The patient-centered medical home (PCMH) aims to provide accessible, coordinated, and patient-centered care with goals of improving the quality of care, reducing costs, and improving patient experience.1,2 First described in the late 1960s for children with special health care needs,3–5 the PCMH model has expanded to include easy access for patients, coordination among providers, effective communication with patients, timely tracking of patient data, proactive care management, and quality improvement (QI) for all patients. Despite the model’s pediatric roots, we still know very little about the experience of pediatric patients and their families in a PCMH. Patient experience measures provide direct reports from patients on what occurs during the course of seeking care and commonly assess patient satisfaction. Health care providers, administrators, and policymakers are increasingly recognizing the importance of improving patient experience—both as an intrinsically important aspect of caring for patients and as a potential contributor to improved health care quality and outcomes.6 Measures of patient experience, such as the Consumer Assessment of Healthcare Providers and Systems-Clinician and Group survey (CAHPS-CG), are also beginning to be used to adjust payments to primary care providers.7 One previous study by Cooley et al8 examined the experience of pediatric patients with chronic conditions in 43 practices in 5 states but found no correlation of pediatric patient experience with PCMH attributes.
As part of a larger PCMH study,9–11 this report examines the association between PCMH characteristics and pediatric patient experience in the safety net setting, as reported by parents. Our study expands on the existing literature in 3 important ways. First, we examine patient experience outcomes using the CAHPS-CG, a widely used experience measure validated in pediatric populations.12 Second, we focus on the experience of a general population of pediatric patients and their families; we did not focus on a specific disease condition. Finally, we study safety net primary care clinics, a critically important setting in which to understand the effects of the medical home. Safety net clinics provide primary care for patients who are largely racial and ethnic minorities and of low income.13–15 Safety net health center (HC) leaders are looking to the PCMH as a model that can facilitate improvements in processes and outcomes of patient care, with studies underway supported by Centers for Medicare & Medicaid Services and Health Resources and Services Administration.16,17 By providing timely information about the relationship between the PCMH and patient experience, we hope to inform these efforts and provide insights into whether the PCMH appears to be having an impact on patient experience and which aspects of the model appear to be most strongly associated.
Twenty-four HCs were randomly selected from the 65 HCs participating in The Commonwealth Fund-supported Safety Net Medical Home Initiative (SNMHI), a 4-year intervention to implement and evaluate the medical home in safety net clinics. Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute led the implementation of the medical home model in this Initiative using 8 “change concepts” for practice transformation that are based on medical home principles and tailored to the safety net setting.18 We assessed the cross-sectional correlation between clinic PCMH characteristics and parents’ ratings of their children’s health care in 24 safety net clinics across 5 states (5 clinics each from Colorado, Idaho, Massachusetts, and Oregon, and 4 from Pennsylvania).
PCMH characteristics of the HCs were assessed to create a total PCMH score, the key independent variable. PCMH characteristics were measured via self-administered surveys10 mailed to 271 randomly selected health care providers and staff from the 24 clinics between January and June 2010, early on in the larger PCMH intervention (intervention months 8–13). Providers included physicians, nurse practitioners, and physician assistants. Staff included behavioral health specialists, educators, certified medical assistants, counselors, dieticians, nurses (licensed practical nurses and registered nurses), psychiatrists, psychologists, and social workers. Detailed description of provider and staff survey administration has been previously published.10
The PCMH survey produced 0 (worst) to 100 (best) scores for a total PCMH score and 5 PCMH subscales: access and communication with patients, communication with other providers, tracking data, care management, and QI. The “access and communication with patients” subscale assessed whether patients can contact and see their clinician on a timely basis and whether interpreter services are available when necessary. The “communication with other providers” subscale assessed each clinic’s ability to exchange information with specialists, hospitals, and emergency departments. The “tracking data” subscale assessed the ability of providers and staff to identify patients with a particular disease, monitor test results, and follow-up. The “care management” subscale assessed the ability to individualize services for patients, coordinate care among providers within each clinic, and support patient self-management, utilizing community resources when necessary. The “quality improvement” subscale assessed the ability to systematically collect measures of clinician and practice performance and use these to improve care.
