Effects of patient-centered medical home attributes on patients' perceptions of quality in federally supported health centers

Staffing transformation following Patient-Centered Medical Home recognition among Health Resources & Services Administration-funded health centers

INTRODUCTION

Patient-Centered Medical Home (PCMH) recognition is designed to promote whole-person team-based and integrated care.

PURPOSE

Our goal was to assess changes in staffing infrastructure that promoted team-based and integrated care delivery before and after PCMH recognition in Health Resources & Services Administration (HRSA)-funded health centers (HCs).

METHODOLOGY/APPROACH

We identified changes in staffing 2 years before and 3 years after PCMH recognition using 2010-2019 Uniform Data System data among three cohorts of HCs that received PCMH recognition in 2013 ( n = 346), 2014 ( n = 207), and 2015 ( n = 115). Our outcomes were team-based ratio (full-time equivalent medical and nonmedical providers and staff to one primary care physician) and a multidisciplinary staff ratio (allied medical and nonmedical staff to 1,000 patients). We used mixed-effects Poisson regression models.

RESULTS

The earlier cohorts served fewer complex patients and were larger before PCMH recognition. Three years following recognition, the 2013 and 2014 cohorts had significantly larger team-based ratios, and all three cohorts had significantly larger multidisciplinary staff ratios. Cohorts varied, however, in the type of staff that drove this change. Both ratios increased in the longer term.

CONCLUSION

Our study suggests that growth in team-based and multidisciplinary staff ratios in each cohort may have been due to a combination of HCs' perceptions of need for specific services, HRSA funding, and technical assistance opportunities.

POLICY IMPLICATIONS

Further research is needed to understand barriers such as costs of employing a multidisciplinary staff, particularly those that cannot directly bill for services as well as whether such changes lead to practice transformation and improved quality of care.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

A Health Care Value Framework for Physical Therapy Primary Health Care Organizations

BACKGROUND AND OBJECTIVE

To develop a health care value framework for physical therapy primary health care organizations including a definition.

METHOD

A scoping review was performed. First, relevant studies were identified in 4 databases (n = 74). Independent reviewers selected eligible studies. Numerical and thematic analyses were performed to draft a preliminary framework including a definition. Next, the feasibility of the framework and definition was explored by physical therapy primary health care organization experts.

RESULTS

Numerical and thematic data on health care quality and context-specific performance resulted in a health care value framework for physical therapy primary health care organizations-including a definition of health care value, namely "to continuously attain physical therapy primary health care organization-centered outcomes in coherence with patient- and stakeholder-centered outcomes, leveraged by an organization's capacity for change."

CONCLUSION

Prior literature mainly discussed health care quality and context-specific performance for primary health care organizations separately. The current study met the need for a value-based framework, feasible for physical therapy primary health care organizations, which are for a large part micro or small. It also solves the omissions of incoherent literature and existing frameworks on continuous health care quality and context-specific performance. Future research is recommended on longitudinal exploration of the HV (health care value) framework.

The convergence of racial and income disparities in health insurance coverage in the United States

Objective

This study applied the vulnerability framework and examined the combined effect of race and income on health insurance coverage in the US.

Data source

The household component of the US Medical Expenditure Panel Survey (MEPS-HC) of 2017 was used for the study.

Study design

Logistic regression models were used to estimate the associations between insurance coverage status and vulnerability measure, comparing insured with uninsured or insured for part of the year, insured for part of the year only, and uninsured only, respectively.

Data collection/extraction methods

We constructed a vulnerability measure that reflects the convergence of predisposing (race/ethnicity), enabling (income), and need (self-perceived health status) attributes of risk.

Principal findings

While income was a significant predictor of health insurance coverage (a difference of 6.1–7.2% between high- and low-income Americans), race/ethnicity was independently associated with lack of insurance. The combined effect of income and race on insurance coverage was devastating as low-income minorities with bad health had 68% less odds of being insured than high-income Whites with good health.

Conclusion

Results of the study could assist policymakers in targeting limited resources on subpopulations likely most in need of assistance for insurance coverage. Policymakers should target insurance coverage for the most vulnerable subpopulation, i.e., those who have low income and poor health as well as are racial/ethnic minorities.

