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Tools to Gauge Progress During Patient-Centered Medical Home Transformation
Denise D. Quigley, PhD; Zachary S. Predmore, AB; and Ron D. Hays, PhD

Tools to Gauge Progress During Patient-Centered Medical Home Transformation

Denise D. Quigley, PhD; Zachary S. Predmore, AB; and Ron D. Hays, PhD
We reviewed operational details and content of tools designed to evaluate patient-centered medical home (PCMH) transformation. These tools assist practice leaders in understanding specific information about the process and progress of becoming a PCMH.
ABSTRACT

Objectives: To review tools designed to evaluate and improve the extent of patient-centered medical home (PCMH) implementation.

Study Design: Literature search and review of tools to evaluate PCMH “medical homeness” and track progress toward practice transformation.

Methods: We conducted a literature search to identify tools designed for evaluation and quality improvement during the PCMH change process. We identified and reviewed the content of 5 publicly available PCMH survey tools used by an administrator or clinical lead to collect data at the practice level for evaluation and/or quality improvement during PCMH implementation. We assessed each tool’s coverage of PCMH content, standards, and requirements. 

Results: We found that 3 tools (Patient-Centered Medical Home Assessment [PCMH-A], Primary Care Assessment Tool–Facility Edition, and Medical Home Care Coordination Survey–Healthcare Team [MHCCS-H]) are actionable for quality improvement. PCMH-A assesses the broadest array of practice capabilities and includes items pertaining to all National Committee for Quality Assurance PCMH standards. MHCCS-H was the only tool to contain items on comprehensiveness of care. There was variation in emphasis on main domains, with some content areas covered by only 1 tool. 

Conclusions: There is currently little evidence on which PCMH tools are associated with improved quality outcomes, as relatively few longitudinal studies have been conducted. Of the 5 tools we reviewed, only PCMH-A and MHCCS-H impose a light administrative burden (less than 10 minutes to complete) and can identify specific actions to improve a given practice capability. Each tool is lacking in a particular content area: PCMH-A, for example, lacks items on comprehensiveness of care, whereas MHCCS-H lacks items addressing access to care.

The American Journal of Accountable Care. 2017;5(4):e8-e18
The patient-centered medical home (PCMH) model is promoted as a way to transform US primary care practices.1,2 It incorporates current best practices for access to care, prevention, chronic disease management, care coordination, and responsiveness to patients.3-10 Monitoring the transformation of primary care practices to PCMHs requires understanding the context, change process, patient experiences of care, and outcomes of care.11,12 Even after obtaining recognition from one of the several organizations that grant “official” PCMH status, practices continue their transformation into a PCMH.13-17

Practices, networks, and federally qualified health centers need an evaluative and quality improvement (QI) tool to collect data and conduct real-time analyses that help them understand their level of “medical homeness,” track progress toward transformation goals, and identify possible improvements. Practice coaches, payers, and pilot or demonstration sponsors may also use these tools. Most primary care practices cannot engage in a third-party evaluation or large-scale demonstration with medical record audits, site visits, and staff surveys, but need a practical survey tool they can use to gauge achievement of PCMH standards. 

Despite their importance, information about tools for assessing PCMH progress is limited. Malouin et al18 found that the Primary Care Assessment Tool (PCAT), available in multiple formats, was the only tool that scored high on primary care features, as it was designed to assess both structural and process features of primary care, but their evaluation was conducted early in PCMH adoption and focused on a narrower set of components than currently delineated in PCMH definitions and standards.19,20 The evaluation by Burton et al21 included tools primarily used for the PCMH recognition process, which itself requires adequate and appropriate documentation, rather than for practice self-improvement, research, evaluation, or quality measurement. 

This article reviews PCMH tools designed for evaluative and QI purposes to assist practices and researchers wanting to select a survey tool to track outcomes of PCMH transformation. We also assess how well the identified PCMH tools align with the 2014 and 2011 standards of the National Committee for Quality Assurance (NCQA), the organization responsible for the largest share of PCMH recognition across the United States.22   

METHODS

Using traditional bibliographic databases (PubMed, Google Scholar, and PsycInfo), we systematically reviewed the peer-reviewed literature on patient-centered healthcare to identify surveys or tools designed to evaluate or monitor the process of becoming a PCMH. We also searched the Agency for Healthcare Research and Quality’s online primary care measure directory. Search terms included “patient-centered medical home” OR “PCMH” OR “medical home” OR “care coordination” OR “team-based care” AND “questionnaire*” OR “telephone” OR “phone” OR “survey” OR “surveys” OR “tool” OR “tools.” We limited our search to English-language articles published since 1990 on adult populations. We identified additional resources through reference citations. 

Our primary inclusion criteria were that a tool: 1) was designed as a survey with questions and response options, 2) was publicly available, 3) measured half or more of the PCMH domains (ie, access, team-based care [including continuity of care], population health management, care management and support [including shared decision making and self-care/self-management support], care coordination [including care transitions], and performance measurement and QI), 4) was based on 2014 PCMH standards of care, 5) was designed for QI or evaluation (not for PCMH recognition), 6) focused on the practice (not the health system) as the unit of change, and 7) did not require an external surveyor or site visit but could be administered by practice site administrators or evaluators.  

