Table 5 CFIR Elements and implementation: qualitative examples

Relative Advantage

High

“You know, [the enrollment tool] sure beats the notes that you’d have to put in. I mean before it was, you know, note after note. Now there’s a place for a comment and there’s a place for what you did, and you just click different things. It’s really quick … I think you tend to capture more of the people you helped.” Enrollment assister Interview, Health Center A

Stakeholders’ perception of the advantage of implementing the intervention versus an alternative solution

Low

“We talk to the assister about what she would like to see in the [enrollment] tool. She wants to have multiple boxes so that each family member, their DOB, and Medicaid number can be all the same form, and she would like a tool that would be good for tracking. Her supervisor asks what she likes better, the [enrollment] tool or the Access database system they used previously. The assister immediately and emphatically says that the Access database was better.” Fieldnotes, Health Center C

Implementation Climate

Strong

“… Our EPIC clinic applications team really owned the training of the [enrollment] tool. So we sat down in a group [with assisters], and we had a guide … a step by step, here’s what you do. And then we logged into computers, all in the same room, and practiced with it as well …” Operations Manager Interview, Health Center G

The absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization

Weak

“I don’t know if we got an email or what it was. The [EHR specialist] said that starting October 1st … we would have to use it so it made it sound like it was not an option, and I will be honest, we were not happy about making it, but we made the changes and so we did start using it as of August 1st. We did have a lot of hiccups in the beginning … I didn’t read the instructions as thoroughly as I should have, but it wasn’t well received in the beginning.” Enrollment assister Interview, Health Center C

Leadership engagement

Strong

“Our goal, or hope as an FQHC is to provide care for every single Medicaid-covered person in the county... With the alternative payment model and with some of the, sort of incentives or quality metrics that [our Accountable Care Organization] has put in front of us, we definitely need to be doing more outreach. And I think that’s where the [enrollment tool] helps a lot … Yeah, it’s very helpful to be able to track that and-, and keep ahead of that because, um, the Medicaid system is our best payer.” Chief Financial Officer, Interview, Health Center F

Commitment, involvement, and accountability of leaders and managers with the implementation.

Weak

“I [sighs] am very upfront and open about the fact that the outreach worker position is an area that I don’t know much about. It was put under me kind of as an afterthought. … Someday I would like to know more about all of that stuff, and what the tools look like and what the process is and where we can go from there. But right now, it’s just like – it’s the next thing on my agenda. Behavioral Health Director [and head of department that includes enrollment assisters] Interview, Health Center A