Development of a safety net medical home scale for clinics.
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ABSTRACT: Background
Existing tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.Objective
Develop a scale to measure PCMH adoption in safety-net clinics.Research design
Cross-sectional survey.Subjects
Sixty-five clinics in five states.Main measures
Fifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales (0-100): Access and Communication, Patient Tracking and Registry, Care Management, Test and Referral Tracking, Quality Improvement, and External Coordination. The scale was tested for internal consistency reliability and tested for convergent validity using The Assessment of Chronic Illness Care (ACIC) and the Patient-Centered Medical Home Assessment (PCMH-A). The scale was applied to centers in the sample. In addition, linear regression models were used to measure the association between clinic characteristics and medical home adoption.Results
The SNMHS had high internal consistency reliability (Cronbach's alpha?=?0.84). The SNMHS score correlated moderately with the ACIC score (r?=?0.64, p?8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (? 8.4 95% 1.6-15.3).Conclusion
The SNMHS demonstrated reliability and convergent validity for measuring PCMH adoption in safety-net clinics. Some clinics have significant PCMH adoption. However, room for improvement exists in most domains, especially for clinics with fewer providers.
SUBMITTER: Birnberg JM
PROVIDER: S-EPMC3235610 | biostudies-literature | 2011 Dec
REPOSITORIES: biostudies-literature
Publications
Development of a safety net medical home scale for clinics.
Birnberg Jonathan M JM Drum Melinda L ML Huang Elbert S ES Casalino Lawrence P LP Lewis Sarah E SE Vable Anusha M AM Tang Hui H Quinn Michael T MT Burnet Deborah L DL Summerfelt Thomas T Chin Marshall H MH
Journal of general internal medicine 20110812 12
<h4>Background</h4>Existing tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.<h4>Objective</h4>Develop a scale to measure PCMH adoption in safety-net clinics.<h4>Research design</h4>Cross-sectional survey.<h4>Subjects</h4>Sixty-five clinics in five states.<h4>Main measures</h4>Fifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales ...[more]
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Project description:OBJECTIVE:To develop a short-form Safety Net Medical Home Scale (SNMHS) for assessing patient-centered medical home (PCMH) capability in safety net clinics. DATA SOURCES/STUDY SETTING:National surveys of federally qualified health centers (FQHCs). Interviews with FQHC directors. STUDY DESIGN:We constructed three short-form SNMHS versions and examined correlations with full SNMHS and related primary care assessments. We tested usability with FQHC directors and reviewed scale development with an advisory group. DATA COLLECTION:Federally qualified health center surveys were administered in 2009 and 2013, by mail and online. Usability testing was conducted through telephone interviews with FQHC directors in 2013. PRINCIPAL FINDINGS:Six-, 12-, and 18-question short-form SNMHS versions had Pearson correlations with full scale of 0.84, 0.92, and 0.96, respectively. All versions showed a level of convergent validity with other primary care assessment scales comparable to the full SNMHS. User testers found short forms to be low-burden, though missing some PCMH concepts. Advisory group members expressed caution over missing concepts and appropriate use of short-form self-assessments. CONCLUSIONS:Short-form versions of SNMHS showed strong correlations with full scale and may be useful for brief assessment of safety net PCMH capability. Each short-form SNMHS version may be appropriate for different research, quality improvement, and assessment purposes.
| S-EPMC6056591 | biostudies-literature
Project description:ObjectiveTo examine the relationship between medical home transformation and patient experience of chronic illness care.Study settingThirteen safety net clinics located in five states enrolled in the Safety Net Medical Home Initiative.Study designRepeated cross-sectional surveys of randomly selected adult patients were completed at baseline (n = 303) and postintervention (n = 271).Data collection methodsQuestions from the Patient Assessment of Chronic Illness Care (PACIC) (100-point scale) were used to capture patient experience of chronic illness care. Generalized estimating equation methods were used to (i) estimate how differential improvement in patient-centered medical home (PCMH) capability affected differences in modified PACIC scores between baseline and postintervention, and (ii) to examine cross-sectional associations between PCMH capability and modified PACIC scores for patients at completion of the intervention.Principal findingsIn adjusted analyses, high PCMH improvement (above median) was only marginally associated with a larger increase in total modified PACIC score (adjusted ? = 7.7, 95 percent confidence interval [CI]: -1.1 to 16.5). At completion of the intervention, a 10-point higher PCMH capability score was associated with an 8.9-point higher total modified PACIC score (95 percent CI: 3.1-14.7) and higher scores in four of five subdomains (patient activation, delivery system design, contextual care, and follow-up/coordination).ConclusionsWe report that sustained, 5-year medical home transformation may be associated with modest improvement in patient experience of chronic illness care for vulnerable populations in safety net clinics.