The total PCMH score was calculated as the mean of the 5 PCMH subscale scores. The communication with other providers subscale score was based only on provider responses, as that section was excluded from the staff survey. In statistical analyses, provider and staff PCMH scores were averaged for each of the 24 clinics.
Pediatric patient experience, the key dependent variable, was measured via self-administered surveys mailed to randomly selected parents or guardians (hereafter referred to as “parents”) of 70 pediatric patients from each participating clinic seen during the 3 months before the survey. Surveys were completed between June 2010 and November 2011 (intervention months 13–30). We increased 1 clinic’s sample size to 111 patients because the clinic anticipated low response rates from a large refugee patient population. Surveys were translated into the patient’s preferred language (Spanish or Portuguese) as reported by the clinics. Initial mailings included a one-time incentive of $2, and up to 3 more rounds of follow-up surveys were sent to individuals who did not respond. The survey included questions from the child version of the CAHPS-CG.19 The CAHPS-CG instrument produces 4 measures of patient experience expressed in 0–100 scores: timeliness, physician communication, staff helpfulness, and overall provider rating.
We included covariates demonstrated in the literature to be associated with patient assessments of the quality of their care.20 Patient-level covariates were child age group, sex, race or ethnicity, type of insurance, number of clinic visits in the last 12 months, duration of relationship with provider, parents’ report of the child’s health status, parent age group, and parent education level. Clinic-level covariates were number of full-time equivalent providers (used as a proxy for clinic size), and the state in which the clinic is located.
To investigate the relationship between PCMH characteristics and patient experience, we fit bivariate and multivariate models using generalized estimating equations with an exchangeable correlation structure to account for clustering effect within clinic. We excluded respondents with missing covariate data from analysis. In multivariate analyses, patient experience was modeled in 2 ways, once as a function of total PCMH score and covariates, and again as a function of the 5 PCMH subscales and covariates in 1 model. To interpret the impact of higher PCMH scores, we display the effects of a 10-point higher PCMH score on patient experience. To illustrate a 10-point difference in PCMH score, consider a scenario that compares 2 hypothetical clinics, clinic A and clinic B. In response to “my patients see me rather than some other provider when they come for a routine visit” clinic A strongly agrees, whereas clinic B strongly disagrees; and second, in response to “how often is it difficult to communicate with outside specialists,” clinic A reports “rarely” and clinic B reports “almost always.” The combined differences in responses from these 2 survey questions would yield a 10-point higher total PCMH score for clinic A compared with clinic B.
To examine potential differences between providers and clinical staff and how they may perceive various PCMH features, we also conducted secondary analyses to examine (1) ratings of PCMH characteristics separated by role; (2) association between patient experience and PCMH rating as assessed by providers; and (3) association between patient experience and PCMH rating as assessed by staff.
Providers, Staff, and PCMH Scores
Of the 271 providers and staff surveyed at the 24 study clinics, we received 214 (79.0%) responses (Table 1) with an average of 8.9 provider and staff responses per clinic. Provider and staff response rates to the survey did not differ significantly. Providers and staff were mostly female (74.8%) and non-Hispanic white (73.8%), with an average of 13.7 years since the end of their clinical training and 6.4 years of working at the study clinic. Of the 24 clinics represented, 16 (66.7%) were designated as Federally Qualified Health Centers (FQHCs), 11 (45.8%) were located in a city or suburban setting, 9 (37.5%) had >8 provider time equivalents, and 17 (70.8%) had electronic medical record systems functioning at the time of the study. Mean total PCMH score was 62.9 (SD=7.0). Table 2 provides the distribution of survey responses used to construct the PCMH subscale scores and PCMH total score. PCMH subscale scores ranged from a low of 60.7 (SD=10.5) for access and communication with patients to a high of 64.7 (SD=8.7) for care management.