We identified 20 potential survey tools and abstracted details on each tool’s identifying information, including whether it was designed for recognition (for a national organization like NCQA or state agencies), evaluation, or QI; whether it assessed at the practice level; form (eg, paper or web); who completes the tool; and publications documenting its reliability. We estimated time burden of a tool by counting the number of questions overall and by type (eg, closed- or open-ended questions).23 Once tools not meeting these initial criteria were excluded, we coded each question in the remaining tools by content domain and related NCQA PCMH standard and element.18,21 We chose the NCQA PCMH standards because they are the most widely used standards, with recent estimates suggesting 15% to 18% of primary care physicians work in a NCQA-recognized PCMH.21 We created a summary worksheet to record the percentage of items in each content domain and the percentage of items related to each of the current (2014) and previous (2011) NCQA PCMH standards and elements. The project was approved by RAND Corporation’s institutional review board (Number: FWA00003425).

RESULTS

Table 111,24-29 provides inclusion and exclusion information on all 20 identified tools. Of these, we excluded 3 that were not publicly available, 1 that was based on 2008 NCQA PCMH standards,30 4 that were not designed for evaluation, 1 that was not a survey, 3 that focused on the health system rather than the practice, 2 that had limited PCMH content, and 1 that required an external surveyor and site visit. 

We were left with 5 current publicly available tools designed to collect data at the practice level by an administrator or clinical lead for practice improvement, research, evaluation, or quality measurement: Medical Home Index-Long Version (MHI-LV) and -Short Version (MHI-SV), Medical Home Care Coordination Survey–Healthcare Team (MHCCS-H), Primary Care Assessment Tool–Facility Edition (PCAT-FE), and Patient-Centered Medical Home Assessment (PCMH-A) tool. 

Operational Details

Table 2 shows details of these 5 tools. All except PCAT-FE have a light (less than 10 minutes to complete) or medium (approximately 20 minutes) administrative burden, with zero monetary cost and web-downloaded availability. Based on the Berry23 method of estimation, completion times for the tools range from 8 to 37 minutes (for 36 to 167 items). None require self-reported documentation or verification of responses. For 4 of these tools, a key clinical lead at the practice responds; for the PCAT-FE, a system administrator does so. Both the MHCCS-H and the PCMH-A also recommend that a multidisciplinary team of practice staff (including primary care physicians, physician assistants, nurses, and clinical administrative staff) collectively complete 1 survey per practice. 

Answer format varies by tool, leading to different levels of data actionability. To be actionable, a survey question must outline specific practices or elements that can be identified and changed/improved, link the specific information to a numerical value/score, and cover no more than 1 practice or element.

We judged that the PCMH-A, PCAT-FE, and MHCCS-H are generally actionable for QI, whereas the other 2 tools have actionability limitations. The PCMH-A uses a numerical 1 to 12 rating based on the extent to which recommended practices and behaviors are implemented, divided across 4 levels with specific actions or practices described for each item; it is also sensitive to practice change over a time period as short as 6 months.31 The PCAT-FE and MHCCS-H both have items that are specific to 1 action and align with the response scales, making them fully actionable. The MHCCS-H has only 1 ambiguous item (regarding primary care team roles). By contrast, the MHI-LV and MHI-SV do not help the user determine specific practices to implement. For example, the MHI-LV asks a respondent to rate whether there is “partial” or “complete” implementation of an item with several components of patient- and family-centered care; an answer of “partial” does not allow understanding of which specific component needs further work. Burton et al21 similarly documented these actionability problems with the Medical Home Index (MHI) tool. 

All 5 tools have detailed scoring instructions and include a summary-score calculation. The PCMH-A asks teams to rate their care delivery in 36 key areas associated with the 8 change concepts. Each item is scored from 1 to 12 based on the extent to which recommended practices and behaviors are implemented. The MHI-LV has groups of items that are considered “themes,” with a total of 25 items using an 8-point scale where “partial” mastery of the most basic item equals 1 point and “complete” mastery of the most advanced of the 4 items equals 8 points. The MHI-SV is a 10-item survey that scores a practice on a continuum of care across 3 levels reflecting the degree to which it has achieved components of a medical home, scored on a 1 to 5 scale. Level 1 is “good, responsive primary care”; Level 2 is “pro-active primary care (in addition to Level 1)”; and Level 3 is “primary care at the most comprehensive levels” (in addition to Levels 1 and 2). The reporter is asked to respond to each of the 10 indicators with: Level 1, Level 2–partial, Level 2–complete, Level 3–partial, or Level 3–complete. The MHCCS-H has 8 care coordination domains and a total of 35 items (34 items plus 1 global-rating item), with 5-point categorical-response scales, plus 2 responder-characteristic items. The PCAT-FE is scored by taking the average score (on a 1 to 4 scale) of each domain.

Reliability and validity have been estimated for the MHI-LV24 and the MHCCS-H.25 For the MHI-LV, Cooley et al24 examined interrater reliability between 2 project staff and between practices and project staff and the internal consistency of MHI domains and themes. The intraclass correlation coefficients between the summary scores of the interviewers was .98 and between the scores of the 2 interviewers and scores of the practices, .97. Standardized coefficient alphas for the 6 domains of the MHI ranged from .81 to .91, and the overall standardized alpha was .96. In the sample of practices studied, the MHI was an internally consistent instrument with acceptable reliability and support for validity for use by pediatric primary care practices to assess PCMH implementation. For the MHCCS-H, Zlateva et al25 conducted analysis to examine internal consistency, reliability and validity of the MHCCS-H using structural equation modeling. All domains had Cronbach’s coefficient alphas above 0.80.

 
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