| S-EPMC5785313 | biostudies-literature
Project description:BackgroundQuality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.MethodsQualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.ResultsThree themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.ConclusionAligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.
| S-EPMC6222992 | biostudies-literature
Project description:ImportanceThe patient-centered medical home (PCMH) model holds promise for improving primary care delivery, but it has not been adequately tested in teaching settings.Design, setting, and participantsWe implemented an intervention guided by PCMH principles at a safety-net teaching clinic with resident physician providers. Two similar clinics served as controls.Main outcomes and measuresUsing a cross-sectional design, we measured the effect on patient and resident satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, respectively. Both surveys were conducted at baseline and 1 year after the intervention. We also measured the effect on emergency department and hospital utilization.ResultsFollowing implementation of our intervention, the clinic’s score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points, although our clinic did not achieve all must-pass elements to qualify as a PCMH. During the 1-year study period, 4676 patients were exposed to the intervention; 39.9% of these used at least 1 program component. Compared with baseline, patient-reported access and overall satisfaction improved to a greater extent in the intervention clinic, and the composite satisfaction rating increased from 48% to 65% in the intervention clinic vs from 50% to 59% in the control sites (P = .04). The improvements were particularly notable for questions relating to access. For example, satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic vs from 14% to 18% in the control clinics (P < .001). Resident satisfaction also improved in the intervention clinic: the composite satisfaction score increased from 39% to 51% in the intervention clinic vs a decrease from 46% to 42% in the control clinics (P = .01). Emergency department utilization did not differ significantly between the intervention and control clinics, and hospitalizations increased from 26 to 27 visits per 1000 patients per month in the intervention clinic vs a decrease from 28 to 25 in the control clinics (P = .02).Conclusions and relevanceOur PCMH-guided intervention, which represented a modest but substantive step toward the PCMH vision, had favorable effects on patient and resident satisfaction at a safety-net teaching clinic but did not reduce emergency department or hospital utilization in the first year. Our experience may provide lessons for other teaching clinics in safety-net settings hoping to implement PCMH-guided reforms.
| S-EPMC4254756 | biostudies-literature
Project description:ObjectiveTo assess the impact of provider incentive policy on smoking status documentation.Data sourcesPrimary data were extracted from structured electronic medical records (EMRs) from 15 community health centers (CHCs).Study designThis was an observational study of data from 2006 to 2013, assessing changes in documentation of smoking status over time.Data extraction methodsWe extracted structured EMR data for patients age 18 and older with at least one primary care visit.Principal findingsRates of documented smoking status rose from 30 percent in 2006 to 90 percent in 2013; the largest increase occurred from 2011 to 2012 following policy changes (21.3% [95% CI, 8.2%, 34.4%] from the overall trend). Rates varied by clinic and across patient subgroups.ConclusionsDocumentation of smoking status improved markedly after introduction of new federal standards. Further improvement in documentation is still needed, especially for males, nonwhite patients, those using opioids, and HIV + patients. More research is needed to study whether changes in documentation lead to improvements in counseling, cessation, and patient outcomes.
| S-EPMC7080378 | biostudies-literature
Project description:ObjectivesEvaluate effects of a multicomponent intervention (human papillomavirus [HPV] vaccine-specific brochure and recalls) on HPV vaccination and secondarily examine if race/ethnicity moderates effects.MethodsUnvaccinated girls aged 11 to 18 years attending 4 safety-net pediatric clinics and their parent/guardian (n = 814 dyads) were randomized to (1) active comparison (general adolescent vaccine brochure), or (2) intervention consisting of a HPV vaccine-specific brochure, telephone recalls to parents who declined, and recalls to patients overdue for doses 2 and 3. HPV 1-dose and 3-dose coverages were assessed via electronic health records 12 months after randomization. Multivariate logistic regressions estimated adjusted odds and marginal predicted vaccine coverage by study arm and race/ethnicity.ResultsIntent-to-treat analyses found no main effect of the HPV vaccine-specific brochure on 1-dose coverage (42.0% vs 40.6%); however, secondary analyses found race/ethnicity was a significant moderator such that the intervention was effective only for Hispanic individuals (adjusted odds ratio [AOR] 1.43; 95% confidence interval [CI] 1.02-2.02), and not effective for black individuals (AOR 0.64; 95% CI 0.41-1.13). Recalls to parents who declined the vaccine during the index visit were not effective, but recalls to patients overdue for doses 2 and 3 were effective at increasing 3-dose coverage regardless of race/ethnicity (AOR 1.99; 95% CI 1.16-3.45).ConclusionsEducational materials describing only the HPV vaccine were effective for Hispanic but not black individuals. Future research should test mechanisms that may mediate intervention effects for different racial/ethnic groups, such as different informational needs or vaccine schemas (experiences, beliefs, norms).