Of the 1721 surveys sent to parents of pediatric patients, 93 were returned-to-sender as undeliverable, and we ultimately received 535 responses, reflecting a 32.9% response rate. After excluding respondents with missing covariate data, we included 440 parent respondents in the analysis. Characteristics of the pediatric study sample are shown in Table 3. The majority of pediatric patients were non-Hispanic white (53.0%), male (54.8%), and insured via Medicaid (64.3%). Respondents predominantly reported their child’s health was either excellent (44.8%) or very good (37.0%) and that their child had visited his or her provider ≥3 times in the last 12 months (63.9%).
On a 0–100 scale, the mean ratings of patient experience were 86.3 (SD=19.0) for physician communication, 82.6 (SD=20.4) for overall rating of provider, 79.2 (SD=24.4) for helpful office staff, and 67.5 (SD=22.5) for timeliness (Table 4). Fifty-seven percent of respondents gave their child’s provider an overall rating of 9 or 10 (highest) on a 10-point scale.
Multivariate Correlation of Medical Home Capability and Patient Experience
In multivariate analyses (Table 5), total PCMH score was not associated with any patient experience outcome. PCMH subscale ratings; however, showed several significant correlations with patient experience. A 10-point higher PCMH subscale score for QI was associated with higher patient experience ratings of timeliness [10.3, 95% confidence interval (CI), 7.2–13.3], physician communication (5.5, 95% CI, 1.8–9.2), helpful office staff (5.4, 95% CI, 1.5–9.3), and overall provider rating (7.8, 95% CI, 3.4–12.2). A 10-point higher PCMH subscale score for tracking data was also positively associated with patient experience ratings: timeliness (2.6, 95% CI, 0.9–4.2), physician communication (1.4, 95% CI, 0.1–2.7), and helpful office staff (2.3, 95% CI, 0.005–4.6). The PCMH subscale score for care management was negatively correlated with patient experience ratings, with a 10-point higher care management score associated with lower ratings of timeliness (−9.1, 95% CI, −12.2, −6.0), physician communication (−5.6, 95% CI, −9.1, −2.0), helpful office staff (−8.4, 95% CI, −12.7, −4.1), and overall provider rating (−5.5, 95% CI, −10.1, −0.9). A 10-point higher PCMH subscale score for access and communication with patients was negatively associated with patient ratings of timeliness (−3.5, 95% CI, −5.7, −1.3). In secondary analyses we examined provider and staff PCMH responses separately. We found no association between total PCMH score and patient experience; however, some PCMH subscale ratings by providers and staff demonstrated associations with various aspects of patient experience (see Supplemental Tables 1–3, Supplemental Digital Content 1, http://links.lww.com/MLR/A815).
PCMH is a challenging and complex intervention to improve primary care. Identifying key aspects of the PCMH that significantly affect patient experience can help us better prioritize and improve the various activities that comprise the model. In this study, we found that a measure of overall PCMH characteristics was not associated with pediatric patient experience; however, individual subscales of the PCMH were significantly associated with experience ratings in differing directions. In particular, the PCMH subscale for QI was strongly positively associated with patient experience and the PCMH subscale for care management was negatively associated with patient experience.
Our QI PCMH subscale asks providers and staff whether their clinic has structures and processes in place to assess and improve quality of care. Patient experience is a common focus of QI activities21 and our QI subscale (Table 2) specifically asks providers and staff about their clinic’s willingness to change in response to feedback. It may be the case that provider and staff who incorporate QI approaches into their regular workflow are more attuned to meeting patient expectations and improving patient experience in a variety of ways, making QI an important strategy for improving patient experience through the PCMH.
