Table 5.

Change Process Capability to Implement Self-Management Support (SMS) Changes

Propelling factors pushing for change process capabilities
Supporting infrastructure: Most practices at baseline had at least some resources, workflows, visits, and roles already deployed that aligned with delivering more robust patient SMS, such as, patient health educators/care coordinator, group visits, or existing workflows.““I found this team attentive and engaged in the topic…. I was struck by the empowered role of the MAs here. They do so much more than room patients take vital signs and follow the clinician's directions…. . I see the benefits as two-fold: the MAs seem happy and engaged and the clinicians don't appear stressed. Their workflow is working for them.” [FN 110].”
Functional Care Teams or QI Teams: At least moderately functional teams (QI or care teams) were observed in some practices where clinicians, staff, and administrators were present and at least minimally engaged in some decision making around SMS changes; or they appeared to have systems in place to communicate across care team roles or QI teams about changes planned.“The team already has many of the attitudes and skills (follow up calls to check on action plan progress, etc.) that will help them be successful in expanding SMS with their patients.” [MF 202]
Staff and clinician stability: There were several practices that described staff and clinicians who had been with the practice and for multiple years, and had good knowledge of how the clinic operates and experience with practice change or quality improvement.“After 24 years in this small clinic, she [practice manager] is well aware of every aspect of the practice. It is a very pleasant practice. She understands practice redesign. [MF 116” [MF 202]
Repelling factors pushing against change process capabilities
Siloed infrastructure: Especially, in larger practices, clinical roles were siloed with integration across roles beyond an initial referrals or hand-offs. Most practices appeared to have ad hoc approaches to quality improvement work. Among those in systems, there was no specific mention of how the systems would directly support the QI processes at the practice level.“I don't cross paths with the PHEs.” [BHP 110]
“I don't know exactly what the providers do about SMS.” [PHE 110]
“Does not feel diabetes care is collaborative. The lack of collaboration is a “company issue” because it “takes time and providers slow down”. [FN clinic 110]
Communication issues: Communication across roles or from systems leaders to practices was incomplete. This extended to how decisions were made, with staff and clinicians in several clinics feeling that the decision to participate was “made for us” by someone else in their system.“She noted that the team is “not quite as knit as it should be” because the provider and their MA “circle” but the rest of the team may not know due to “limited communication.” [MF clinic 110]
Time and resource constraints: The capacity to take on additional work, was acknowledged widely among the clinical leadership as a potential threat to fully implementing SMS. There were numerous concerns raised about capacity of clinicians—and especially staff—to take on new work or different work, change workflows, and adopt new tools.“She noted that the team is “not quite as knit as it should be” because the provider and their MA “circle” but the rest of the team may not know due to “limited communication.” [MF clinic 110]
Potential turnover/arrival of key people: Even at baseline, eight practices described the recent arrival or anticipated departure of key clinicians, including medical directors, SMS champions, diabetes clinic directors, or behavioral health providers.“A new development was that our previous contact, a PA, is leaving [the practice]. This person was also the lead clinician for the Shared Medical Appointments that [practice] is putting stock into to help manage the diabetes populations for each clinician.” [FN clinic 101]
Competing programs: Just a few practices made notable mentions, at baseline, of the potential for competing programs to affect implementation of CTH/SMS.“They seem to have a lot going on. A new QI tracking program that is discussed in the PA interview, a mandated state Wise Women's Program and now this project.” [FN, 104]
  • CTH, Connection to Health.