ashton_mph_thesis_fall2014

FEDERALLY QUALIFIED HEALTH CENTER TRANSFORMATION

TO THE PATIENT-CENTERED MEDICAL HOME MODEL:

A QUALITATIVE STUDY OF PROVIDER EXPERIENCES

by

DAVID WESLEY ASHTON, BA

APPROVED:

PAUL ROWAN, PHD, MPH

OSAMA MIKHAIL, PHD, MBA

Copyright by

David Wesley Ashton, BA, MPH 2014

DEDICATION

To Jeannie




by

DAVID WESLEY ASHTON BACHELOR OF ARTS, THE UNIVERSITY OF TEXAS AT AUSTIN, 2006

Presented to the Faculty of The University of Texas

School of Public Health

in Partial Fulfillment

of the Requirements

for the Degree of

MASTER OF PUBLIC HEALTH

THE UNIVERSITY OF TEXAS SCHOOL OF PUBLIC HEALTH

Houston, Texas December, 2014

ACKNOWLEDGEMENTS

I sincerely wish to thank Dr. Paul Rowan for his experienced leadership and patience

throughout this project; and to Dr. Osama Mikhail for his valued guidance. Without their

continued support I would not have been able to bring this project to fruition. It is an honor

and pleasure to contribute original work to the scientific community to which I owe so much.




David Wesley Ashton, BA, MPH The University of Texas

School of Public Health, 2014 Thesis Chair: Paul Rowan, PhD, MPH

A semi-structured interview was conducted with administrators within four separate

federally qualified health centers (FQHCs) that previously achieved level 3 patient-centered

medical home (PCMH) recognition from the National Committee for Quality Assurance

(NCQA). It was hypothesized that these organizations may be able to share valuable lessons

with other sites who are interested in pursuing NCQA-PCMH recognition. A qualitative

framework analysis was performed, revealing various themes and sub-themes including

reasons for seeking recognition, organizational performance improvements, diagnosis of

approach, effectiveness of approach and overall lessons learned. Difficulties reported

include interpretation of NCQA standards, data collection and reporting, patient engagement,

restructuring of personnel responsibilities and emphasizing the importance of gaining

participation throughout the organization.

TABLE OF CONTENTS

List of Tables ......................................................................................................................... viii

List of Figures .......................................................................................................................... ix

List of Appendices .....................................................................................................................x

Background ..............................................................................................................................11

Methods....................................................................................................................................14

Results ......................................................................................................................................18

Discussion ................................................................................................................................25

Conclusion ...............................................................................................................................27

Appendices ...............................................................................................................................31

References ................................................................................................................................42

LIST OF TABLES

Table 1: Semi-structured Interview Questions Organized by Framework Analysis Category ……………………………………………………………………………28

viii

LIST OF FIGURES

Figure 1: Structure for Identifying Barriers to Implementation of NCQA-PCMH Standards....................................................................................................................30

ix

List of Appendices

Appendix A: Script for Initial Contact………………………………………………31 Appendix B: Letter of Information………………………………….………………32 Appendix C: Baseline Questionnaire………………………………………………..33 Appendix D: Semi-structured Interview Questions…………………………………34 Appendix E: Coding Template (with quotes)……………………………………….36

x

BACKGROUND

The importance of delivering high quality, patient centered health care to the

underserved, chronically uninsured and underinsured is well understood. Complications

resulting from unmet medical needs in this population increase demand for care in hospital

emergency rooms, account for a high portion of uncompensated care for providers and is a

known driver of increasing costs for the entire population. One long-standing approach to

addressing the needs of uninsured and underinsured individuals in the U.S. is the availability of

grants and loan guarantees offered by the Health Resources and Services Administration (HRSA)

to organizations that qualify. In 2011, federally qualified health centers (FQHC) addressed

health care needs of more than 20 million patients (HRSA National Report, 2011). An

increasingly preferred model of primary care delivery is the patient-centered medical home

