Clinic practitioner and support staff perspectives on implementation strategies to increase patient referrals to diabetes self-management education and support services

BACKGROUND: The prevalence of diabetes in Appalachian Kentucky is among the highest in the United States. Diabetes self-management education and support (DSMES) is a cost-effective, evidence-based intervention that improves patient outcomes yet is underutilized due to multilevel barriers. Throughout 2023-2024, we implemented a 9-month learning collaborative with two regional healthcare systems to increase DSMES referrals and documented their clinical strategies. At study conclusion, we assessed clinical perceptions of each strategy's feasibility, acceptability, appropriateness, as well as likelihood of sustainment of the clinical DSMES referral program. METHODS: After 6 months of participation and at study conclusion, participants (N = 13) described timing and intended outcomes for activities, which were then mapped to relevant Expert Recommendations for Implementing Change (ERIC) domains. Intended outcomes were coded to Practical, Robust Implementation and Sustainability Model (PRISM) contextual factors and implementation outcomes, and refinements to implementation strategies were documented iteratively throughout the study. At study end, participants (n = 9) individually assessed each strategy's acceptability, appropriateness, and feasibility, as well as its potential for sustainment. Assessments used 5-point unidimensional Likert scales that were summed and averaged, with higher numbers indicating greater favorability. RESULTS: To help facilitate DSMES referrals, clinic learning collaborative participants most frequently employed implementation strategies within the ERIC stakeholder interrelationshipsand supporting clinicians domains. Specific activities included creating a new electronic health record referral system, utilizing morning huddles to identify eligible patients, and creating patient face sheets for providers to review during visits. Strategies were refined minimally, primarily to increase provider and staff participation and patient and provider acceptability of activities. Across all strategies, mean scores for acceptability, appropriateness, and feasibility were mostly high, as was the overall likelihood of sustainment. CONCLUSIONS: The process of developing and refining implementation strategies to fit context was associated with positive clinical perceptions of acceptability, appropriateness, feasibility, and sustainability. Systematically documenting strategies along with their intended outcome targets throughout an intervention can help contextualize the dynamic nature of implementation and inform future scale-up.