Schilling LM, Sills MR, Fairclough D, Kwan MB. Practice Variability in and Correlates of Patient-Centered Medical Home Characteristics. SAFTINet Convocation. Aurora, Colorado. 13 Feb 2013.

1. PRACTICE VARIABILITY IN AND
CORRELATES OF PATIENT-
CENTERED MEDICAL HOME
CHARACTERISTICS
Lisa M. Schilling, MD, MSPH, SAFTINet Principal Investigator
Lisa.schilling@ucdenver.edu
Marion R. Sills, MD, MPH Lead, SAFTINet CER Team
marion.sills@childrenscolorado.org
Diane Fairclough, DrPH, Biostatistician, SAFTINet CER Team
Diane.fairclough@ucdenver.edu
Bethany M. Kwan, PhD, MSPH, SAFTINet Project Manager
bethany.kwan@ucdenver.edu

2. Research aims
 To determine the extent to which there is an
association between practices’ characteristics of
organized care delivery and health outcomes
 Asthma (in children and adults), hypertension and
hypercholesterolemia outcomes
 To measure and describe practice-level
variability in and correlates of Patient-Centered
Medical Home (PCMH) characteristics in a
sample of safety net primary care practices
 Selection bias (non-random allocation of patients to
practices with more/less medical homeness)

3. Measuring “Medical Homeness”
 Measuring existing medical home characteristics
 Literature review: definitions/domains of PCMH
 Joint Principles of the Patient-Centered Medical Home
 American Academy of Pediatrics
 Safety Net Medical Home Initiative
 NCQA
 Review of existing surveys/measures
 Medical home index (MHI), Adults and Pediatric versions,
http://www.medicalhomeimprovement.org/knowledge/practices.html
 NCQA-Physician Practice Connection-Readiness Survey (PPC-RS) – a
research version of the PPC-PCMH used by NCQA for PCMH
recognition.
 TransforMed, Medical Home IQ
 Primary Care Assessment Tool (PCAT)
 Primary Care Clinician Assessment Tool (P Dickinson)
 PCMH Practice Monitor (P Dickinson)
 Safety Net Medical Home Initiative: Patient-Centered Medical Home
Assessment (PCMH-A), http://www.qhmedicalhome.org/safety-
net/upload/PCMH-A_SNMHI_102910.pdf)

4. Medical Home Domains
Domain Example Goals
Personal Clinician & Sustained
Partnership
 Clearly link patients to a clinician and/or care team so both the patient
and provider/care team recognize each other as partners in care.
Personal Clinician Led/ Team-
Based Care
 Team-based care led by clinician
Coordinated and Integrated
Care
 Link patients with community resources to facilitate referrals and
respond to social service needs.
Patient/Family-Centered
Care/Support Shared Decision-
Making
 Assess and respect patient and family values and expressed needs.
Quality Improvement &
Safety
 Establish and monitor metrics to evaluate improvement efforts and
outcomes and provide feedback.
Use of Organized Care &
Evidence-based Medicine
 Use point of care reminders based on clinical guidelines.
Access  Provide scheduling options that are patient- and family -centered and
accessible to all patients.
Engaged Leadership  Provide visible and sustained leadership overall culture change and
specific strategies to improve quality and sustain and spread change.
Registries, Performance
Reporting and QI Programs
 Use of patient tracking registries to monitor and inform clinical
interventions for persons with specific health care needs.

5. Delivery of Coordinated Care
Survey (DoCCS)
 No single existing, validated survey that met
the needs of the SAFTINet project
 Many measuring progress towards a specific
PCMH model
 Assumes decision to become PCMH
 Partner sensitivity to PCMH label
 Delivery of Coordinated Care Survey (DoCCS)
adapted for SAFTINet based on concepts and
items from several sources
 9 Domains, Total “medical home” score

6. Methods
 Measures
 Baseline Practice Characteristics (BPC) survey
 Organizational Features (e.g., ACO membership)
 Practice Features (e.g., FQHC, integrated care)
 Patient population
 Provider/staff characteristics
 HIT infrastructure (e.g., EMR)
 Delivery of Coordinated Care Survey (DoCCS): Practice-level self-report
survey of clinician and staff perceptions of medical home characteristics
 Average score for each domain (5 to 17 items per domain, measured on 1-5
scale, “No/Almost Never” to “Almost Always)
 Overall “medical home” score – mean of domain scores (Possible range 1-5)
 Participants
 All sites in SAFTINet with primary care (N = 47)
 Up to 3 DoCCS per practice: lead clinician/medical director, practice
manager, lead member of nursing staff
 BPC completed by central data person/team and/or practice managers
 Timeline
 Completed 7/2012-9/2012

7. Results: All DoCCS responses
N α M (SD) Range Related to PCMH
status (0 = none,
1 = seeking, 2 =
recognized) (r, p)
Overall Medical Home Score 101 .81 3.87 (0.56) 2.29 – 4.86 -.03 (.71)
Personal Clinician &
Sustained Partnership
100 .72 4.49 (0.53) 1.83 – 5.00 -.18 (.05)
Personal Clinician Led/ Team-
Based Care
100 .96 3.51 (1.31) 1.00 – 5.00 -.07 (.46)
Coordinated and Integrated
Care
101 .82 3.93 (0.56) 2.18 – 4.95 -.25 (.006)
Patient/Family-Centered
Care/Support Shared
Decision-Making
100 .77 3.87 (0.75) 1.83 – 5.00 -.22 (.01)
Quality Improvement &
Safety
101 .83 3.73 (0.60) 2.00 – 4.88 .08 (.36)
Use of Organized Care &
Evidence-based Medicine
101 .76 3.58 (0.86) 1.00 – 5.00 -.13 (.16)
Access 84 .74 4.03 (0.60) 2.80 – 5.00 -.28 (.006)
Engaged Leadership 96 .90 3.61 (0.92) 1.00 – 5.00 .06 (.54)
Registries, Performance
Reporting and QI Programs
96 .85 4.23 (0.90) 1.00 – 5.00 .25 (.01)
• What may be a better indicator of concurrent validity? (Don’t Know = ?)

8. Interrater Differences
 Practice managers tend to agree with nursing staff, but both
tend to differ from the provider; what does this tell us?
Practice Manager
vs Provider (mean
difference, p)
Practice
Manager vs
Nurse (mean
difference, p)
Provider vs
Nurse (mean
difference, p)
Overall Medical Home Score .36 (.01) .01 (.94) -.35 (.008)
Personal Clinician & Sustained
Partnership
.18 (.15) -.04 (.75) -.22 (.04)
Personal Clinician Led/ Team-Based Care .68 (.03) .37 (.02) -.31 (.30)
Coordinated and Integrated Care .32 (.02) -.02 (.90) -.34 (.009)
Patient/Family-Centered Care/Support
Shared Decision-Making
.34 (.04) .08 (.67) -.26 (.12)
Quality Improvement & Safety .23 (.09) -.06 (.66) -.29 (.08)
Use of Organized Care & Evidence-
based Medicine
.30 (.11) -.03 (.88) -.33 (.11)
Access .44 (.002) .003 (.99) -.44 (.004)
Engaged Leadership .54 (.02) .35 (.20) -.20 (.44)
Registries, Performance Reporting and
QI Programs
.44 (.03) -.04 (.85) -.48 (.03)

9. Distributions: All DoCCS responses

10. Questions raised
 Validity of the DoCCS
 Disagreement among members of the same
practice (different roles, low interrater agreement)
 Valid tool to use to correlate with patient-level
outcomes
 Second administration – what should we do
differently?
 Who is the best informant for each question?
 Getting closer to the truth