| S-EPMC7313721 | biostudies-literature
Project description:ContextLow-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups.BackgroundThe study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics.DesignRandomized controlled trial.Setting/participantsAdults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited.InterventionThe intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy).Main outcome measuresThe primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013).ResultsThe study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening.ConclusionsThe results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.
| S-EPMC4311575 | biostudies-literature
Project description:BackgroundHealth centers provide care to vulnerable and high-need populations. Recent investments have promoted use of health information technology (HIT) capabilities for improving care coordination and quality of care in health centers. This study examined factors associated with use of these HIT capabilities and the association between these capabilities and quality of care in a census of health centers in the United States.MethodsCross-sectional secondary data from the 2015 Health Resources and Services Administration's Uniform Data System was used to examine 6 measures of HIT capability related to care coordination and clinical decision support and 16 measures of quality (12 process measures, 3 outcome measures, 1 composite measure) for health centers in the United States. Adjusted logistic regressions were used to examine health center characteristics associated with use of HIT capabilities, and adjusted linear regressions were used to examine associations between HIT capabilities and quality of care.ResultsMany health centers reported using HIT for care coordination activities, including coordinating enabling services (67.3%) or engaging patients (81.0%). Health center size and medical home recognition were associated with significantly greater odds of using HIT for enabling services and engaging patients. These HIT capabilities were associated with higher overall quality and higher rates of six process measures (adult screening and maternal and child health) and hemoglobin A1c control.ConclusionUse of HIT for such activities as arranging enabling services and engaging patients are underleveraged tools for care coordination. There may be opportunities to further improve quality of care for vulnerable patients by promoting health centers' use of these HIT capabilities.
| S-EPMC6996474 | biostudies-literature
Project description:ImportanceNational patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.ObjectiveTo measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians.Design, setting, and participantsThis multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics.ExposuresComparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%).Main outcomes and measuresDelivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit.ResultsOverall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services.Conclusions and relevanceOveruse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.
| S-EPMC5540058 | biostudies-literature
Project description:ImportanceThe 2017 Clinical Practice Guideline (CPG) for the diagnosis and management of pediatric hypertension (PHTN) categorizes a greater proportion of children with elevated blood pressure and PHTN, yet several barriers to CPG adherence have been noted.ObjectiveTo assess adherence to the 2017 CPG for the diagnosis and management of PHTN and use of a clinical decision support (CDS) tool to calculate blood pressure percentiles.Design, setting, and participantsThis cross-sectional study used electronic health record-extracted data from January 1, 2018, to December 31, 2019, among patients visiting 1 of 74 federally qualified health centers in AllianceChicago, a national Health Center Controlled Network. Children and adolescents (aged 3-17 years; hereinafter referred to as children) who attended at least 1 visit and had at least 1 blood pressure reading at or above the 90th percentile or diagnosis of elevated blood pressure or PHTN were eligible for data to be included in the analysis. Data were analyzed from September 1, 2020, to February 21, 2023.ExposuresBlood pressure at or above the 90th or 95th percentile.Main outcomes and measuresDiagnosis of PHTN (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10], code I10) or elevated blood pressure (ICD-10 code R03.0) and CDS tool use; blood pressure management (antihypertensive medication, lifestyle counseling, referral); and follow-up visit attendance. Descriptive statistics described the sample and rates of guideline adherence. Logistic regression analyses identified patient- and clinic-level associations with guideline adherence.ResultsThe sample consisted of 23 334 children (54.9% boys; 58.6% White race; median age, 8 [IQR, 4-12] years). Guideline-adherent diagnosis was observed in 8810 children (37.8%) with blood pressure at or above the 90th percentile and 146 of 2542 (5.7%) with blood pressure at or above the 95th percentile at 3 or more visits. The CDS tool was used to calculate blood pressure percentiles in 10 524 cases (45.1%) and was associated with significantly greater odds of PHTN diagnosis (odds ratio, 2.14 [95% CI, 1.10-4.15]). Among 15 422 children with blood pressure at or above the 95th percentile, antihypertensive medication was prescribed to 831 (5.4%), lifestyle counseling was provided to 14 841 (96.2%), and blood pressure-related referrals were given to 848 (5.5%). Guideline-adherent follow-up was observed in 8651 of 19 049 children (45.4%) with blood pressure at or above the 90th percentile and 2598 of 15 164 (17.1%) with blood pressure at or above the 95th percentile. Differences in guideline adherence by patient- and clinic-level factors were observed.Conclusions and relevanceIn this study, fewer than 50% of children with elevated blood pressure had a guideline-adherent diagnosis code or attended guideline-adherent follow-up. Using a CDS tool was associated with guideline-adherent diagnosis, but the tool was underused. Further work is needed to understand how to best support implementation of tools promoting PHTN diagnosis, management, and follow-up.
| S-EPMC10105315 | biostudies-literature