Table 2

Examples of contextual factors where plans did and did not incorporate the factor

Method of identification of contextual factorHandling of contextual factorExamples
Elicited by providerIncorporated into planPatient with diabetes has high HgA1C.
Physician asks if he is taking his insulin.
Patient not taking insulin because he can't afford food and was told to take insulin with food.
Physician addresses finances and food insecurity by referral to social worker. Patient has uncontrolled hypertension.
Physician asks if he is taking pills as prescribed.
Patient responds he is on many medications and confused about how to take them; has taken only one blood pressure pill instead of two.
Provider changes prescription to a combination pill that reduces total number of pills to take.
Revealed spontaneously by patientIncorporated into planPatient missed three appointments in last 4 months.
Patient reveals that work hours are 9:00 to 6:00 and he can't get to clinic early enough for appointments. Physician tells patient there are now Saturday hours and offers to schedule visits on Saturdays. Patient missed 11 out of 22 appointments.
Patient's behaviour reveals cognitive impairment making it impossible to travel to the clinic.
Physician arranges for home healthcare.
Elicited by providerNot incorporatedPatient's blood pressure is high and he states he is not taking his medication.
Physician asks what is preventing patient from taking medication.
Patient says his wife has stage 4 cancer, and he is taking care of her (‘putting his wife first’)
(Physician does nothing but remind patient to take medication) Patient with diabetes has high HgA1C.
Physician asks what is going on in the patient's personal life.
Patient says there has been a death in his family and other personal upheaval and he has been too upset to take his medication.
(Provider does nothing in response)
Revealed spontaneously by patientNot incorporatedPatient refuses to start insulin despite HgA1C of 15.7.
Patient reveals he doesn't think he's capable of giving himself injections.
(Provider does not discuss further). Patient with diabetes has high HgA1C.
Patient reveals he stopped taking insulin because he is now being charged for it and can no longer afford it due to being unemployed for a while.
(Provider does not discuss further)