Table 3 Focus Group Themes: Barriers and Facilitators to Telemedicine Program Implementation

Outer Context Factor

Service Demand

State and regional demand, support and advocacy for maternal mental health and substance abuse healthcare needs.

We have such a range of socioeconomics with our group that patients don’t have that access to go to [the academic medical center], so that’s huge – transportation issues are difficult for some of our patients, and so I think this is a great service to be able to offer them. (Clinic 3)

Trying to find counseling or psychiatry for them [mothers] was near to impossible before this… And also the convenience of it being available…there was one situation where I had a mom who was really quite significantly affected, and I think that her [telehealth] appointment was like two days later, or something just ridiculously wonderful. You know? And that was something that never, there’s no way we could have gotten her to see a psychiatrist in two days without this program. (Clinic 1)

It’s an area in our state that has some of the highest rates of opioid use and opioid overdose deaths. And so…any access to additional care for that population meant a lot to them. (Telehealth Team)

Inner Context Factors

Structure

Structural factors in the clinic (e.g., space, staffing, workflows) that provide an infrastructure to complete program implementation steps.

Because we were already doing genetic telemedicine we’ve already got it set up. We do have an extra room, space, so we haven’t had any significant issues… As long as we’ve got someone that keeps the room going and makes sure we don’t double book somebody we’re good. (Clinic 3)

So we were already doing the screening, so that was fairly easy in that we have it electronic where it uploads automatically into the EMR. So that was in place. And then in terms of the referrals, that just goes to our referral coordinator, and is fairly straightforward. (Clinic 1)

I think maybe one of the reasons why it’s gone so well is that they’ve had the time to – to prioritize it whereas I think if you have bigger, busier practices, it still might be a priority, but so are many other things and if you just don’t have the time to figure out how to do scheduling to figure out how to reschedule someone if they didn’t make it there on their day…that timing probably is a large factor. (Telehealth Team)

Change Readiness

Clinic and staff commitment, preparedness and ability to take on telehealth program.

It really wasn’t an issue. We just talked about it being rolled out, and they got it started, and I think everyone was happy to be able to provide the service. (Clinic 1)

Well, the nursing staff definitely didn’t… I mean, it was the OB providers that wanted this, but probably didn’t do enough or we didn’t do enough to kind of champion it to get people comfortable with it. And it didn’t feel like there was room to get in to work with them to make them comfortable. (Telehealth Team)

There are some groups that really know nothing about this and really don’t want to know anything about it. Then there were others that knew nothing about it but were really receptive to learning about it. (Telehealth Team)

Culture ^a

Clinic norms, values, and assumptions regarding change and meeting the maternal mental health and substance abuse needs in their patients.

She was the one person in that whole entire clinic that got it and thought it was an important service. So that was their culture, “We don’t really know what this is and we don’t really think it’s important.“ (Telehealth Team)

As soon as you have a pregnant woman that is even just a little bit complicated, they don’t want them in their practice and they send them to [the academic medical center]. And a 100% of our patients are complicated. And we didn’t understand that for a long time. We were like, “Why do you keep sending these poor people here when they could get tele there?“ And so they just did not believe that anybody that was high risk should be in their practice or getting care via tele. (Telehealth Team)

I think mental health kind of made her [a nurse at the clinic] nervous. She didn’t really buy into it. We went to visit [the site] for a second time to try to revamp them. There was definitely some uncomfortableness she had with mental health. (Telehealth Team)

Resources

Level of resources/technology dedicated for implementation and on-going operations of telehealth program (e.g., finances, staffing, physical space, time).

Equipment was the big one. Just everyone knowing how to use it, and so we started having the training for everybody and regular training to make sure everyone knew how to use it. At one point we had two offices and so sometimes they helped one another out about how to use telemedicine. … Making sure it was running, internet connections and all of that was probably the biggest problem initially, but once we got all of that taken care of it wasn’t that difficult. (Clinic 2)

But I’ll be honest, because we didn’t have one specific person. I’m the clinical supervisor. I help to get the telemedicine…but it was one of our staff that was bringing them back. Again, they were just doing it in between patients. (Clinic 4)

Our IT was basically needing to connect to their IT and they had no IT person. Or the IT person was – they resourced them out, so they were there only occasionally. Our IT people here were just like, “Well, they don’t have IT. We can’t help you.“ So when we had patients scheduled, that was a big issue…when they had no IT support there. (Telehealth Team)

Leadership ^a

Key stakeholder identified and committed to program implementation with accountability.

If we could have a key person there, that makes the planning so much easier to have somebody who wants this program for the patients and can understand it and is willing to just work through the kinks. That’s really key for planning the scheduling and what’s it going to be like when the patient walks in the door for their tele-appointments. (Telehealth Team)

But, you know, having that person’s kind of endorsement of us, I think went a really long way with getting a lot of the community and clinic on board. (Telehealth Team)

They have a nurse… who has I guess championed [the WRBT program] more or less from the beginning. She’s taken this program under her wing and helped get everything figured out within the clinic to make it work. (Telehealth Team)

Teamwork ^a

Nature and quality of communications and interactions among clinic team members around program implementation.

It seems like they’re a unified team…I don’t feel like they’re separate entities in the same building or they’re not on the same page and whenever I request [the scheduler] to communicate with [the nurse manager] or vice versa, I see that it happens. I mean, I feel comfortable that it’s happening. (Telehealth Team)

They had more time to dedicate to get all the staff together to say this is how we’re going to do referrals. This is how it’s all going to work when the patient comes in. I feel like with them, it was just slower to get their groove down and to get the system going. (Telehealth Team)

There’s a little bit of confusion with the front desk staff. Sometimes you might get one person on the phone who knows how to schedule and they know what you’re talking about or then you might get someone else who’s kind of like, “Oh, I don’t know what this is…” So I feel like they’re not totally on the same page, there’s not great communication happening. (Telehealth Team)

Attitudes

Beliefs and perceptions of program implementation processes and outcomes.

It’s definitely an awesome service to have. So we’re grateful for it because our patients don’t need to travel. It was positive. Couldn’t say anything negative about it at all. (Clinic 4)

And I mean patients are doing much better, happy with the medications and feeling much better, and so when we see them back, I’ve seen a few that saw [a WRBT provider] at two weeks postpartum and then they come back in six weeks and they’re much, much better. So this was very welcome – the patients are loving it and it’s been helpful. (Clinic 3)

I also feel like their staff and nurses really want to help this population. They really see it as important… they want to pick these people up and get them help. (Telehealth Team)

Bridging Factor

Telehealth Team-Clinic Partnerships

The relationships built between the telehealth team partners and clinics including the operational style, strategies for support and involvement in implementation of program.

They were great. I definitely could e-mail…the two physicians or the doctors, I had both of their e-mails. I had [the Telehealth Coordinator’s] phone number and her e-mail. [The telehealth team member] who was in charge, I had all of their phone numbers and they were great… Always responded. (Clinic 4)

I just think patient educational materials are always good and just making sure we know what’s available through telemedicine, and it’s going to be – word of mouth is a big thing here in this area. And again, when you have a resource available, particularly with those with limited transportation, I think it would be well received. Anything that you can provide us to give to a patient to reassure them that this is an appropriate and accessible resource to use probably will reassure them. (Clinic 5)

And we weren’t able to ever get in front of them as a group. That never happened. We were just making visits and getting a few key people to get excited about it. I think it’s an important step in that you have a lot of people… getting on the same page and asking questions and understanding what the service is about. (Telehealth Team)