Patient-Centered Medical Home Activities Associated With Low Medicare Spending and Utilization

PURPOSE

To identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries.

METHODS

Regression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services' 8-state Multi-Payer Advanced Primary Care Practice demonstration.

RESULTS

Six activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM) (P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P =0.00).

CONCLUSIONS

Practices seeking to deliver more efficient care may benefit from implementing these 6 activities.

Some Aspects of Patient Experience Assessed by Practices Undergoing Patient-Centered Medical Home Transformation Are Measured by CAHPS, Others Are Not

BACKGROUND AND OBJECTIVES

Delivering care as a patient-centered medical home (PCMH) is being widely adopted across the United States by primary care practices to better meet patient needs. A key PCMH element is measuring patient experience for practice improvement. The National Committee for Quality Assurance (NCQA) PCMH recognition program requires practices to both measure patient experience and engage in continuous practice/quality improvement to attain PCMH recognition and then throughout full PCMH transformation. The NCQA recommends but does not require that practices administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) clinician and group patient experience survey (CG-CAHPS) plus 14 CAHPS PCMH items, known as the CAHPS PCMH survey. We examine aspects of patient experience measured by practices with a varying number of years on their journey of PCMH transformation.

METHODS

We randomly selected practices from the 2008-2017 NCQA directory of practices that had applied for PCMH recognition based on region, physician count, number of years and level of PCMH recognition, and use of the CG-CAHPS PCMH survey. We collected characteristics of the practices from practice leader(s) knowledgeable about the practice's PCMH history and patient experience data. We confirmed the patient experience surveys used during their PCMH history and requested copies of their non-CAHPS survey(s). For practices not administering the recommended CG-CAHPS survey (53/105 practices), we obtained and coded the content of their non-CAHPS surveys (68%; 36/53). We mapped the patient experience domains and specific measures to the CG-CAHPS survey (versions 2.0 and 3.0), CAHPS PCMH item set (versions 2.0 and 3.0), and the available CG-CAHPS supplemental items.

RESULTS

Whether or not practices administered the CG-CAHPS items, most of them addressed topics contained in the CG-CAHPS survey such as Access to care, Provider communication, Office staff helpfulness/courteousness, Care coordination, and Shared decision-making. The most common CAHPS measures included were Office staff helpfulness/courteousness and Provider communication. Common non-CAHPS measures included were Ease of scheduling, Being informed about delays, and Provider helpfulness/courteousness.

CONCLUSION

NCQA PCMH practices included CAHPS items on their patient experience surveys even if they did not administer the full CG-CAHPS survey or the recommended CAHPS PCMH survey. To enhance the usefulness of patient experience surveys for practices undergoing PCMH changes, additional CAHPS measures could be developed related to key areas of PCMH change, including expanded access to care (ie, after-hours and weekend visits, ease of scheduling, being informed about delays), use of shared decision-making, and improvements in provider communication (ie, the provider is courteous, communication by other clinical staff members with the patient). These additional measures would assist practice leaders in capturing the breadth and depth of their PCMH transformation and its influence on providing more patient-centered care. Developing such items would help standardize the measurement of changes related to patient experience during PCMH transformation. Research is needed to determine whether a CAHPS survey is the best source of this information.

Impact of health information technology optimization on clinical quality performance in health centers: A national cross-sectional study

Background

Delivery of preventive care and chronic disease management are key components of a high functioning primary care practice. Health Centers (HCs) funded by the Health Resources and Services Administration (HRSA) have been delivering affordable and accessible primary health care to patients in underserved communities for over fifty years. This study examines the association between health center organization’s health information technology (IT) optimization and clinical quality performance.

Methods and findings

Using 2016 Uniform Data System (UDS) data, we performed bivariate and multivariate analyses to study the association of Meaningful Use (MU) attestation as a proxy for health IT optimization, patient centered medical home (PCMH) recognition status, and practice size on performance of twelve electronically specified clinical quality measures (eCQMs). Bivariate analysis demonstrated performance of eleven out of the twelve preventive and chronic care eCQMs was higher among HCs attesting to MU Stage 2 or above. Multivariate analysis demonstrated that Stage 2 MU or above, PCMH status, and larger practice size were positively associated with performance on cancer screening, smoking cessation counseling and pediatric weight assessment and counseling eCQMs.