(PCMH) but implementation of this model in a FQHC is not as widespread in resource-

constrained provider organizations. The PCMH model offers an opportunity for primary care

providers to deliver a more integrated system of medical care that promises to reduce the number

of downstream emergency room visits, improve cost as well as quality of services delivered

while ultimately improving the health and well-being of the communities they serve

(Rittenhouse, 2009). The National Council of Quality Assurance (NCQA) is a leading

organization that offers this recognition to providers who can satisfy the criteria listed in their

guidelines. The transformational process may appear to be daunting for many who operate a

FQHC. Provider experiences can illuminate the process so that practical considerations can be

more comprehensively understood by other FQHC managers who are considering a similar

objective. One approach to addressing this problem is to qualitatively collect, analyze and

interpret information from administrative health professionals working in a FQHC who have

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overseen the transformation to a patient-centered medical home (PCMH) model of primary care

delivery. These essential lessons that a limited number of FQHC managers have thus far learned

can prove to be valuable to others who can most readily apply the knowledge gained from

transformational experiences. The overall goal of this study was to identify obstacles associated

with FQHC preparedness for PCMH evaluation by NCQA.

In order to obtain PCMH 2011 program recognition through NCQA a provider must

satisfy all 6 must-pass elements and achieve an overall score of 35–59 (level 1), 60–84 (level 2),

or 85–100 (level 3) (NCQA Standards and Guidelines, 2011). Must-pass elements include:

access during office hours, use of data for population management, care management, support

self-care processes, referral tracking & follow-up, and implementation of continuous quality

improvement. Overall there are 6 categories containing 27 standards/elements for a total

possible score of 100 points. The current fee structure varies, but can often start at $8,500 and

increases as necessary for discretionary reviews, annual renewals and reconsideration requests.

Reconsideration and reevaluation is an option although will invariably require additional

organizational resources. Because baseline preparedness for the NCQA specified criteria will

vary among provider applicants the internal investment of resources would appear to be unique

to each organization. One example of this is use of electronic health records and whether or not

the initial expense of implementation has previously been incurred or if it will be an added cost

that contributes to the overall burden of transformation.

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SPECIFIC AIMS: Interview FQHC administrators who have previously achieved

medical home recognition, gather valid guidance for FQHCs facing the challenge of achieving

this recognition with maximum efficiency. An overall research agenda structure was developed

(Figure 1) in order to delineate the aims of the present study from subsequent studies that could

build upon current findings. Future studies may either address individual needs of a unique

FQHC or any broadly identified barriers that pose a commonly perceived challenge to

implementation.

1. Sub-aim 1: Preparation: Determine what steps were taken by management in

preparation for NCQA evaluation. Identify:

a. Initial preparation steps.

b. How responsibilities and tasks were delegated within the organization.

c. If everything was handled within the organization, whether additional staff or an

outside consultant was hired for the process.

d. Information, materials, or resources gathered to plan.

2. Sub-aim 2: Evaluation: Determine what was successful or unsuccessful for NCQA

evaluation in the initial preparation. Assess:

a. Mistakes and successes

b. Usefulness of preparation materials provided by NCQA

c. Usefulness of outside resources (materials, consultants, publications)

3. Sub-aim 3: Recommendations: Experiences applicable to other FQHC managers who

are considering this challenge.

a. If someone were to repeat the process, what would have been done differently

b. Motives for pursuing recognition; achievement of expected benefits

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c. Any other lessons that can be shared

METHODS

A preliminary consultation was obtained from a manager of a local FQHC who was

preparing for NCQA recognition and was able to clarify specific and general concerns of an

organization in this position. The questions composed for the interview were developed in order

to address specific aims and themes identified as relevant to this project. A local administrative

staff person volunteered to review the interview for relevance and ease of comprehension.

