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.
Coalition Domain:
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.
Intervention characteristics:
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.
Inner setting:
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.
Process:
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.
Outer 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.
Table 5
CFIR Constructs Most Often Associated with Respondents’ Explanation of RIR Performance
Performance Category | |
| Reduction in Readmission Rates | Minimal Change in Readmission Rates | Increase in Readmission Rates | Total Number of Communities Reporting this Factor |
Explanation of RIR Performance- Outer Setting: Healthcare Market Characteristics | 2 | 2 | 6 | 10 |
Explanation of RIR performance-Coalition Implementation Climate (all) | 4 | 2 | 1 | 7 |
Explanation of RIR performance-Outer Setting: Population Characteristics | 1 | 4 | 1 | 6 |
Explanation of RIR performance-Outer Setting: Physical Features of the Community | 2 | 2 | 2 | 6 |
Explanation of RIR performance-Inner Setting: Implementation Climate (all) | 2 | 0 | 3 | 5 |
Table 6
Quotations for Explanation of RIR Performance
Co-occurring construct | Community category (Performance on RIR) | Relevant quote(s) |
Outer Setting: Healthcare Market Characteristics | Reduction in readmission rates | “The other places the turnovers are just phenomenal. We see that in every setting, especially in a leadership position.… I think that's a key right there. Is that this hospital, and I will say that other major hospital in that coalition, also is active in a similar intervention…. You have two rather large hospital systems do something very similar in terms of follow-up after discharge and I think that had a lot to do. We have a lot of consistency in there in terms of the staff performing it. Because that's when things tend to fall apart. When somebody leaves and the new person's not aware of what's going on or comes in and changes things. I think that has a lot to do with it.” |
Outer Setting: Healthcare Market Characteristics | Increase in readmission rates | “Well, I think the only thing that really happened during the first part of our scope of work, the economic down turn that we had in [this state], was, you know, statewide. And so we had a number of open positions, a number of staffing issues overall… I think that started in the spring of 2015 and it went on for about a year and a half. The two years where economically, everything was pretty tough in [this state]. We are bouncing back and everything is fine, but again I don't wanna look at that as an excuse. That's kind of the boom and bust cycle of [this state] and we kinda look at it that way, but during the time period everybody was looking at other priorities other than readmissions. Let’s put it that way, so.” |
Outer Setting: Healthcare Market Characteristics | Minimal change in readmission rates | “I think one of the issues what that a high number of our readmitting beneficiaries in this community are in the under 65 community; that is almost 50%. And it is very difficult to get those patients on the radar at the hospital because they don't have a penalty. I think the expectation in the meantime, there have been several a couple other hospitals have been bought and sold in this community. But I do think that this led to some aha moments in terms of communication.” |
Coalition: Implementation Climate (all) | Reduction in readmission rates | “At the bare minimum, they were residing in hospitals where every day they had readmission discussions going on. So it became a real hospital system level priority. I've mentioned it already, the hospital C Suites being very plugged into the C Suite visits and sharing data and talking to them about what is working and what is not working. And engaging the post-acute providers. We had such a robust post-acute provider coalitions going, where a hospital would meet with seven or eight of their preferred provider nursing homes and home health agencies, we were always a part of those meetings. We were often the facilitators for those meetings, because they would get sometimes a little bit ugly, where the hospitals would just almost thrash about the nursing homes, which never seems to be a great motivation for getting people to work with you on things. And so we would often serve as the mediator, or as the facilitator of that meeting to talk through different issues. That was really important while they learned how to talk to each other.” |
Coalition: Implementation Climate (all) | Increase in readmission rates | “It was kind of what we see in a lot of communities that was one more thing that somebody was asking them to do. And so, that may have added to the lack of enthusiasm. I mean it wasn't that they didn't believe that it was something that was needed. But there just were competing priorities, I believe.” |
Coalition: Implementation Climate (all) | Minimal change in readmission rates | “I think just the collaborative effort of the community in general compared to some of the other coalitions we've seen, this one is consistently well-attended. It’s the right people in the room that are really working with patients and doing the readmissions work. So I think that’s probably contributed to the success is that it’s the same consistent people that have been coming together, monthly, looking at data, so it’s data-driven and it’s been a long time. It's an older coalition, so they've been meeting consistently and I think just kind of know how to work well together….I mean, I definitely think it's had an impact on the readmission rates just because they're able to talk freely and as I said, they're comfortable sharing their data because I think, they trust each other and they trust that the goals are all aligned with what their trying to do. I just think the relationships have a big impact on the overall success of the readmission work within the coalition. And again, just having the right people in the room. We've seen other coalitions where it tends to start being geared towards more marketing folks attending. But these are really case managers, people that are directly working with the beneficiaries.” |
Outer Setting: Population Characteristics | Reduction in readmission rates | “And also go back and start looking at system-level changes that needed to occur, if that makes sense. When you start looking at social determinants of health, probably one of the biggest things we learned around this project was the need around affordable housing, food, and transportation, things that came out in the root cause analysis that we do–the coalition. But it was particularly highlighted around this set of patients. The reason, in part, that they were re-admitting was because of these social determinants of health. Then we could go back and have system-level change or system-level discussions within the coalition and whether or not they wanted to take anything on.” |
Outer Setting: Population Characteristics | Increase in readmission rates | “What we know about patients in this community - there are [certain patients] that go to the ER and end up being admitted. There's data out there that you can look at… If these patients are showing up to the ER [and] they have multiple issues, and they're coming to the ER late, they're being admitted.” |
Outer Setting: Population characteristics | Minimal change in readmission rates | “I think one of the struggles has been, and I don’t think this is just a struggle for [this community], to get the basics done well. A great example would be a person comes in and you identify who they are by their name and their birthday. That would be an easy two-factor identification of someone, but I don't see that we have consistency around some of those basic things that result in care getting delivered where it needs to be, when it needs to be, how it needs to be for that individual. I think that lack of coming at the problem at the community is problematic. We have a whole lot of special-ness, where everybody thinks that their patient population is special, and that they're special, and their providers are special. And the reality is there's a whole lot of–common problems are common–I guess is the best way to say it.” |