Conclusions

Organizational advancement in MU stages has led to improved quality of care that augments HCs patient care capacity for disease prevention, health promotion, and chronic care management. However, rapid technological advancement in health care acts as a potential source of disparity, as considerable resources needed to optimize the electronic health record (EHR) and to undertake PCMH transformation are found more commonly among larger HCs practices. Smaller practices may lack the financial, human and educational assets to implement and to maintain EHR technology. Accordingly, targeted approaches to support small HCs practices in leveraging economies of scale for health IT optimization, clinical decision support, and clinical workflow enhancements are critical for practices to thrive in the dynamic value-based payment environment.

The context, strategy and performance of the American safety net primary care providers: a systematic review

PURPOSE

The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided.

DESIGN/METHODOLOGY/APPROACH

A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases.

FINDINGS

28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance.

ORIGINALITY/VALUE

Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context-strategy-performance relationships in the context of FQHCs.

Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Review of patient-reported experience within Patient-Centered Medical Homes: insights for Australian Health Care Homes

Understanding patient experience is necessary to advance the patient-centred approach to health service delivery. Australia's primary healthcare model, the 'Health Care Home', is based on the 'Patient-Centered Medical Home' (PCMH) model developed in the United States. Both these models aim to improve patient experience; however, the majority of existing PCMH model evaluations have focussed on funding, management and quality assurance measures. This review investigated the scope of evidence reported by adult patients using a PCMH. Using a systematic framework, the review identified 39 studies, sourced from 33 individual datasets, which used both quantitative and qualitative approaches. Patient experience was reported for model attributes, including the patient-physician and patient-practice relationships; care-coordination; access to care; and, patient engagement, goal setting and shared decision-making. Results were mixed, with the patient experience improving under the PCMH model for some attributes, and some studies indicating no difference in patient experience following PCMH implementation. The scope and quality of existing evidence does not demonstrate improvement in adult patient experience when using the PCMH. Better measures to evaluate patient experience in the Australian Health Care Home model are required.

Association between Types of Usual Source of Care and User Perception of Overall Health Care Service Quality in Korea

Background

Patients’ perceptions of care tend to correlate with the quality of care provided. Different health care systems and service environments may show different associations between types of usual source of care (USC) and overall service quality assessment. We attempted to analyze this association as a benefit of having a USC.

Methods

This study used the 2012 Korea Health Panel data version 1.1 as representative national household survey data. The total number of subjects aged 18 years or more was 12,708. The number of subjects in the final analysis was 10,665. Multiple logistic regression analysis was used to assess the association between types of USC and overall health care service quality. The main outcome variable was users’ ratings of the quality of health care service.

Results

People having a usual doctor (n=1,796) were more likely to positively assess the quality of health care they received than those not having a USC (n=7,920; odds ratio [OR], 1.39; 95% confidence interval [CI], 1.20–1.60) or with those having only a place as a USC without a usual doctor (n=949; OR, 1.29; 95% CI, 1.05–1.58) after adjustment for demographic characteristics and health-related variables.

Conclusion

People having a usual doctor rated overall health care service quality as high, which might be due to benefits of primary care attributes related to usual doctors. Further studies are needed to elucidate the causal relationship. This finding implies that health policies encouraging people to have a usual doctor are needed in Korea.

The Association of Patient-centered Medical Home Designation With Quality of Care of HRSA-funded Health Centers: A Longitudinal Analysis of 2012-2015

OBJECTIVES

(1) To evaluate the relationship between Patient-centered Medical Home (PCMH) recognition and quality of clinical care among health centers, and (2) to determine whether the duration of recognition is positively associated with cumulative quality improvement over time.

METHODS

Data came from the 2012 to 2015 Uniform Data System, health centers' PCMH recognition status, and the Area Resource File. Health center was the unit of observation. The outcome variables included 11 measures of clinical quality. We pooled all years of data and modeled longitudinal data with generalized estimating equations to examine the degree of improvement in health care quality in health centers with and without PCMH recognition over the years 2012-2015.

