Development of a safety net medical home scale for clinics

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 < 0.0001) and the PCMH-A (r = 0.56, p < 0.001). The mean SNMHS score was 61 ± SD 13. Among the subscales, External Coordination (66 ± 16) and Access and Communication (65 ± 14) had the highest mean scores, while Quality Improvement (55 ± 17) and Care Management (55 ± 16) had lower mean scores. Clinic characteristics positively associated with total SNMHS score were having more providers (β 15.8 95% CI 8.1-23.4 >8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (β 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.

Figure 1

Safety Net Medical Home Scale Total Summary Score and Domain Scores (N = 61). The horizontal line in the box represents the median value, and the edges of the box are the first and third quartiles. The lines extending from the edges of the box indicate the 10th and 90th percentile. Domain scores calculated from Safety Net Medical Home Scale [Appendix 1 (available online)]. Total score calculated from mean of other six domains. A clinic's data were included in a domain score if the clinic responded to more than 50% of the items in the domain and more than 50% of the core items in that domain. In addition, to be included in the total PCMH score, clinics had to have more than 50% of items answered for all domains and more than 50% of core items present for all domains. For surveys that had missing items but had fewer than 50% missing items in a domain (n = 9), we imputed the missing values based on the average score of the rest of the domain items. Four centers were excluded from analysis because of missing data, leaving 61 (94%) clinics with total scores calculated.