In contrast, higher provider and staff ratings of care management were associated with more negative patient experience ratings. This finding is surprising, and suggests the need for further study. Our care management subscale has several questions that focus on care for patients at high risk for poor outcomes and patients with chronic illness. Our sample included approximately 20% pediatric patients with fair or poor health and these patients may have had particularly strong needs for care management support. It may be that in the setting of constrained resources, staff time and effort devoted to care management for a minority of patients with greater health needs detracts from staffs’ ability to provide a positive patient experience for the broader patient population overall. Some studies have documented improved outcomes for pediatric patients with specific medical conditions (asthma, sickle cell disease) in clinical settings with certain PCMH features22,23; however, no other studies have documented effects of care management on overall patient experience for a general pediatrics population in the context of the PCMH. Our finding regarding care management suggests that providers and staff may need improved strategies to identify and communicate proactively with families experiencing significant care burdens related to chronic illness, while streamlining care and communications for healthy patients. Such strategies may lead to improved patient experience overall.
Our study has several limitations. First, as this is a cross-sectional analysis of clinics at baseline of a PCMH intervention, we are able to demonstrate association but not establish causality between PCMH characteristics and patient experience. In future work, it will be important to examine how patient experience changes over time with improvements to a clinic’s PCMH capabilities. Second, we cannot determine when clinics implemented PCMH characteristics, and whether there was sufficient time for those changes to have an effect on patient experience. Provider and staff PCMH score was assessed over months 8–13 of the 4-year intervention, whereas patient experience was assessed over months 13–30, with the clinics varying in specific survey start and end dates within those timeframes. These timings may have resulted in some temporal mismatch in our measures. Third, we were not able to limit our survey sample exclusively to pediatric providers. Provider and staff respondents to the PCMH characteristics survey were sampled from all providers and staff practicing at least half time at a clinic. Many providers in community HCs work with both children and adults, including family practice physicians (the most common primary care physicians in HCs) and clinical staff.24 Fourth, we cannot generalize our findings to all safety net clinics. Clinics that chose to participate in the overall study may have had higher motivation and a different trajectory for implementing PCMH characteristics than safety net practices at large. Fifth, while our response rates of 78.2% for providers and staff and 32.9% for parents are reasonable for the populations surveyed, response bias is possible and we had limited ability to compare respondents to nonrespondents. Finally, the survey instruments used in this study to assess medical home characteristics (as reported by providers and staff) and patient experience may not adequately capture some aspects of the PCMH and experience. Although our PCMH measure covers a more comprehensive scope of activities than many PCMH studies, it still may lack elements that some believe to be important to the PCMH. For example, the survey does not include questions on team-based care or shared decision making. Measures of the PCMH and patient experience should continue to evolve to incorporate the most salient features of patient-centered care.
This study on pediatric patient experience in the safety net setting has important implications. First, incorporating regular QI activities and culture into safety net clinics can be a powerful tool for improving patient experience. Second, care management, especially important for patients with chronic disease, needs to be implemented in ways that minimally disrupt overall patient experience in safety net settings. Some studies of adult patients have revealed ways in which efforts to achieve key PCMH aims can result in unintended consequences. For example, one PCMH practice implemented a symptom-based questionnaire for patients administered by medical assistants before the clinician interaction in an effort to increase efficiency during the patient’s visit; however, the use of the questionnaire correlated with worse patient satisfaction measures.25 The PCMH aims to improve multiple aspects of care, including access, quality, coordination, and continuity. We need to bolster characteristics of PCMH which are working well for patients while recognizing that some improvement efforts may negatively affect other aspects of patients’ experience, to optimize the model overall.
To provide care that results in a positive patient experience, patient feedback should be routinely incorporated into the design, implementation, and continued improvement efforts surrounding the PCMH. Features of the PCMH that contribute to negative patient experience should be revamped with ample input from patients. Safety net health care settings such as FQHCs provide a promising setting for incorporating reports of patient experience, as governance requirements stipulate that each FQHC board must include a majority of active, registered clients of the HC, representative of the population served.26 For key components of the PCMH to be effective and to achieve the patient-centered mission of the medical home model, future strategies should regularly incorporate patients’ perspectives to realize the full promise of the PCMH model, which originated in pediatrics to provide comprehensive, coordinated care for all.27
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