Identification of recognized medical homes for interview: Potential sites were identified

in states where demand for care in community based clinics is expected to be greatest. Utilizing

Statehealthfacts.org, a resource maintained by the Kaiser Family Foundation, it was discovered

that the same 5 states contain the highest population of uninsured individuals while

simultaneously enrolling the greatest number of Medicaid beneficiaries – California, Florida,

Illinois, New York, and Texas (Statehealthfacts.org, 2012). These states would presumably have

the highest consistent demand and opportunity for efficient and comprehensive health services

offered in a community health center setting. NCQA publishes a list of providers who have

obtained PCMH recognition on their public website, www.ncqa.com. The providers were then

cross-referenced to the FQHC list published by HRSA, yielding 13 health organizations, most of

them operating multiple locations within the same state. For the purposes of this study, the goal

was to interview all 4 identified single site providers and up to 4 randomly chosen multi-site

providers, bringing the overall sample size between 4 and 8. The emphasis was on the single site

locations based on the rationale that experiences of a single site FQHC present a clearer picture

that should be relevant for a single site as well as an organization operating multiple sites. As

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http://www.ncqa.com/

the sample size for single site locations is relatively low, additional data from multi-site locations

may prove useful. Following identification of prospective interviewees, the organizations were

individually contacted via telephone so that an interview could be requested and scheduled.

The goal was to conduct the interview with an individual in each organization who

played a direct administrative role in preparing the submission materials, including interfacing

with upper management as well as other parties in the FQHC, and was substantially involved in

interacting with NCQA. Ideally, the interview would be conducted with the “lead” person, or

one of the “lead” people involved in this effort. Therefore, the websites of the selected

organizations were reviewed and whenever possible an administrator was identified who was in

this role, such as a chief operations officer or a quality improvement officer. When this

information was not available on the organization’s webpage, we identified either an

administrator who could readily identify this person or the chief executive officer/executive

director, and asked for the name of the most appropriate person. Of the websites that were

visited, it was more common to find a named chief executive officer rather than an expanded

listing of senior management and their respective responsibilities.

A phone script was devised for initial contact (see Appendix A). The goals for the initial

phone contact were: make contact; identify the best administrator for the interview; receive an

initial willingness; obtain an email address for sending informed consent information and further

contact information; and establish an interview date, if possible. Alternately, it was also

considered that at the time of phone contact, a potential interviewee might want to conduct the

interview at that moment or very soon, such as later that same day or the next day, so the plan

was made to have the phone consent information ready, and have the recording apparatus ready

at the time of any recruitment call.

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Upon contact, the potential interviewee was given a concise but thorough explanation of

what is being requested of them throughout participation in the study: a telephone appointment to

gather voluntary responses during a recorded 20-30 minute semi-structured interview;

preliminary background information about the organization; and consent to provide this

information for the current study. If verbal consent was obtained at that time an email address

was requested in order to send comprehensive information including an officially approved

consent form and preliminary baseline questions (Appendix C). General patient population

information was requested in the baseline questions (age, payer-mix, number of outpatient visits

in a given period) to describe the sites. In addition, it was necessary to understand the range of

services offered in each FQHC. Prior to concluding the recruitment phone call a time was

established to conduct the 20-30 minute semi-structured interview. A reminder email was sent

up to one week prior to the scheduled interview time in order to confirm the appointment

followed by another reminder one day in advance. The interviewee was asked if correspondence

should be coordinated directly with them or through an administrative assistant. Receipt of the

baseline questionnaire was monitored by the PI; if not received within one week, a weekly email

reminder was sent to the contact email address no more than a total of 3 times.

Composition of semi-structured interview: When phone contact is made the participant,

having received study information in advance was reminded that their participation is voluntary

and confidential. In addition, consent to be recorded was obtained prior to initiation of the

recording device, then again with recording rolling. It will be repeated that consent has been

delivered by email and reaffirmed at the present moment. A statement was gathered that the

interviewee has reviewed this information, and verbally agrees to participate. Interviews were

recorded on a password protected audio recording device that was kept in a locked office and

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transcribed with full anonymity by a professional medical transcriptionist who regularly works

with medical and legal data. Interviews were burned to an audio compact disk and archived by

the faculty advisor in a locked cabinet in a locked office at the institution at which this study was

performed. All other versions of the recordings were permanently deleted.

