Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.

Formative evaluation provides stakeholders with timely feedback to support an intervention's improvement during implementation to maximize its effectiveness. We describe the qualitative methods that guided one study within a formative evaluation of a multicomponent care delivery intervention. We then describe the challenges and lessons learned that emerged from this study, organizing them by the study's four overarching challenges: (1) addressing multiple research questions, (2) working with a large interdisciplinary team, (3) triangulating qualitative results with quantitative results, and (4) studying implementation in real-world delivery settings. Overall, the evaluation generated important findings to support improvement of the intervention during implementation. We hope that sharing the lessons learned will increase the rigor and efficiency with which formative evaluations of complex care delivery interventions are conducted and the likelihood that they will improve implementation in real time. We also hope the lessons learned will enhance the satisfaction of the researchers working on these evaluations.

PURPOSE Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. METHODSWe used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within-and cross-case comparative analysis. RESULTSThe 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. CONCLUSIONSThe AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.