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HealthLinc, a Federally Qualified Health Center headquartered in Valparaiso, IN with locations across Northern Indiana, has installed Forward Health Group’s PopulationManager® and The Guideline Advantage™. The implementation of The Guideline Advantage was made possible by a grant from The GE Foundation and in collaboration with the Indiana State Department of Health, and leverages population health management tools from Wisconsin-based Forward Health Group, Inc. In 2014, all HealthLinc clinics were recognized as Level 3 Patient-Centered Medical Home by the National Committee on Quality Assurance.
Health Data and the Rearview Mirror: Advanced Population Health Management Up and Running at C. China has the largest number of type 2 diabetes mellitus (T2DM) cases globally and individuals with T2DM have an increased risk of developing mental health disorders and functional problems. Barriers and enablers perceived by doctors as being relevant to the delivery of psychological care for patients with T2DM were primarily categorised within eight TDF domains.
The utilisation of the TDF allowed for the comprehensive understanding of barriers and enablers to the implementation of psychological care recommendations for patients with T2DM, and consequently, has given direction to future interventions strategies aimed at improving the implementation of such recommendations. BackgroundDiabetes Mellitus (DM) has emerged as a major global health concern and the number of DM cases is rising in every country [1]. AnalysisData were analysed independently by two of the authors (AC & HY) using deductive thematic analysis [32]. ResultsFourteen women and nine men participated in the study, with all participants employees of urban, government-administered CHCs. The medical training received by CHC doctors was commonly cited as a key reason to the lack of knowledge and skills in psychological care.
Whilst perceiving overall that psychological care was relevant to their role when managing patients with T2DM, some CHC doctors did not consider the patienta€™s level of social support (a component in psychological care recommendations) to be of relevance to their professional role. Beliefs about consequencesSeveral CHC doctors stated that they were not convinced of the benefits and evidence-base of psychological care for the management of patients with T2DM, and did not believe the delivery of psychological care would offer any additional advantages to their current management approaches. Participants also anticipated a negative reaction from their patients if they were to spend time delivering the psychological care recommendations, instead of providing medications to control or manage T2DM-related outcomes. ReinforcementThis domain includes constructs such as rewards, incentives and punishments that increase the likelihood of a behaviour being performed through the establishment of a dependant relationship with a given stimulus.The lack of monetary incentives available to CHC doctors for the delivery of psychological care to patients with T2DM was another commonly identified barrier. Memory, attention & decision makingSeveral CHC doctors reported the intentional disregard of the computerised management system that prompts for a psychological assessment to be performed for patients with newly diagnosed T2DM. Environmental context & resourcesSecondary only to the domains of knowledge and skills, time constraints were heavily referred to by CHC doctors as being a major barrier to the delivery of psychological care for patients with T2DM.
CHC doctors did indicate however, that session times in the afternoon or evening would be more suited to the delivery of psychological care recommendations to patients with T2DM. In addition to time, cost was also referred to as a potential barrier for the delivery of psychological care recommendations to patients with T2DM, particularly for patients with a low socio-economic status, and low education level. Social influencesThe societal perception of psychological health as being less important than physical health was a further identified barrier to the delivery of psychological care. The lack of guidance from opinion leaders regarding the importance of psychological care for the management of T2DM was also frequently raised by CHC doctors as a source of concern. DiscussionThe experiences of CHC doctors indicate that numerous barriers and enablers influence the implementation of psychological care recommendations to patients with T2DM in China. ConclusionUsing a validated framework, the key barriers and enablers to the implementation of psychological care recommendations for patients with T2DM were identified.
Availability of data and materialsThe data supporting the conclusions of this article are available upon request from the corresponding author. The Guideline Advantage is a quality improvement program of the American Cancer Society, American Diabetes Association and American Heart Association. In addition to primary and preventive medical and behavioral health services, HealthLinc provides health and wellness education, dental services, optometry, OB services, chronic disease management, women’s and men’s health services, wellness checks and immunizations. Despite guidelines recommending that psychological care be delivered in conjunction with standard T2DM care; psychological care is not routinely delivered in China. The discussion guide applied the Theoretical Domains Framework (TDF) that examines current practice and identifies key barriers and enablers perceived to influence practice. Over the last decade, China has become the leader in the global DM epidemic [1, 2], and DM prevention and management have become critical public health issues in China [3].
Specifically, focus group discussions were chosen as the preferred method of data collection due to their interactive nature and their well-established ability to explore peoplea€™s knowledge and experiences in relation to a specific behaviour [29]. The 14 theoretical domains of the TDF previously described were used as the coding framework (TableA 1). The majority of participants held a professional title of attending physician (n = 16), with the remainder classified as either associate physician (n = 3) or chief physician (n = 4). Conversely, the incorporation of a psychological care component into existing medical training and continuing medical education programs were perceived as potential enablers to increase the knowledge and skill base of CHC doctors.