RESULTS

Health centers with PCMH recognition generally performed better on clinical quality measures than health centers that did not have PCMH recognition for all years studied. After accounting for health center and county-level potential confounders, health centers with longer periods of PCMH recognition were more likely to have improved their clinical quality on 9 of 11 measures, than health centers with fewer years of PCMH recognition.

CONCLUSIONS

Health centers' length of time with PCMH recognition was positively associated with additive quality improvement. Adoption of the PCMH model of care may serve as a strategy to enhance quality of primary care services.

ALIGNed on adherence: subanalysis of adherence in immune-mediated inflammatory diseases in the DACH region of the global ALIGN study

Background

Non‐adherence to medication is a challenging problem in daily clinical practice.

Objective

To assess reasons for non‐adherence in patients with chronic immune‐mediated inflammatory diseases (IMIDs) in a direct comparison including evaluation of treatment necessity and concerns.

Methods

ALIGN was a non‐interventional, multicountry, multicentre, self‐administered, cross‐sectional, epidemiologic survey study. Here, we investigate the German, Austrian and Swiss (DACH) cohort. Six hundred thirty‐one patients with different IMIDs (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, Crohn's disease and ulcerative colitis) under systemic therapies were evaluated concerning adherence, beliefs of necessity and concerns towards treatment in patients with IMIDs.

Results

The DACH cohort had significantly different levels of adherence depending on the IMID (P < 0.05) and the type of therapy (P < 0.05). Based on the significant influence of concerns on treatment adherence (P < 0.05) and the high belief of treatment necessity, patients could be classified in four attitudinal segments, which were unequally distributed throughout various IMIDs. High concerns had a significant influence on non‐adherence, whereas necessity did not. Older age, female sex, TNFi mono‐, conventional combination and TNFi combination therapy are positively associated with adherence.

Conclusions

In the DACH region, patients are less concerned about medication and believe in the necessity of treatment. Therefore, we suggest adapting the communication in the various patient groups.

Implementation of Practice Transformation: Patient Experience According to Practice Leaders

OBJECTIVE

Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience.

SUBJECTS

Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10).

METHODS

Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items.

RESULTS

We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation.

CONCLUSIONS

PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

Patient-Centered Medical Home Measurement in School-Based Health Centers

School-based health centers (SBHCs) have been suggested as potential medical homes, yet minimal attention has been paid to measuring their patient-centered medical home (PCMH) implementation. The purposes of this article were to (1) develop an index to measure PCMH attributes in SBHCs, (2) use the SBHC PCMH Index to compare PCMH capacity between PCMH certified and non-PCMH SBHCs, and (3) examine differences in index scores between SBHCs based in schools with and without adolescents. A total of six PCMH dimensions in the SBHC PCMH Index were identified through factor analysis. These dimensions were collapsed into two domains: care quality and comprehensive care. SBHCs recognized as PCMHs had higher scores on the index, both domains, and four dimensions. SBHCs based in schools with just young children and those with adolescents scored similarly on the overall index, but analysis of individual index items shows their strengths and weaknesses in PCMH implementation.

Patient Centered Medical Home Care Among Near-Old and Older Race/Ethnic Minorities in the US: Findings from the Medical Expenditures Panel Survey

Access to Patient Centered Medical Home (PCMH) care has not been explored among older racial/ethnic minorities. We used data on adults 55-years and older from the Medical Expenditure Panel Survey (2008-2013). We account for five features of PCMH experiences and focus on respondents self-identifying as Non-Latino White, Black, and Latino. We used regression models to examine associations between PCMH care and its domains and race/ethnicity and decomposition techniques to assess contribution to differences by predisposing, enabling and health need factors. We found low overall access and significant racial/ethnic variations in experiences of PCMH. Our results indicated strong deficiencies in access to a personal primary care physician provided healthcare. Factors contributing to differences in reported PCMH experiences relative to Whites differed by racial/ethnic grouping. Policy initiatives aimed at addressing accessibility to personal physician directed healthcare could potentially reduce racial/ethnic differences while increasing national access to PCMH care.

Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers

BACKGROUND

Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models.

