administrator, other.). Is that correct?
Did you have any role in facilitating classes?
For those in an SMA facilitator role: What experiences, formal training or credentials do you have that prepared you for the SMA facilitator role?
Practice Experience with Diabetes SMAs: Implementation, Adaptation, and Sustainability
This practice was assigned to the Patient-Driven SMA Condition. Patient-Driven SMAs include delivering the Targeted Training in Illness Management (or “TTIM”) curriculum using a multi-disciplinary care team – including health educators, behavioral health providers, diabetes peer mentors, and prescribing providers. As you might know, in the patient-driven condition, the TTIM topic order and emphasis is tailored to the patients in each cohort, such that the patients pick the topic order and the SMA facilitators spend more time on topics that best match the patients’ needs and interests. Patients meet with a prescribing provider for brief individual visits and address personal health concerns that emerge during the SMAs. Patients also have the opportunity to connect with peer mentors outside of the SMAs for peer support. I’m going to ask about your experience with each aspect of this model.
TTIM Curriculum
[Note to interviewer – keep section brief, <10 min].
First, tell me about your experience with the TTIM curriculum itself, including things like the content and the materials provided, the overall number of sessions and the length of time in each session.
a. Considering both the topics and the way the material was organized, what worked well about the TTIM curriculum? What did not work well?
a. For SMA facilitators: What topics of the curriculum were you typically responsible for delivering? How well prepared were you to deliver this curriculum? What would help you be better prepared?
b. How did patients react to the curriculum and materials? What did they respond well to (meaning what did they like and seem interested in as well as what seemed to make a difference/impact on their health status)? Not so well?
• Probe: topics, patient handouts, PROs
c. Did your practice make any changes to the curriculum or the materials during the final half of the project? Whose decision was it to make this change? When was the change made? Why was the change made? What was the impact of the change? Think about changes both before and after COVID-19.
• Probe: curriculum or materials changes in response to COVID-19, whether or not they did vSMAs.
d. If your practice were to continue offering diabetes SMAs, would you personally want to continue using TTIM in the future? If not, why not? If so, would you make any changes? [note: get personal opinion, not practice decision here]
e. Anything else to add about the curriculum?
SMA Processes
[Note to interviewer: Major focus area, contrast patient-driven and standardized condition, 15 min].
Next, tell me about your experience with the SMA processes, meaning the care team members involved and the workflows related to recruitment, delivery of SMAs, prescribing provider visits, use of the patient surveys, and any follow-up conducted. For each question, we’re interested in what went well and what didn’t go as well, and what you would keep vs do differently. [Probe these]
a. What was your experience with the SMA processes and workflows in general?
b. What was your experience with the topic selection process? How did patients react to topic selection?
c. Who else was involved in delivering the SMAs?
• Probe: BHPs, Peer mentors, prescribing providers, others.
i. What worked well vs not so well with the multidisciplinary care team approach with respect to involving behavioral health and peer mentors?
• Probe: burden and complexity, scheduling issues, communication
ii. How did patients react to the multidisciplinary care team approach? How did patients react to the peer mentors?
d. [If PP] How did the provider visits work for your practice? Were patients utilizing the visits? Did they bring up topics covered?
• Probe: work flow, interest in PP visit
e. In general, during the second half of the project, did your practice make any changes to the SMA processes? Did you make any changes specifically to address COVID-19? Whose decision was it to make this change? When was the change made? Why was the change made? What was the impact of the change?
a. Please confirm – your practice DID/DID NOT implement virtual SMAs. [Note: don’t go into detail on the process; this is covered in the process mapping and other data sources]
• If yes, what made it possible to make that transition? How did patient react? What did you like or not like about virtual SMAs?
• If not, why not?
f. If your practice were to continue diabetes SMAs, what aspects of the patient-driven model would you personally want to continue using? Why these aspects? Probe: topic selection, BHPs, peer mentors, prescribing provider visits. What changes would you make? [note: get personal opinion, not practice decision here]
Perceived Value of Patient-Driven SMAs using TTIM
1. Now that the project is over, what have you seen in terms of impact on patients? How about impact on the practice?
2. In your experience, what types of patients do you think would benefit most from SMAs using the TTIM curriculum? How did the patient-driven processes impact benefit to patients?
• Probe: Who is most likely to actually participate and experience improvements in their health?
• Probe: What types of patients were resistant to participate?
3. Are there particular types of practices that you think would do best with patient-driven SMAs using TTIM?
4. For practices that did vSMAs: How did the impacts differ for virtual vs in-person SMAs? Were virtual any more or less effective than in-person? In what ways? For what types of patients?
Sustainability of Patient-Driven SMAs using TTIM
[Note to interviewer – next section is very important for interviewee who has knowledge about this. Will confirm at time of scheduling]
1. To your knowledge, does your practice plan to continue offering diabetes SMAs?
a. If yes/maybe, what will these diabetes SMAs look like in terms of the curriculum, number of sessions, virtual or in-person, care team members, prescribing provider visits, etc? What will carry over from the Invested in Diabetes project?
2. Who was (or will be) involved in decisions to continue or discontinue offering diabetes SMAs at your practice?
a. What factors influenced this decision? PROBE: patient acceptance/participation in the SMAs, patient outcomes/satisfaction, meeting quality metrics, practice clinician or staff push for SMAs, reimbursement mechanisms and other financial factors, staffing availability, perceived burden or complexity, etc.)
3. For those with practice administrator/leadership roles only: To your knowledge, how will this practice sustain SMAs financially?
• PROBE: fee-for service, alternative payment plans, patient out-of-pocket cost
• PROBE: What billing codes will be used? What will be the reimbursement rate?
• PROBE: Are the SMAs part of any alternative payment models (APMs) or justification for recognition as a PCMH or other quality initiatives? If so, please explain.
• What changes in health policy (local, state, federal) might better support sustainability?
Wrapping Up
[Note: <5 min]
Other than COVID-19, has anything else happened in the community or in the practice that may have affected your practice’s involvement or results from this project?
Is there anything I should have asked you, but didn’t, that would be helpful to this project?
Thank you for participating and providing me with your answers. These will be very helpful as we move forward in our research that focuses on effective management of diabetes in primary care. If I realize at a later time that I would like to clarify or follow-up on an answer you gave me today, would it be alright to contact you again?
Notes
This article was externally peer reviewed.
Funding: Research reported in this manuscript was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (IHS-1609-36322). The views, statements, and opinions presented in this work are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.
Conflict of interest: The authors have no conflicts of interest to declare.
- Received for publication August 26, 2024.
- Revision received May 12, 2025.
- Accepted for publication June 9, 2025.
References
Jump to section
Related Articles
Cited By...
- No citing articles found.