However, it was further acknowledged that within the current system, specialist services were largely responsible for the delivery of psychological care in general, with the role of the CHC doctors frequently limited to the detection of severe psychological problems and the monitoring of patients with regard to medication following discharge from a psychiatric hospital.
Additionally, they did not associate social support structures as being influential to a patientsa€™ self-management ability.
Participants compared the funding models of the Australian and Chinese primary health care systems and felt that Australian initiatives, such as the Practice Incentives Program (Diabetes Incentive), encouraged the delivery of comprehensive T2DM management.
A high volume of patients (particularly in the morning) commonly resulted in short consultations times, placing limitations on the CHC doctora€™s ability to address anything other than the primary reason for CHC attendance.
A number of CHC doctors also stated that they would be more likely to address psychological care if longer consultation times were specifically scheduled. It was perceived that patients would not be willing to spend more money on a consultation that they didna€™t view as essential to their T2DM management.
It was also stated that for an increase of psychological care recommendations to occur in the CHC setting, the perception of psychological health in the community would need to shift.
The only things they [patients] want to see are physical changes, like a blood test after treatment.
Opinion leaders such as medical educators, specialists in tertiary hospitals, and the Chinese Diabetes Society were all perceived to have an influential role impacting on the behaviour of CHC doctors. This information is a necessary first step in the development of a complex intervention to increase the implementation of recommendations.
The Guideline Advantage works to help improve patient health through prevention, early detection and management of cancer, diabetes, and heart disease.
HealthLinc clinics are located in Valparaiso, Valparaiso Porter-Starke Services, Michigan City, Knox, Mishawaka, and East Chicago, and accept Medicare, Medicaid, Healthy Indiana Plan (HIP), some commercial insurance plans, and uninsured patients on a sliding-fee scale based on their income. FHG’s PopulationManager® platform provides best-in-class data collection, validation, and visualization. Community Health Centre (CHC) doctors play a key role in the management of patients with T2DM in China.


Focus groups were conducted with an interpreter, and were digitally recorded and transcribed. Initially, both authors independently classified participant statements into the 14 domains, and all statements could be applied to at least one domain. These classifications primarily relate to the experience and skill level of the doctor, which in turn reflects their consultation fee. Specifically, a need was expressed for practical, skill based training in psychological care that was relevant to their clinical practice. The majority of CHC doctors favoured a restructuring of the current CHC funding model, and believed that for psychological care to be delivered to patients with T2DM in China, a specific incentive would need to be introduced. Additional human resources were also favoured, such as the role of a diabetes educator, to assist CHC doctors in delivering psychological care to patients with T2DM. Indeed, the newly formed International Institute for Primary Health Care Research in Shenzhen, China is leading a methodologically rigorous program of research that intends to increase the implementation and uptake of psychological recommendations for individuals with T2DM. AC drafted the manuscript and HY, KS, ST & CB contributed to the writing and review of the manuscript. The data delivered by FHG enables health care stakeholders to track quality and financial measures, assess and manage risk and take action to positively impact clinical outcomes and lower costs. Understanding the behavioural determinants of CHC doctors in the implementation of psychological care recommendations allows for the design of targeted and culturally appropriate interventions.
Two researchers independently coded transcripts into pre-defined themes using deductive thematic analysis.
Additionally, the World Health Organization have estimated that between 2005a€“2015, China will forego USD$558 billion due to the premature mortality associated with DM and its related conditions - heart disease and stroke [4].Type 2 Diabetes Mellitus (T2DM) forms the majority of DM cases (~90a€“95 %), and is a complex, chronic condition that requires effective long term medical management to prevent or delay chronic complications [5]. Shenzhen is a major city within Guangdong Province, situated in the southeast of China, adjacent to Hong Kong.
On completion of coding, both authors compared coding selections and when discrepancies occurred, consensus was reached through discussion with a third author (KS). In China, doctors have a four-level professional title system that is nationally consistent. In the short term, future research is planned to determine which of the identified barriers and enablers should be prioritised for intervention. As such, this study aimed to examine barriers and enablers to the delivery of psychological care to patients with T2DM from the perspective of CHC doctors in China. A multifaceted range of behavioural, lifestyle and psychological changes are integral to the effective management of T2DM, and patients and health care professionals need to collaborate to ensure clinical and self-care recommendations are adhered to [6].
All CHC doctors were participants in a residential medical training program being conducted in Melbourne, Australia through a joint initiative of the Shenzhen City of Guangdong Province, the Chinese Journal of General Practice and the School of Primary Health Care, Monash University, Australia. Increasing in seniority, these titles consist of resident physician, attending physician, associate physician, and chief physician [33]. The utilisation of the TDF allowed for the comprehensive understanding of barriers and enablers to the implementation of recommendations, and as such, has given direction to future intervention strategies.The TDF domains of knowledge and skills were the most salient factors influencing the non-implementation of psychological care recommendations for the management of patients with T2DM in China. Consideration is also being given to the views of patients with T2DM to the delivery and uptake of psychological care recommendations.