Questions were asked in the order listed (Appendix D). The interviewee was given

ample opportunity to expound upon their responses. Follow-up questions were developed to

delve further into topics that are believed to be of central relevance to the project. After all

questions have been asked the interviewer stated, “thank you, the interview is concluded” prior

to hanging up.

Data analysis plan: A qualitative framework analysis approach was employed as

described by Ritchie and Spencer which “involves a systematic process of sifting, charting and

sorting material according to key issues and themes” (1994). The five key stages of the analysis

process, noted here, were followed. (1) Familiarization, where the researcher acquires an

overview of the topic being examined. This has been done through becoming acquainted with

peer-reviewed literature on the subject (Coleman 2010, Crabtree 2011, Gilfman 2010, Jaen 2010,

Nutting 2011, Stange 2010) and meeting with a FQHC manager who is in the process of

pursuing NCQA PCMH recognition. (2) Identifying a thematic framework begins with

familiarization but culminates into identifying central themes that are in need of exploration and

development. For the most part, these themes are often known prior to the interview phase and

are used to guide the preparation of the questions in a semi-structured interview situation. After

the interviews have been conducted and transcribed the data are (3) indexed and (4) charted

according to the predetermined themes. This will be hierarchical in nature, containing

subcategories within the overarching themes. The chosen model for coding themes is template

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analysis, detailed by Nigel King (Symon & Cassell, 1998). This template coding approach

allows for the flexibility that is required as questions have been prepared beforehand but are

intentionally open-ended so that the interviewee is allowed ample opportunity to expound on the

themes believed to be of central relevance to the project. Finally, (5) mapping and interpretation

of the charts will be the substance of the results section following completion of the previous

four stages. It represents the end product of the qualitative analysis which details lessons learned

by FQHC managers who shared their valuable experiences with transforming a primary care

practice that serves a medically underserved population into a more comprehensive model of

health care delivery.

RESULTS

After attempts to recruit from several FQHCs, administrators at four sites agreed to be

interviewed, and these interviews were completed. Transcriptions were prepared from the audio

recordings and then, following the five steps of framework analysis, a coding template was

compiled. Responses were organized under the four major domains and sub-domains: 1)

Contextual/reasons for seeking recognition: three sub-domains; 2) Diagnostic/describe the

approach that was taken: two sub-domains; 3) Evaluative/how approach was effective or

problematic: one sub-domain with 3 subsequent areas; 4) Strategic/lessons learned: two sub-

domains. The full template is provided in Appendix E.

Contextual/reasons for seeking recognition: The first sub-domain relates to external

evaluation of the organization, either from the community, grantors or payors. Community

perception was of importance to all sites, mostly relating to improvement of their reputation

through marketing or word-of-mouth. Another motivation was to attract more insured patients,

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as stated, “[We wanted] to show that we are not just [serving the] homeless, that we can actually

provide care to insured patients.” Granting agencies such as the Health Resources and Services

Administration (HRSA) and the Department of Housing and Urban Development (HUD) as well

as industry sponsors (i.e.- General Electric) also factored into their decision scheme, either

through efforts to sustain current funding levels or to increase eligibility for additional

opportunities. Financial incentives from meaningful use reimbursements were equally relevant,

“in some areas, [satisfying] meaningful use is just staying 50 percent or greater and in most of

the areas, we are meeting above 80 percent and getting close to 100 percent in most of our

targeted areas.”

