Table 5 Facilitators ( +) and barriers (-) to the first steps of the CMI implementation – Characteristics of the CMI

Clinical and managerial support for CMI

( +) Nursing and medical leadership

( +) Nursing, medical, and managerial leadership

( +) Group discussion with clinical team and clinic manager about scheduling and individual involvement

( +) Group discussion with clinical team and clinic manager about scheduling and individual involvement

( +) Managerial leadership

( +) Clinic manager introduced CMI to clinical team

( +) Managerial leadership

(-) Difficulty in coordinating multiple supports that are physically located in several places

Capacity development (including team)

( +) Pre-existing community of practice

(-) Lack of information to clinical team members about CMI

( +) Team meetings to discuss CMI planning and organization

( +) Team meetings to discuss CMI planning and organization

( +) Pre-existing team meetings to discuss complex patients

(-) More training and support needed for NCM role

(-) More training and support needed for CMI and NCM role

(-) NCM does not work within the clinic

( +) Pre-existing team meetings to discuss complex patients

(-) NCM does not work within the clinic

Experience of NCMs

( ±) Experienced and skilled NCM, but needed support to start the CMI

( +) CMI activities already performed

( +) Case management activities already performed

(-) NCM lack of knowledge of certain chronic diseases

( +) Experienced NCM

(-) NCM needed support to feel comfortable in CMI

( +) Experienced and skilled NCM

( +) Experienced and skilled NCM

Time required

(-) Time consuming, work overload

(-) Time consuming, work overload

(-) Concern about being overburdened with complex cases

(-) Time and resources consuming

( ±) Information gathering is considerable upfront, but useful investment of time

(-) Time consuming, work overload

( ±) Information gathering is considerable upfront, but useful investment of time

(-) Time consuming, work overload

(-) Referring the patient to other services may introduce delays and missed appointments and is time consuming

Identifying patients

( +) NCM planned to identify patients with the help of family physicians

(-) Recruitment criteria not aligned with what providers had anticipated

( +) Involvement of other providers to create list of frequent users

(-) Difficulty finding the appropriate patients

(-) Recruitment criteria not aligned with what providers had anticipated

(-) Difficulty finding the appropriate patients

(-) Recruitment criteria not aligned with what providers had anticipated

(-) Difficulty recruiting patients (time consuming)

( +) NCM and family physicians identified patients

(-) More guidance required for patient recruitment

( +) Family physicians identified targeted patients

(-) Steps to identify high needs patients necessary but challenging in a clinical setting

Recruiting/enrolling patients

( +) Family physicians introduced NCM to patients to foster trust

(-) NCM concerns about first contact with patients and recruitment

( +) NCM confidence about first contact with patients

(-) NCM concerns about first contact with patients and recruitment and consent process

(-) NCM concerns about first contact with patients and recruitment and consent process

(-) NCM concerns about first contact with patients and recruitment

( +) Family physicians introduced NCM to patients to foster trust

ISP

(-) NCM concerns about ISP planning and organization

(-) NCM concerns about ISP planning and organization

(-) Concern about difficulty in assembling all of the providers together for ISP

( +) Team brainstorming about best way to do ISP, potential debriefing after the first one

(-) Concern about difficulty in getting all of the providers together

(-) Risk of providers not having interest or time to engage

Patient engagement

(-) Providers’ concerns about motivating/ mobilizing patients with complex needs

(-) Concern about the targeted “complex” clientele

(-) Providers’ concerns about motivating/ mobilizing patients with complex needs

(-) Need for more training of NCM in self-management support

(-) Provider concern about time commitment for patients with complex needs

( ±) Concern about the self-management support for patients, but the ISP could help

( +) Access to translation services

(-) Providers’ concerns about motivating/ mobilizing patients with complex needs

( +) Fostering patient commitment to intervention

Provider perception of CMI

( +) Positive perception from family physicians and NCM

( +) Similar to what clinic was doing, but CMI is more organized

( +) Individual approach with patients is more appropriate than group approach

(-) Concern about potential confusion due to duplication with other programs

( +) Positive perception in general from other primary care settings

(-) Physician skepticism

(-) Concern about potential confusion due to duplication with other programs

( +) NCM sees CMI as natural fit

( +) Similar to what clinic was doing, but CMI is more organized, streamlines what is needed

(-) Concern about how patients will experience this new way of doing things

( +) Comprehensive approach to care

( +) More resources for patients

(-) Concern about implementing the intervention

(-) Provider skepticism

( +) Research team support

( +) Adaptability of CMI

( ±) NCM had positive perception, but felt pressure due to work overload

(-) Physician skepticism

(-) Difficult for family physicians to hand over CMI-related tasks

(-) Physician skepticism and concern about missing out on their patients’ care

( ±) Concern about patients’ adherence to CMI