Traditionally, T2DM management approaches have placed considerable emphasis on blood glucose, cholesterol and blood pressure maintenance within normal range. Established in 2009, this program aims to enhance the primary health care capacity of leading CHC doctors and intends to build a pool of family medicine a€?championsa€™ practicing within Shenzhen, China.ProcedureAll invited CHC doctors (n = 23) agreed to participate in the present study.
With regard to highest medical degree obtained, most participants had completed a Bachelor of Medicine (n = 17), a further five participants had completed a Masters of Medicine, and one participant a Diploma of Medicine.Barriers and enablers perceived by CHC doctors as being relevant to the delivery of psychological care for patients with T2DM were primarily categorised within eight of the TDF domains.
A large body of evidence indicates that firstly, health professionals need to be adequately educated and trained in order to accept and incorporate evidence-based guidelines into their daily practice [34, 35]. Given Chinaa€™s increasing T2DM burden and the potential for psychological care to reduce the morbidity of patients with T2DM, it is crucial that effective strategies are put in place to deliver the psychological care recommendations. However, it is now well established that patients with T2DM are at increased risk of developing mental health disorders, and functional problems associated with living with their condition [7]. Two focus groups were conducted in May (n = 10) and August (n = 13) 2015 at Monash University, Melbourne.
Doctors in China do not receive any formal training in psychological care as part of their medical education [36].
Indeed, the utilisation of psychological interventions in the management of T2DM has been shown to have direct and measurable benefits for patients, in particular for glycated haemoglobin and psychological status [8a€“11].International evidence-based guidelines outline psychological care recommendations for the medical management of patients with T2DM [12a€“15]. As a result, the knowledge and skill base of CHC doctors is generally limited in the counselling and behaviour change techniques that can assist patients in adhering to the complex regimen of T2DM self-care activities [17]. Focus groups were conducted with a facilitator, and an interpreter fluent in English and Mandarin, and each session ran for approximately 90 min duration.
The TDF domains that did not emerge from analysis of focus group data included beliefs about capabilities, optimism, goals, intentions, emotion, and behavioural regulation.Key barriers and enablers, together with illustrative quotes from participants, are presented within the relevant domains below. Additionally, the knowledge and skills deficiencies of CHC doctors had a flow-on effect to the domains of beliefs about consequences and memory, attention & decision making. Additionally, the Chinese Guideline for Diabetes Prevention and Management also recommends psychological care be delivered to support patients in adjusting to their diagnosis and assisting adherence to lifestyle modifications [16]. Text has been placed in brackets when further clarification was deemed necessary for the readability of quotes.
Specifically, CHC doctors frequently questioned the efficacy of psychological care for the management of T2DM and often opted to intentionally disregard psychological care, even when prompted by their computerised management program. Despite such recommendations, T2DM management approaches in China are not patient-centred, nor do they recognise the individual as having a central role in the self-management of their condition [17]. The interpreter was also an educator in the residential training program and was therefore known to all CHC doctors prior to participation in the study. Given theA potential for the sample to be identified, the characteristics of participants (e.g. It is likely that the barriers identified in a multitude of TDF domains would be resolved by improving the knowledge and skill base of CHC doctors. Typically, doctors have primarily focused on the provision of medications to manage T2DM, and have largely overlooked the facilitation of behaviour change to moderate or control key T2DM-related outcomes [18, 19]. The focus group schedule used to prompt discussion was based on the TDF (version 2) [30] and is outlined in TableA 2. As such, interventions should focus on the incorporation of psychological care training into existing medical education and continuing medical education programs. The observed discrepancy between T2DM clinical recommendations and actual clinical practice in China is likely to be the result of a multitude of organisational and individual factors that influence clinician behaviour. Data from focus groups were audio-taped, transcribed verbatim and were entered into NVivo 10 [31] for data management and analysis.


In particular, there is a strong need for practical, skill-based training that is clinically relevant.The results of the present study also highlight the need to develop strategies to assist time-poor CHC doctors in delivering the psychological care recommendations to patients with T2DM. Consistent with our findings, the majority of implementation research conducted within primary care settings has similarly observed time pressure to be a significant determinant influencing clinician behaviour [25, 28, 37, 38].
The current research has identified a possible opportunity during afternoon and evening clinic sessions for longer consultation times that could potentially be dedicated to the delivery of psychological care to patients with T2DM. None of the participants were aware of the existence of the psychological care recommendations outlined in the global guideline for T2DM, and when informed of the specific recommendations, all participants felt they did not possess the necessary knowledge and skills to be able to effectively deliver the recommendations.