The next sub-domain that emerged was organizational performance. Sub-themes included

increasing the quality of patient care through treatment adherence (i.e.- medication use),

illustrated by this response: “[We are] better able to manage the patient's illnesses, so we are

decreasing the number of medications that we are having to give out; we are decreasing the

number of times that the patient might have to come in within a month.” Other improved aspects

of organizational performance included decreasing hospitalization rates/emergency room visits

as well as increased utilization of preventive care such as vaccinations for children. Additionally,

there were reports of their organization’s ability to increase the number of patients seen in a

given time period resulting in decreased waiting times and queuing on the street. “It is very hard

to see somebody who has been sitting out there for three hours and you are telling him, sorry, we

have three slots, we can refer you to an emergency room; and that's not what we were here for.

Our goal was focusing on the patient care and making sure that the patient left here with what

they needed.” There were also reports of better scheduling availabilities. “You would think that

a lot of providers are of the mind-set that if they spend additional time with the patient they will

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be able to see fewer patients, but it is through overall efficiencies that they have actually been

able to increase patient volume.” Consistency of operations was also important, either for

FQHCs operating single or multiple sites, allowing a single set of standards to dictate processes,

which was perceived to reduce variability among clinical teams.

Diagnostic/description of the approach that was taken: One sub-domain relates to the

determination of the approach beginning with development of an understanding of the NCQA

recognition process. All sites reported struggling with informational materials provided: “the

standards are open for interpretation…even with NCQA, their reviewers do not interpret the

same. So, we had some things that came back from one reviewer, ‘no you didn't get these

points,’ and the next reviewer turned around gave them to us. So, it’s more subjective.” There

were reports of gaining a clearer understanding by attending an NCQA conference with

workshops and by arranging an early site visit with representatives including question and

answer sessions.

Adding to the determination of the approach taken was assessment of their individual

readiness. It was important to evaluate the available resources for the planning process. One site

described applying for a grant to improve diabetes outcomes based on the PCMH model which

allowed them to hire an additional nurse dedicated solely to patient education, a critical

component of NCQA recognition. Prior accreditations/recognitions also influenced their

approach. This could include accreditations from other organizations, Joint Commission for

instance, or previous attempts at NCQA-PCMH recognition and falling short of points required

for level 3. Through these prior attempts some of the standards may have already been

implemented. One respondent stated, “It was important to look at the standards and how we

aligned it with our practices and our policies that we currently had. So, that gave us an idea as to

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what we needed to do, if we needed change anything.” It was a common theme for sites to

undergo a degree of trial and error throughout their respective organizations, building upon

experiences over time.

All respondents reported forming a team of at least two or more individuals, then

growing as the initiatives gained momentum. One site described participating in a network of

different FQHCs in their geographical area. Through that collaboration they were able to share

insights and also seek the assistance of a consultant who provided help to multiple sites more

efficiently. No other sites reported hiring a consultant for two primary reasons: lack of available

resources and also the unique characteristics that distinguish FQHCs from other types of

organizations or provider groups. One interviewee – drawing from personal experience – made

it clear that the differences between other private providers and FQHCs were very clear in his

organization and that many experiences did not translate well to more resource-constrained

FQHCs.

Formation of internal teams was essential to progress in meeting NCQA standards. One

specific site reported that it began as an initiative led by their executive officers and medical

directors but later realized the importance of participation across all departments. All of the

organizations interviewed discussed the importance of involvement from accounting departments

as well as information technology departments in large part due to the data tracking and

reporting requirements that are a notably burdensome component of NCQA reporting. There

was an aspect that included internal human resources representatives as well, including revisions

to job descriptions, duties and titles. Participation from case managers and clinical staff was

required as well. This extended to nurses and medical assistants as well as physicians. The

following quote points to the importance of including all personnel within the organization,

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“When we told them the importance of NCQA recognition, that our center would be better for all

these things, they bought into it. And the fact that they were each given something to do within

their department, that did a complete change within our company.”

The second sub-domain relates to defining the approach taken. A major theme was the

establishment of timelines and intermediate goals. Leading the system of prioritization was

imbedded within the NCQA standards. The six must-pass elements dictate that without meeting

those stated criteria, the effort dedicated to the process will not have yielded the desired results.