OBJECTIVE

We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes.

DESIGN

Cross-sectional, propensity score-weighted, multivariable regression analysis.

PARTICIPANTS

A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites.

MAIN MEASURES

PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011.

KEY RESULTS

Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]).

CONCLUSIONS

Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

When colocation is not enough: a case study of General Practitioner Super Clinics in Australia

Developed nations are implementing initiatives to transform the delivery of primary care. New models have been built around multidisciplinary teams, information technology and systematic approaches for chronic disease management (CDM). In Australia, the General Practice Super Clinic (GPSC) model was introduced in 2010. A case study approach was used to illustrate the development of inter-disciplinary CDM over 12 months in two new, outer urban GPSCs. A social scientist visited each practice for two 3-4-day periods. Data, including practice documents, observations and in-depth interviews (n=31) with patients, clinicians and staff, were analysed using the concept of organisational routines. Findings revealed slow, incremental evolution of inter-disciplinary care in both sites. Clinic managers found the facilitation of inter-disciplinary routines for CDM difficult in light of competing priorities within program objectives and the demands of clinic construction. Constraints inherent within the GPSC program, a lack of meaningful support for transformation of the model of care and the lack of effective incentives for collaborative care in fee-for-service billing arrangements, meant that program objectives for integrated multidisciplinary care were largely unattainable. Findings suggest that the GPSC initiative should be considered a program for infrastructure support rather than one of primary care transformation.

Colorectal cancer screening at US community health centers: Examination of sociodemographic disparities and association with patient-provider communication

BACKGROUND

Colorectal cancer (CRC) screening rates are low among underserved populations. High-quality patient-physician communication potentially influences patients' willingness to undergo CRC screening. Community health centers (HCs) provide comprehensive primary health care to underserved populations. This study's objectives were to ascertain national CRC screening rates and to explore the relations between sociodemographic characteristics and patient-provider communication on the receipt of CRC screening among HC patients.

METHODS

Using 2014 Health Center Patient Survey data, bivariate and multivariate analyses examined the association of sociodemographic variables (sex, race/ethnicity, age, geography, preferred language, household income, insurance, and employment status) and patient-provider communication with the receipt of CRC screening.

RESULTS

Patients between the ages of 65 and 75 years (adjusted odds ratio [aOR], 2.49; 95% confidence interval [CI], 1.33-4.64) and patients not in the labor force (aOR, 2.32; 95% CI, 1.37-3.94) had higher odds of receiving CRC screening, whereas patients who were uninsured (aOR, 0.33; 95% CI, 0.18-0.61) and patients who were non-English-speaking (aOR, 0.42; 95% CI, 0.18-0.99) had lower odds. Patient-provider communication was not associated with the receipt of CRC screening.

CONCLUSIONS

The CRC screening rate for HC patients was 57.9%, whereas the rate was 65.1% according to the 2012 Behavioral Risk Factor Surveillance System and 58.2% according to the 2013 National Health Interview Survey. The high ratings of patient-provider communication, regardless of the screening status, suggest strides toward a patient-centered medical home practice transformation that will assist in a positive patient experience. Addressing the lack of insurance, making culturally and linguistically appropriate patient education materials available, and training clinicians and care teams in cultural competency are critical for increasing future CRC screening rates. Cancer 2017;123:4185-4192. © 2017 American Cancer Society.

Patient Experience in Health Center Medical Homes

The Human Resource and Services Administration, Bureau of Primary Health Care Health Center program was developed to provide comprehensive, community-based quality primary care services, with an emphasis on meeting the needs of medically underserved populations. Health Centers have been leaders in adopting innovative approaches to improve quality care delivery, including the patient centered medical home (PCMH) model. Engaging patients through patient experience assessment is an important component of PCMH evaluation and a vital activity that can help drive patient-centered quality improvement initiatives. A total of 488 patients from five Health Center PCMHs in south Florida were surveyed in order to improve understanding of patient experience in Health Center PCMHs and to identify quality improvement opportunities. Overall patients reported very positive experience with patient-centeredness including being treated with courtesy and respect (85 % responded “always”) and communication with their provider in a way that was easy to understand (87.7 % responded “always”). Opportunities for improvement included patient goal setting, referrals for patients with health conditions to workshops or educational programs, contact with the Health Center via phone and appointment availability. After adjusting for patient characteristics, results suggest that some patient experience components may be modified by educational attainment, years of care and race/ethnicity of patients. Findings are useful for informing quality improvement initiatives that, in conjunction with other patient engagement strategies, support Health Centers’ ongoing transformation as PCMHs.