To seize this opportunity, interventions should focus on promoting the efficacy of psychological care to patients with T2DM and should advertise the availability of afternoon and evening sessions. Additionally, the application of just one or a few theories creates the potential for critical theories to be missed.
Additionally, the majority of CHC doctors demonstrated a lack of understanding of the term a€?patient-centred carea€™. One approach that seeks to make the plethora of theories more accessible and relevant to health service researchers is the Theoretical Domains Framework (TDF).
In Hong Kong, the establishment of diabetes nurses within primary care settings has successfully been trialled without compromising the care of T2DM patients [39]. The TDF [23] was developed through an expert consultation process and drew upon 128 theoretical constructs from 33 psychological and organisational theories to produce a single integrative framework that can be used when assessing behavioural difficulties associated with guideline implementation, and when designing interventions. Furthermore, the use of trained nurses as educators has also been found to improve self-efficacy and reduce clinical inertia and non-adherence [40].Findings in relation to the TDF domain of reinforcement indicate that the introduction of financial incentives may enhance the implementation of some aspects of the psychological care recommendations.
The original TDF has been validated and recently updated to include 14 theoretical domains (comprising 84 component constructs) and is suitable for use in a variety of settings [24] (TableA 1). A synthesis of systematic reviews has previously found financial incentives to increase the implementation of clinical guidelines by up to 39 % [41].
This set of domains has previously been applied by a number of studies in a variety of health care settings including primary care [25], acute care [26], and chiropractic care [27]. While some elements of the recommendations such as the adoption of a patient-centred care approach cannot be adequately assessed for incentive purposes; the periodic assessment of psychological health has the potential to become incentivised.
Recently, the framework was utilised in Mongolia to explore factors influencing the delivery of hypertension and DM guidelines in primary care settings [28]. Recent primary health care reforms in China have resulted in the restructuring to the funding of CHCs. Despite the wide utilisation of the TDF framework, no studies to date have been conducted in China and none have investigated the factors related to the implementation of psychological care recommendations in general.
The government now fund the basic salaries of all CHC doctors and additionally provides a per-person subsidy of 15RMB for the delivery of a standard service package that includes preventive care, chronic disease management, primary medical care, rehabilitation, health education, and family planning [42].
It is likely that an extension of the current service package to include the assessment of psychological wellbeing may provide CHC doctors with the adequate motivation to deliver this aspect of the guidelines.To further enhance the implementation of psychological care recommendations to patients with T2DM, barriers identified within the TDF domain of social influences will need to be addressed. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Additionally, these opinion leaders also have the opportunity to shift the societal perception of psychological health as being inferior to physical health. The Chinese society respects hierarchy and prestige [43] and as such, recommendations and endorsements by these peak bodies are likely to be viewed upon favourably by the public. An updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicians on glycaemic control and on psychological status. A potential intervention may therefore be a public health campaign highlighting the need and efficacy of psychological interventions for the management of T2DM that additionally promotes CHCs as the preferred setting to seek this aspect of care.LimitationsThis qualitative study used a validated framework and adopted a systematic approach in the design and analysis of focus group data.
The generalisability of this data is limited because of the fixed number of CHC doctors available for recruitment which contributed to a relatively small sample. Additionally, the sample consisted of leading CHC doctors who were specifically chosen by their CHC to receive specialist training in primary care and may not be representative of all CHCs doctors practicing in Shenzhen, China.
Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: A systematic review and meta-analysis. The health care system in China differs greatly in both structure and quality between rural and urban settings [44], and it is highly probable that rural doctors in China would generate a different set of barriers and enablers. Psychological interventions for the management of glycemic and psychological outcomes of type 2 diabetes mellitus in China: A systematic review and meta-analyses of randomized controlled trials. The Chinese culture is highly collectivistic by nature, whereby individuals subordinate their personal beliefs to the beliefs of a group [43].
Focus groups conducted in collectivistic cultures have previously shown a high level of conformity [46], and this was also the case in the present study, whereby personal characteristics (e.g. As a result, some behavioural determinants may not have been raised by individual doctors for concerns regarding social acceptability. Group dynamics may also have been influenced by the pre-existing relationship between participants and the interpreter (as an educator in the residential training program) which could be considered as having a power differential.
Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization. Further research, using a combination of quantitative and alternative qualitative methods (i.e. Making psychological theory useful for implementing evidence based practice: a consensus approach. Validation of the theoretical domains framework for use in behaviour change and implementation research. Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study.
Understanding practice: the factors that influence management of mild traumatic brain injury in the emergency department-a qualitative study using the Theoretical Domains Framework.
Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework.
Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providersa€™ perspectives and experiences. The Development of Online Doctor Reviews in China: An Analysis of the Largest Online Doctor Review Website in China.



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