Kathryn E. Gunter

Associations between Medical Home Characteristics and Support for Patient Activation in the Safety Net: Understanding Differences by Race, Ethnicity, and Health Status

Background:Few studies have evaluated whether the patient-centered medical home (PCMH) supports patient activation and none have evaluated whether support for patient activation differs among racial and ethnic groups or by health status. This is critical because activation is lower on average among minority patients and those in poorer health. Objective:To assess the association between clinic PCMH characteristics and patient perception of clinic support for patient activation, and whether that association varies by patients’ self-reported race/ethnicity or health status. Participants:A total of 214 providers/staff and 735 patients in 24 safety net clinics across 5 states. Measures:Provider/staff surveys produced a 0–100 score for PCMH characteristics. Patient surveys used the patient activation subscale of the Patient Assessment of Chronic Illness Care to produce a 0–100 score for patient perception of clinic support for patient activation. Results:Across all patients, we did not find a statistically significant association between PCMH score and clinic support for patient activation. However, among the subgroup of minority patients in fair or poor health, a 10-point higher PCMH score was associated with a 14.5-point (CI, 4.4, 24.5) higher activation score. Conclusions:In a population of safety net patients, higher-rated PCMH characteristics were not associated with patients’ perception of clinic support for activation among the full study population; however, we found a strong association between PCMH characteristics and clinic support for activation among minority patients in poor/fair health status. The PCMH may be promising for reducing disparities in patient activation for ill minority patients.

How 3 Rural Safety Net Clinics Integrate Care for Patients: A Qualitative Case Study

Background:Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients’ needs. Currently, little is known about care integration for rural patients. Objective:To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. Research Design:Qualitative case study. Participants:Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. Methods:Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. Results:Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. Conclusions:Care integration was supported by 2 fundamental changes to organize and deliver care to patients—(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.

Establishing Effective Health Care Partnerships with Sexual and Gender Minority Patients: Recommendations for Obstetrician Gynecologists

&NA; Sexual and gender minority patients have historically experienced high rates of inappropriate and low‐quality care, disrespect, and discrimination in health care settings, as well as significant health disparities. Obstetricians and gynecologists can take action on multiple fronts if they wish to improve the quality of care for their sexual and gender minority patients. Examples include improving their relationships with sexual and gender minority patients and family members by purposefully reflecting upon individual and team biases, engendering empathy for sexual and gender minority patients, and creating effective working health care partnerships with them. They can also take steps to improve their cultural competency by improving their knowledge base about sexual orientation and gender identity, using welcoming language and creating health care environments that signal to sexual and gender minority patients that they are welcomed and understood. This article documents multiple suggestions and resources that health care teams can use to improve the health and health care of their sexual and gender minority patients.

Medical home characteristics and the pediatric patient experience.

Background:The patient-centered medical home (PCMH) has roots in pediatrics, yet we know little about the experience of pediatric patients in PCMH settings. Objective:To examine the association between clinic PCMH characteristics and pediatric patient experience as reported by parents. Research Design:We assessed the cross-sectional correlation between clinic PCMH characteristics and pediatric patient experience in 24 clinics randomly selected from the Safety Net Medical Home Initiative, a 5-state PCMH demonstration project. PCMH characteristics were measured with surveys of randomly selected providers and staff; surveys generated 0 (worst) to 100 (best) scores for 5 subscales, and a total score. Patient experience was measured through surveying parents of pediatric patients. Questions from the Consumer Assessment of Healthcare Providers and Systems-Clinician and Group instrument produced 4 patient experience measures: timeliness, physician communication, staff helpfulness, and overall rating. To investigate the relationship between PCMH characteristics and patient experience, we used generalized estimating equations with an exchangeable correlation structure. Results:We included 440 parents and 214 providers and staff in the analysis. Total PCMH score was not associated with parents’ assessment of patient experience; however, PCMH subscales were associated with patient experience in different directions. In particular, quality improvement activities undertaken by clinics were strongly associated with positive ratings of patient experience, whereas patient care management activities were associated with more negative reports of patient experience. Conclusions:Future work should bolster features of the PCMH that work well for patients while investigating which PCMH features negatively impact patient experience, to yield a better patient experience overall.

Medical Home Characteristics and Quality of Diabetes Care in Safety Net Clinics

We examined associations between patient-centered medical home (PCMH) characteristics and quality of diabetes care in 15 safety net clinics in five states. Surveys among clinic directors assessed PCMH characteristics using the Safety Net Medical Home Scale. Chart audits among 864 patients assessed diabetes process and outcome measures. We modeled the odds of the patient receiving performance measures as a function of total PCMH score and of PCMH subscales and covariates. PCMH characteristics had mixed, inconsistent associations with the quality of diabetes care. The PCMH model may require refinement in design and implementation to improve diabetes care among vulnerable populations.

Development and Validation of a Short‐Form Safety Net Medical Home Scale

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.

Cross-Sector Collaboration in the High-Poverty Setting: Qualitative Results from a Community-Based Diabetes Intervention

OBJECTIVE To characterize the motivations of stakeholders from diverse sectors who engaged in cross-sector collaboration with an academic medical center. DATA SOURCE Primary qualitative data (2014-2015) were collected from 22 organizations involved in a cross-sector diabetes intervention on the South Side of Chicago. STUDY DESIGN In-depth, semistructured interviews; participants included leaders from all stakeholder organization types (e.g., businesses, community development, faith-based) involved in the intervention. DATA COLLECTION METHODS Data were transcribed verbatim from audio and video recordings. Analysis was conducted using the constant comparison method, derived from grounded theory. PRINCIPAL FINDINGS All stakeholders described collaboration as an opportunity to promote community health in vulnerable populations. Among diverse motivations across organization types, stakeholders described collaboration as an opportunity for: financial support, brand enhancement, access to specialized skills or knowledge, professional networking, and health care system involvement in community-based efforts. Based on our findings, we propose a framework for implementing a working knowledge of stakeholder motivations to facilitate effective cross-sector collaboration. CONCLUSIONS We identified several factors that motivated collaboration across diverse sectors with health care systems to promote health in a high-poverty, urban setting. Understanding these motivations will be foundational to optimizing meaningful cross-sector collaboration and improving diabetes outcomes in the nations most vulnerable communities.

Development and Testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey

This article discusses development and testing of the Provider and Staff Perceptions of Integrated Care Survey, a 21-item questionnaire, informed by Singer and colleagues’ seven-construct framework. Questionnaires were sent to 2,936 providers and staff at 100 federally qualified health centers and other safety net clinics in 10 Midwestern U.S. states; 332 were ineligible, leaving 2,604 potential participants. Following 4 mailings, 781 (30%) responded from 97 health centers. Item analyses, exploratory factor analysis, and confirmatory factor analysis were undertaken. Exploratory factor analysis suggests four latent factors: Teams and Care Continuity, Patient Centeredness, Coordination with External Providers, and Coordination with Community Resources. Confirmatory factor analysis confirmed these factor groupings. For the total sample, Cronbach’s alpha exceeded 0.7 for each latent factor. Descriptive responses to each of the 21 Provider and Staff Perceptions of Integrated Care questions appear to have potential in identifying areas that providers and staff recognize as care integration strengths, and areas that may warrant improvement.

Hypertension Control in the University of Chicago Primary Care Group

In Brief “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful project by faculty at the University of Chicago to improve blood pressure control among hypertensive patients at a general internal medicine clinic on the South Side of Chicago, Ill.