Intervention Content, Delivery, and Training: Adaptations Fit to Context
| Contextual Factors | Invested in Diabetes Practice Characteristics | Corresponding Adaptations |
|---|---|---|
| Data capabilities and population management | All practices had electronic health records Some had registries to help identify eligible patients Varied experience with PRO collection and use | Simplified eligibility criteria for patients (any adult with Type II diabetes, no exclusion criteria) for ease of identification Ensured PROs were relevant to clinical care and SMA discussions |
| Payer mix | Practices vary in payer mix, with different billing and reimbursement practices | Informed guidelines for frequency of prescribing provider visits (at every session/1st/last only etc) Provided documentation templates and common billing codes used for diabetes SMAs |
| Prior experience with SMAs | Some practices had prior experience delivering and billing for diabetes SMAs | Informed intensity of technical assistance, plans for process mapping; practice coaches spent more time with helping practices determine SMA workflows and staffing |
| Team-based care | Practice all had behavioral health Some were fully integrated with behavioral health providers and experienced with integrated team-based care; others had collocated care where the behavioral health provider operated independently of the primary care provider | Influenced plans to include behavioral health providers in trainings alongside health educators (in patient-driven condition) and adaptations to mental health and stress and coping content |
| Patient populations | Practices delivering care to >10% Hispanic/Latino patients opted to provide SMAs in Spanish Patients vary in prior diabetes education, resources, and literacy | Spanish language TTIM materials and Spanish-speaking peer mentors and health educators made available Optional TTIM content with basic vs more advanced information and skills, with instructions to practices for selecting content most appropriate for their patients (e.g., basic carb counting vs glycemic index content) |
| Practice culture | Practices had moderate-to-high chaos and moderate-to-strong change culture; high chaos practices more sensitive to burden and resources | Influenced decisions about how to reduce burden to practices and how much technical assistance was required from the coach |
| Practice location and size | Practices vary in size, urban, suburban, and rural Native American population that travels ≥50 miles for primary care services | Informed flexibility/adaptations around frequency/duration of sessions, expected size of cohorts, and number of sessions |
| Practice clinician and staff availability | Practices vary in number and type of clinicians and staff available to deliver SMAs | Influenced adaptations to health educator and prescribing provider eligibility criteria, frequency of prescribing provider visits |
PRO, patient-reported outcomes; SMA, shared medical appointments; TTIM, targeted training in illness management.