CFIR as a taxonomy for describing QIN-QIO efforts to coordinate care
We found that the CFIR provided an appropriate taxonomy for characterizing the QIN-QIO care coordination efforts and their associated contexts. We note some modifications and additions made to the CFIR to adapt to some of the unique aspects of the QIN-QIO role and the community-based nature of the work. Of the 41 CFIR constructs and subconstructs defined in the online codebook template (25), all were scored for at least one community, and 30 (73%) were coded and rated in at least eight (40%) communities. The CFIR framework allows for adaptation in selecting the most applicable domains or constructs for a particular inquiry, or in adding and adjusting constructs as appropriate. After adding coalition constructs, three evidence strength & quality subconstructs, and seven outer setting codes, our codebook had 70 possible constructs. Of those, 47 were scored in at least eight (40%) of the 20 communities (table 4 located in the appendix).
The domains that QIN-QIOs found most relevant to their coalition’s efforts were outer setting, where all constructs (100%) were consistently scored, and process, for which nine out of ten (90%) constructs and subconstructs were scored. Characteristics of individuals was the least applicable domain, with only one construct consistently detected and rated.
The most frequently applied outer setting constructs were external policy and incentives, needs and resources of population served by the organization, and community characteristics. After inductive coding of text originally coded to community characteristics, we found the newly added sub-construct healthcare market characteristics to be applicable to all 20 communities.
Among constructs in the added coalition domain, coalition structure and coalition implementation climate were scored for all communities. QIN-QIOs described many features of coalition structure, such as composition, meeting frequency, maturity, and use of subgroups like workgroups or committees.
Finally, the constructs related to characterizing individuals in the characteristics of individuals domain and the functional roles in the process engaging subconstructs proved challenging for us. Because individuals were engaged to serve roles within a coalition as well as within their inner settings, we were often unclear on how to assign the engagement roles as suggested by the CFIR process subconstructs (e.g., champion versus key stakeholder). In interviews, we heard many compelling stories about a specific person influencing implementation efforts, but there were no consistent elements in the roles those people served within the coalition, their organizations, or the broader community, nor in the activities that they performed. Additionally, QIN-QIOs were seldom able to provide the depth of personal information about these individuals that would be necessary to reliably ascertain characteristics such as stage of change or self-efficacy. We therefore did not further assess constructs within the characteristics of individuals domain and recommend future work to better define important roles for engagement within a multi-provider coalition-facilitated program.
Constructs associated with care coordination intervention implementation
We found apparent relationships between the influence of certain constructs and performance on RIR. High RIR communities had more constructs rated as positive influences (138/182), as compared to low RIR communities (117/216) and low RIR communities had more constructs rated as negative influences (66/216) compared to high RIR communities (14/182) (table 3 located in the appendix and additional file 4). Of the 70 constructs assessed, 14 distinguished high RIR from low RIR communities.
The quality of networks and communication was more often negative in low performing communities compared to flat or high performers. One of the most valued aspects of coalitions generally was that they provided a rare opportunity for individuals in similar roles from different organizations (e.g., case managers) to interact, even in communities in which coalition participation did not seemingly facilitate implementation of interventions. Among lower performing communities, there were several examples of coalitions in which attendees remained grouped within their own organizations and interacted very little or shared little information.
The aggregated implementation climate construct and the sub-constructs of tension for change and the perceived relative priority of interventions within the coalition environment were also more likely to be negative in low performers. During interviews, we heard that many stakeholders, despite valuing coalition participation, did not necessarily have a sense of urgency to address readmissions or implement an intervention in their organizations. Reasons cited included low baseline readmissions rates, and/or other population factors being perceived as a higher priority for the community.
The coalition structure construct, despite being one of the most commonly scored constructs, did not distinguish performance. This construct incorporates a variety of characteristics, and it is likely that more detailed subconstructs should be established to tease out influential differences.
The constructs within the Intervention Characteristics domain are more likely to be negative for low performing communities compared to others, although this relationship is less evident for the individual constructs.
The compatibility construct was less negative among high RIR communities compared to flat or low RIR communities, indicating interventions well aligned with the values and workflows of providers implementing those interventions are more likely to result in lower readmissions.
Similarly, constructs of readiness for implementation were more positive among high RIR communities relative to low and flat RIR communities, indicating that the capability of implementers to influence readiness is an important component for success. The subconstruct of leadership engagement showed the strongest relationship within this construct, indicating that visible commitment and involvement of leadership was a distinguishing element of successful implementation within this project.
The engaging construct (including all subconstructs) had more positive ratings among high RIR communities compared to all others. Despite our challenges in assigning roles to those engaged, this provides evidence that an important characteristic of high performers is the capability to get the appropriate people involved in facilitating implementation. Conversely, being unable to engage the appropriate people is a significant barrier to implementation within a setting.
The outer setting domain constructs were also rated as negative influences more frequently among low RIR communities, and positive influences among high RIR communities. The construct community characteristics showed the strongest relationship. This code had been added inductively to capture notable features in a community as described in interviews and was rated in all but one of the communities. No low performing community received a positive rating for this construct. The similarly created new construct healthcare market characteristics also showed a strong relationship with RIR performance. Only one low RIR community had a positive rating for this construct, and two high RIR communities rated negatively for this construct. This may indicate that while healthcare market characteristics can be a significant barrier to implementation, it is not necessarily an insurmountable one.
Community characteristics associated with changes in 30-day hospital readmissions
We tabulated codes that co-occurred with explanation of RIR performance, a code we added to capture response to a specific interview question to elicit perceptions of what most influenced successful reduction of readmissions in each community (table 5 located in the appendix).
Healthcare market characteristics was by far the most frequently co-occurring construct (14/20), and was more often cited by low and stable RIR communities (9 of 13), than high RIR communities (3 of 7). Other outer setting constructs, including population characteristics and physical features of the community also frequently co-occurred with RIR performance, though neither of these showed clear association with performance.
The implementation climate construct within the coalition domain also frequently co-occurred (7) with performance, with more high RIR communities (4) noting this than low performers (2). Inner setting implementation climate was also noted (5), though not as often, and not as strongly associated with community RIR. Example quotes associated with the most frequent co-occurring codes with RIR performance are shown in Table 6 located in the appendix.