We conducted 27 interviews at Time 1 and 31 interviews at Time 2. Of the 58 interviews completed, 39 of these were conducted with unique respondents (i.e., only interviewed at Time 1 or Time 2). Thus, 19 participants were interviewed at both Time 1 and Time 2. Each site had between one to five respondents per timepoint. About half of our sample consisted of 11 social workers (28%) and 9 psychologists (24%). Additionally, 6 registered nurses (14%), 4 psychiatrists (10%), 4 vocational rehabilitation counselors (10%), and 5 other disciplines on the CCM implementation teams (e.g., addiction counselors, peer support specialists; 14%) participated in this study. There were 33 team members who did not participate in the study—7 declined participation, 2 left the VA, and 24 did not respond after three recruitment emails.
At Time 1 and Time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from Time 1 to Time 2 were: work role redesign, patient self-management support, and clinical information systems. Table 2 displays the extent of CCM element implementation at Time 1 and Time 2 across all sites. We observed that there was heterogeneity across sites across all CCM elements. Two CCM elements had a mixed change in the extent of implementation, meaning that there were some sites with increased implementation and others with reduced implementation in comparison to Time 1. Specifically, within the community linkages element, three sites had an increase in the extent of implementation while two sites had a decrease in the extent of implementation. Similarly, for the organizational leadership and support element, one site had an increase in the extent of implementation while two sites had a decrease in the extent of implementation. The provider decision support element had few changes in the extent of implementation during our study period. In the following sections, we highlight the elements where there was increased or mixed change in the extent of implementation. Table 3 describes CCM element changes participants attributed to the implementation facilitation and Table 4 includes sample quotes for each CCM element discussed below.
CCM elements with increased extent of implementation
Work Role Redesign. Participants felt that CCM implementation provided them with the time to focus on redesigning care processes that allowed teams to become more efficient. At Time 1, staff mentioned having no-show procedures and same-day access procedures in place. Furthermore, Time 1 interviews indicated that most teams had regular meeting times established although attendance was variable, and a significant portion of within-team communication occurred informally outside of team meetings. At Time 2, staff still discussed same-day patient access and no-show procedures; however, there was more discussion around improved team functioning, cohesion and coordination. Many respondents discussed developing team structures such as formalized intake procedures for patients, brief huddles for staff, and deliberate changes in team composition or work roles to reduce care fragmentation.
Patient Self-management Support. Time 1 interviews revealed an emphasis on evidence-based practices involving self-management components (e.g., cognitive behavioral therapy), telephone contact with patients, and use of treatment plans. At Time 2, in addition to themes presented above, staff from several sites noted that patients were now attending team meetings to discuss their care. Teams also conducted additional patient education, such as providing brochures or informational packets to patients on the team describing available services and team structure.
CCM elements with mixed change in extent of implementation
Community Resources. At Time 1,staff discussed having inconsistent knowledge about community resources such as Vet Centers (which offer outreach, counseling, and referral services to eligible veterans), Alcoholics Anonymous groups, and Veteran Service Organizations (VSOs). Additionally, referral to community providers was most frequently described as an individual process where providers would make their own referrals based on their knowledge of resources or would get expert consultation from other staff members within or outside of their team. At Time 2, familiarity with community resources still varied across team members and providers often were still handling referrals individually. However, at some sites, progress was made on creating and periodically updating guides of available community resources for the teamsto use. Additionally, team meetings provided a structure for more communication about community resources as a team. There were two sites where the extent of implementation decreased due to knowledgeable staff leaving the job or difficulty building community partnerships.
Organizational and LeadershipSupport. At Time 1 staff at many sites felt that leaders broadly supported the implementation of CCM-based care through resources (e.g. staffing and training) and through having the CCM implemented. Some sites described having leaders who were less directive and less involved with CCM implementation. Often times, team members recognized that different levels of leadership were involved in CCM implementation and that direct supervisors or middle managers created a linkage between executive leaders’ expectations and team member needs. However, at Time 2, we found more mixed viewpoints about leadership support for CCM implementation. For example, although some staff reported very supportive leaders, there were more reports of leaders not following through with resources or, in one case, actively not supporting the project.
CCM elements with little to no change in extent of implementation
Provider Decision Support. At Time 1 some staff (e.g. psychologists and social workers) at all 9 sites mentioned utilizing evidence-based psychotherapies to provide care to their patients. In addition, medication algorithms were available at all sites and used to assist in making decisions regarding prescriptions. Sites were more variable in the proceduresproviders used to seek recommendations from clinical experts and for referring patients to specialty services when needed. At Time 2, staff reported very similar levels of implementation within this CCM element. At two sites, there were some limited improvements in information sharing regarding providers’ knowledge and expertise within the team as well as participation from additional staff outside the team to better coordinate care. A few staff mentioned receiving new evidence-based psychotherapy trainings at Time 2, but not enough of a change in training to precipitate a change in the extent of implementation at Time 2.