Table 2 Implementation challenges and modifications/adaptations discussed or observed

Patient-level challenges

Recruitment – Patient Identification

Be flexible on who participates

Clinicians talk to patients directly rather than relying on other staff to recruit patients

Use personal connections or interactions to recruit patients to SMAs

“The very first cohort, we had only the very high A1Cs. The second cohort, our staff wanted to involve patients with lower A1Cs so that they could sort of lend a perspective to those with high A1Cs, but this did not result in any more patients being engaged in showing up. For the third cohort, we just opened it up so that we just had a larger pool to choose from.” (provider, Private Practice # 11)

“We do have patients who are pre-diabetic that do come to the groups. I’ve gotten those referrals from the clinic providers, specifically, actually. One of our clinics, they just have a large pre-diabetic population there, and they send quite a few referrals over” (coordinator, Federally Qualified Health Center # 04)

“I think the first cohort…I went down the list of people and said, “These ones might be potential candidates, just ‘cause I know them or they’re people who are reliable, generally.” Then the second go-around was more, “Oh, yeah, this person would be good. I talked to them today. They expressed interest.” (provider, Federally Qualified Health Center # 03)

"If I have a patient that I see that I think might be a good fit, I’ll recruit them to the class.” (coordinator, Private practice #07)

Recruitment – contacting and enticing patients

Make it sound like something patients don’t want to refuse

Appeal to what is happening outside the clinic

Emphasize that the patient’s primary care provider thinks they could benefit

Recognize that recruitment is challenging

“On the left hand side it says, "What is a diabetes shared medical appointment?" and the other side lookin’ just like a birthday invitation…They get this invitation and they call me, their buttons are already pushed. They wanna come.”(health educator, Federally Qualified Health Center # 05)

“It’s our biggest class, and it was very effective when I said, “You know, the holidays are coming, and one of the things we’re gonna cover is how to deal with stress and the pressure of the holiday season and all the meals and everything.” (coordinator, Private practice #04)

“I do the cold calls. I’ll just go down the list, and I’ll start calling them…it’s really effective if I say, “Well, Dr. so-and-so thought you might be a good candidate for this class and wanted me to give you a call.” (coordinator, Private practice #04)

“We’ve tried a couple of different things. At first, we were doing a lot of cold calls on top of just providers referring. The cold calls have been very hard pulling the data from the EHR. Very, very few get back to us. After 60 phone calls you get maybe 5…Or those patients no-show when they sign up for the group cause you got them on the phone and they felt bad.” (health educator, Federally Qualified Health Center #06)

Retention

Recognize that there will be no-shows and drop-outs and plan for that

“Every time, we have multiple patients who say they’re interested, but then they drop out for a variety of reasons. I think this time, they called 20, 25 people…but still, this cohort’s only consisting of one to two consistent people.” (provider, Private practice #11)

Practice-level challenges

Physical Space

Modify or find other space to accommodate the program if it isn’t working

“It used to be downstairs, but we had two really tiny rooms. If we have more than seven it’s super crowded. We moved upstairs to a really big room, but then that leaves where does the provider see the patient?” (health educator, Federally Qualified Health Center #06)

Yeah, so now, we use the hospital conference room space, which actually has been really nice. They have classroom-style spaces and so I think that’s actually been better than a conference room space (coordinator, Federally Qualified Health Center #04)

Provider involvement and efficacy

Titrate the provider visit portion according to the participation and timing

“I think, a hard sell to get more for—to lose, I think, the regular patient care for more than two sessions. I think that was—I think that was the the biggest thing. I think there’s a lot of concerns on the side of how many patients we can see, that need to be seen on this side of town, that have a need for regular primary care.” (provider, Federally Qualified Health Center #04)

“Honestly, my nurse practitioner and I have felt like they’re not super helpful. That’s part of how we need to do this program, in order to get paid. Unfortunately, that’s the only way for insurance cover the group visits at this point, is to do that face-to-face 10-min visit with the patient.”(provider, Private practice #06)

“If an MD is taking 2-plus hours out their schedule, then they need to see 10 or 12 patients to make that worth their time. If there aren’t 10 or 12 patients to see, then it’s just not worth their time from a productivity model” (coordinator, Private practice #07–10)

Staff turnover

Develop a strategy for addressing employee turnover and retraining

“We have had some turnover in the MAs [who] were helping us with group, the medical assistants. We’ve had to bring on whoever is the new MA who was working with us up to speed on what happened in the diabetes group.” (provider, Federally Qualified Health Center #05)

Scheduling

Base SMA timing on patient characteristics (e.g. working vs. retired)

Consider the reality of space and staffing considerations and how they align

Be prepared to make decisions throughout the process

“Honestly, I think the hardest part was the scheduling piece, because it just seemed like in terms of the patients that we got for different times—’cause we did a few lunchtime groups, and then we did a 4:00 to 6:00 p.m. group.” (BHP, Private practice #06)

“We have a lot of providers who just aren’t available at the same time during the week or have other commitments when the room was available. Our practice has outgrown our space as it is, and so finding a space to have these groups that is patient-friendly and comfortable has limited when we can have the visits.” (provider, Private practice #11)

“Because there was just too much would happen in a month—the provider part got too comprehensive. We thought if we change it to weekly, there’s less that can happen in a week.” (health educator/coordinator, Federally Qualified Health Center #03)