It was said:

…at our first three meetings, it was a lot of understanding the process, how it

works, and then going over each standard, not understanding them, but knowing

that we had the six standards and which one was the most important to meet and

what they imply... If you don't pass that mandatory standard, no matter whatever

else you have you lose all the points… So, that is what basically, the first three

meetings consisted of.

Once unmet standards were identified the plan to address them could be established.

Some examples include preclinical visits, patient education and family participation. The

standards that were already a part of the regular operations could be moved down the list.

Multiple sites reported implementing self-imposed deadlines to stay on schedule.

With a timeline and intermediate goals in place one major theme that was reported was

the training of personnel, establishing clinical teams comprised of a physician, nurse or medical

assistant and a patient service representative. Further cross training of personnel so that

assistance could be provided to other teams with a degree of interchangeability seemed to gain

importance. Examples include assisting other teams with data entry or patient contact as needed.

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Again, the various data collection, formatting and assimilation tasks were often a new

requirement that demanded considerable effort.

Evaluative/how approach was effective or problematic: One of the primary difficulties

reported includes the additional patient engagement and education requirements. Multiple sites

stated that their patient populations posed some challenges. Some FQHCs reported having a

high percentage of immigrant populations with varying levels of health and social literacy.

Another reported serving a large homeless population and the unique obstacles to patient

involvement that seemed to create. Receiving responses to patient satisfaction surveys did at

times delay the pre-established timelines and often needed more extensive follow up to obtain

survey results to the level specified by NCQA.

Another common recurring theme continued to be engagement and training of FQHC

personnel. It was stated:

one of the most difficult parts for our PCMH model was finding specific teams to

work with. As part of a PCMH model, they were requesting for you to have one

specific medical provider, with either a nurse or a medical assistant, and a patient

service representative be part of that team. So, when the patients are coming in,

they have that knowledge of, okay, [name] is the nurse that works with Dr.

[name] and this is my doctor and oh the service representative registering me

today is [name], so it would make it more of a friendly environment and he would

feel comfortable, especially with the type of population that we deal with.

Further difficulties included data gathering:

our patient services and our financial department play a big role for this

recognition. They tend to want to know exactly how many patients are seen, how

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many outpatient visits, how many people are coming in that are not compensated,

how many are coming in that are [covered through] Medicaid, and I think that is

the most difficult part to maintain.

Strategic/lessons learned: A recurring theme continued to be the interpretation of NCQA

standards. Because NCQA does not perform a site visit to verify satisfying the recognition

standards, everything must be compiled and reported in a certain manner that ultimately was not

clear enough to any of the sites interviewed. If interpretation of the standards is not aligned with

NCQA expectations it is very difficult to achieve level 3 recognition. Only through NCQA

related trainings, frequent communication with NCQA representatives and receiving feedback

could any of the sites meet the overall goal of obtaining level 3 recognition. One site reported

lapses in communication with their representative which led to considerable difficulties in

making progress, or they reported not being effectively informed that they were appointed a

different representative – again, creating barriers for them.

The term transformation is applied to the process because provider organizations are

required to truly transform the way patient care is delivered. This was a challenge for many, but

not all, of the sites that agreed to be interviewed. The operational changes are reportedly

burdensome for FQHC staff who are asked to alter the manner in which their duties are

performed. Another example continues to be the data intensive elements. All sites were

consistent in this. One stated, “getting to a level 3 without having significant ongoing data

analytics capabilities, I think would be difficult,” another clarified, “what we are doing is we are

running reports on a monthly basis, so that at the end of the year, whenever we have to report, we

are not pulling the report on 12-month data. We are just doing it month to month to make our

life much easier.”

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Participation at all levels is critical, continuous and resource intensive. The statement

below is illuminating:

When you first hear, create teams, create huddles, meet with the doctors and

nurses, improve your no-show rate, call the patient the day before, give them that

one-on-one, you know, that human touch… I was one of the ones that said these

teams are never going to work, what they are asking for is very difficult, but give

it a try. It really does work and it is beneficial.