Patient-Centered Medical Home Recognition and Clinical Performance in U.S. Community Health Centers

INTRODUCTION

America's community health centers (HCs) are uniquely poised to implement the patient-centered medical home (PCMH) model, as they are effective in providing comprehensive, accessible, and continuous primary care. This study aims to evaluate the relationship between PCMH recognition in HCs and clinical performance.

METHODS

Data for this study came from the 2012 Uniform Data System (UDS) as well as a survey of HCs' PCMH recognition achievement. The dependent variables included all 16 measures of clinical performance collected through UDS. Control measures included HC patient, provider, and practice characteristics. Bivariate analyses and multiple logistic regressions were conducted to compare clinical performance between HCs with and without PCMH recognition.

FINDINGS

Health centers that receive PCMH recognition generally performed better on clinical measures than HCs without PCMH recognition. After controlling for HC patient, provider, and practice characteristics, HCs with PCMH recognition reported significantly better performance on asthma-related pharmacologic therapy, diabetes control, pap testing, prenatal care, and tobacco cessation intervention.

CONCLUSION

This study establishes a positive association between PCMH recognition and clinical performance in HCs. If borne out in future longitudinal studies, policy makers and practices should advance the PCMH model as a strategy to further enhance the quality of primary care.

Health Center Patients' Insurance Status and Healthcare Use Prior to Implementation of the Affordable Care Act

INTRODUCTION

U.S. health centers provide primary and preventive care to underserved populations, including low-income and uninsured patients. The purpose of this study is to examine patterns of publicly funded health center use according to patient insurance status (private, public, none), prior to implementation of the Affordable Care Act.

METHODS

National data came from the 2009 Health Center Patient Survey, and were analyzed in 2013. Descriptive analysis of health center patient insurance coverage and health center utilization variables was conducted, followed by adjusted multivariate analysis.

RESULTS

About 91% of uninsured patients received at least half their annual healthcare visits at a health center, and 86% had at least one usual source of care that included a health center; these rates were not significantly different from those for publicly or privately insured patients. About half of uninsured patients (48%) had long tenures at the health center (≥3 years since first visit), not significantly different from the publicly insured (52%), but lower than the privately insured (63%, p<0.01). Uninsured patients highlighted affordability as the main reason for visiting a health center, whereas insured patients emphasized convenient location and quality of care.

CONCLUSIONS

Insured patients used health centers for the majority of their care, and in similar proportions to their uninsured counterparts. The primary motivation for visiting a health center differed based on insurance type. Future studies should be able to examine whether health center demand across insurance categories follows a similar pattern following the Affordable Care Act insurance coverage expansions.

Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation

Over the last 50 years, the incidence of cervical cancer has dramatically decreased. However, health disparities in cervical cancer screening (CCS) persist for women from racial and ethnic minorities and those residing in rural and poor communities. For more than 45 years, federally funded health centers (HCs) have been providing comprehensive, culturally competent, and quality primary health care services to medically underserved communities and vulnerable populations. To enhance the quality of care and to ensure more women served at HCs are screened for cervical cancer, over eight HCs received funding to support patient-centered medical home (PCMH) transformation with goals to increase CCS rates. The study conducted a qualitative analysis using Atlas.ti software to describe the barriers and challenges to CCS and PCMH transformation, to identify potential solutions and opportunities, and to examine patterns in barriers and solutions proposed by HCs. Interrater reliability was assessed using Cohen's Kappa. The findings indicated that HCs more frequently described patient-level barriers to CCS, including demographic, cultural, and health belief/behavior factors. System-level barriers were the next commonly cited, particularly failure to use the full capability of electronic medical records (EMRs) and problems coordinating with external labs or providers. Provider-level barriers were least frequently cited.