title: Comparing the implementation of team approaches for improving diabetes care in community health centers.
abstract: BACKGROUND
  Patient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients.
  
  
  METHODS
  Mixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources.
  
  
  RESULTS
  Implementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth.
  
  
  CONCLUSIONS
  Implementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities.
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. philip.vanderwees@radboudumc.nl.|Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands. philip.vanderwees@radboudumc.nl.|The RAND Corporation, Boston, MA, USA. philip.vanderwees@radboudumc.nl.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Van der Wees
authors.affiliation: The RAND Corporation, Boston, MA, USA. mfriedbe@rand.org.|Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. mfriedbe@rand.org.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Friedberg
authors.affiliation: Community Health Partnership of Santa Clara County, San Jose, CA, USA. elena@chpscc.org.
authors.forename: Elena Alcala
authors.initials: EA
authors.lastname: Guzman
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. ayanian@med.umich.edu.|Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. ayanian@med.umich.edu.|Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. ayanian@med.umich.edu.
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
authors.affiliation: Division of Health Policy and Management, University of California, Berkeley 50 University Hall, Room 245, Berkeley, CA, 94720, USA. hrod@berkeley.edu.
authors.forename: Hector P
authors.initials: HP
authors.lastname: Rodriguez
mesh_terms: D003151:Community Health Centers; D003150:Community Health Workers; D003920:Diabetes Mellitus / Q000628:therapy*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D007857:Leadership; D015141:Los Angeles; D008297:Male; D009936:Organizational Innovation; D010348:Patient Care Team; D036301:Qualitative Research; D058996:Quality Improvement; D012648:Self Care