DISCUSSION

Determination of gaps in readiness was truly a site-specific exercise. It may be difficult

to address this on a large scale because of the variation among FQHCs. Few of the sites reported

experiencing the same benefits of obtaining level 3 recognition. Two of the four sites reported

being considerably transformed, one was still looking for greater improvement in quality

measures, yet another site made it clear that they did not gain many benefits at all, that their

operational standards were already reflective of best practices and made no revisions to their

approach to the delivery of care. One influence may be the patient population that is served. It

may be important that the sites that reported greater difficulties as well as achieving greater

benefits of transformation also had higher rates of uncompensated care, ranging from 60-80% of

their overall payer mix. Further studies will likely prove beneficial.

All sites reported grappling with the documentation and reporting aspects however. They

all acknowledged that it is to the advantage of the FQHC to be able to develop their own

strategies and implementation processes, that it can’t be completely detailed by NCQA due to the

variability across sites. All sites were able to overcome the reporting challenges by increased

dialogue with NCQA representatives.

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The principal lesson that emerged was that interpretation of standards must be considered

from the NCQA perspective rather than based on any other assumptions or heuristics on which

one might rely upon when reviewing the materials. It appeared to be worthwhile to attend

NCQA sponsored conferences or workshops dedicated to this pursuit. Also, the level of

cooperation between FQHCs is not consistent. One site reported being contacted by another

FQHC, asking to review their standard operating procedures in preparation for their initial

attempt at recognition. This was not favorably received in part due to the amount of effort that

was spent to acquire these experiences and implement the changes, and so seemingly regarded as

proprietary knowledge that should be guarded. An organization belonging to an external FQHC

network also seemed to gain an advantage by sharing perspectives, insights and a consultant.

There was common agreement that the standards are beneficial, even if they are already

in practice. Most of the sites confirmed that their organization is providing a higher standard of

care within their respective communities after adopting the recommended processes. All

reported a sense of esteem from receiving level 3 recognition. Some thought recertification

would be difficult but others felt that the difficult aspects had already been addressed by the

initial process. One site noted, “I think that re-certification is going to be tough … mostly

because of the staff [who] may be doing a great job and we might find that, now, your great job

is just average and so now you have to do a better job.” Additionally, the importance of their

role in the community as a safety-net provider was widely perceived, “first of all, credentialing

and accreditation for any organization in the managed care world provides better be first rate…”

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CONCLUSION

Implementation of the patient-centered medical home model in federally qualified health

centers may be an important step toward improving the health of medically underserved

populations in this country. Gaining insight from administrators who have fostered their

organizations through the lengthy process of obtaining this recognition from NCQA can possibly

help others with the transformational process. We found that focusing greater attention on

interpretation of NCQA standards along with enhanced communication with representatives

could help organizations throughout this endeavor. Additionally, engaging both internal staff

and patients can present greater challenges than some may initially anticipate. The data intensive

nature of this undertaking is a remarkable hurdle as well. Further studies may be helpful in

addressing the following: expansion of the current sample size to further identify common or

widespread obstacles; examining the environment within FQHCs that have not endeavored to

implement the model; patient engagement in chronically underserved communities and barriers

within these sub-populations that may interfere with the type of engagement that is required by

NCQA; or evaluating the rationale behind FQHCs seeking certification from various accrediting

organizations. Reporting to NCQA is a resource-intensive endeavor regardless of current

practices. Many FQHCs can individually address site-specific barriers by simply initiating the

process within their organizations, learning from other sites as well as the experiences that are

unique to them. Efficient management of resources is a constant process for all organizations.

Developing a tailored approach to pursuing, obtaining and maintaining PCMH recognition with

added attention to lessons previously learned may help to facilitate adoption of these evidence-

based standards.

