52]\], "Nurse practitioner role in implementation" \[[@CR53]\]"Staff turnover" \[[@CR19]\], "Large size of medical group" \[[@CR40]\], "Unions unsupportive of staff role change" \[[@CR40]\], "Medical director turnover" \[[@CR38]\], "Need to expand role of provider" \[[@CR44]\], "Staff turnover and loss meant very few staff could assume additional responsibilities" \[[@CR44]\], "Lack of staff expertise in team approach to implementation" \[[@CR48]\], "Lack of flexibility in reorganizing model of care" \[[@CR52]\], "Smaller organizations had difficulty addressing barriers" \[[@CR45]\]**C. Culture**"Support from primary care physicians" \[[@CR35]\], "Support from physicians" \[[@CR36]\], "Recognition of benefit of care managers" \[[@CR39]\], "Stable work relationships" \[[@CR40]\], "Recognition of patient role in self management" \[[@CR44]\], "Persistence despite extra work" \[[@CR44]\], "Organizational culture and enthusiasm for care improvement" \[[@CR45]\], "Promoting multidisciplinary approach" \[[@CR51]\], "Change to patient-centred care" \[[@CR52]\], "Receiving personal recognition" \[[@CR37]\]"Providers need for clear structure and autonomy" \[[@CR19]\], "Organizational culture unsupportive of change" \[[@CR40]\], "Lack of commitment or tradition of working in interdisciplinary teams" \[[@CR50]\], "Difficulty changing provider care to patient-centered care" \[[@CR52]\], "Rigid role expectations and thought processes" \[[@CR52]\]**D. Implementation climate**"Clear, shared long term commitment for change" \[[@CR40]\], "Recognized need for change" \[[@CR40]\], "Work credit to ensure staff buy-in" \[[@CR42]\], "Institutional commitment for change" \[[@CR45]\], "Commitment to follow guidelines" \[[@CR48]\], "Provider dissatisfaction with current system" \[[@CR50]\], "Financial reimbursement for attending meetings" \[[@CR51]\], "Organizational will to promote change and manage change" \[[@CR51]\] "Career promotion opportunities" \[[@CR37]\], "Incentives such as skill development" \[[@CR37]\]"Lack of physician int