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Table 1: Semi-structured Interview Questions Organized by Framework Analysis Category

Category

Framework Analysis Emphasis* Current Study Interview Questions

Contextual: Identifying the form and nature of what exists:

“What were the reasons for seeking recognition? …meaningful use reimbursement opportunities? …other reimbursement opportunities? …marketing purposes: positioning your organization as a leading provider? …were there any other mandates that you were responding to? (i.e.- from the State) ...cost-effectiveness savings from better clinical management? ...at what point do you expect to see any operational efficiencies from improved management of patient care? ...any other reasons?”

e.g. What are the dimensions of attitudes or perceptions that are held?

What is the nature of people's experiences?

What needs does the population of the study have?

What elements operate within a system?

Diagnostic: Examining the reasons for, or causes of, what exists:

“Prior to seeking NCQA recognition, what expectations of the process did you have?”

e.g. What factors underlie particular attitudes or perceptions?

“When you began seeking recognition, did you have a clear understanding of what would be required?”

Why are decisions or actions taken, or not taken?

“How did you plan your preparation approach? Did you…form a team? ...seek and hire a consultant? ...develop a structured time line or intermediate goals? ...develop priorities or an action plan?”

Why do particular needs arise?

Why are services or programs not being used?

Evaluative: Appraising the effectiveness of what exists:

"In what ways was your planning adequate? …how could it have been better?"

e.g. How are objectives achieved?

“What were the most difficult parts of preparing for recognition?”

What affects the successful delivery of programs or services?

"Were you able to anticipate what the most difficult parts would be?"

How do experiences affect subsequent behaviours?

"Was it easier or more difficult than you thought it would be?"

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What barriers exist to systems operating?

"Did you feel satisfied with the preparation information that was provided by NCQA?"

"What additional information would have assisted the planning process?"

“What aspects of seeking and maintaining recognition appear to require the greatest amount of resources from your organization?”

“Do you think overall quality of patient care has improved since obtaining recognition?”

“What will be the most challenging issues for recertification?”

Strategic: Identifying new theories, policies, plans or actions:

“Are there any lessons learned or further information that would be helpful for other FQHCs that are considering transformation to the medical home model?” e.g. What types of services

are required to meet needs?

What actions are needed to make programs or services more effective?

How can systems be improved?

What strategies are required or overcome newly defined problems?

*Quoted and paraphrased from Ritchie and Spencer, 1994. **Complete interview, in interview order, contained in Appendix.

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Figure 1: Structure for Identifying Barriers to Implementation of NCQA-PCMH Standards

Criteria to be met for

NCQA recognition as a PCMH

Assessment of FQHC relative to criteria

Determination of gaps in “readiness” Development of

plan to close gaps

Identification of implementation

issues

Methods (Current survey)

Methods (Future directions)

1 2 3 4 5

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APPENDICES

Appendix A: Script for Initial Contact

Hello,

I am a graduate student at the University of Texas School of Public Health and I am conducting a study about the medical home model in federally qualified health centers. Is there someone I could talk to about your organization’s experience with the transition? I am looking for an operations manager or someone who dealt with the majority of the transformational process.

[Requested contact person or voicemail]

[Hello, my name is David Ashton and I am a graduate student at the University of Texas School of Public Health…and I am conducting a study about implementation of the medical home model in federally qualified health centers. I am hoping to gather some information from someone who has overseen the transition process, perhaps an operations manager or whoever was principally responsible for implementation the new standards.]

My goal is to hold an interview for a period of 20 to 30 minutes and to gather some information regarding experiences throughout the transition and any lessons that you may have learned within your organization. Would it be possible to set up some time that works with your schedule? I can be as flexible as needed so that I don’t disrupt your workday.

If I have your consent to be interviewed, I would like to send an email containing letter of information and some preliminary baseline questions about your organization – is this acceptable to you?

May I have your contact information?

Name:

Title:

Phone:

Email:

Best time to call:

Preference for coordinating through administrative assistant:

Thank you very much.

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Appendix B: Letter of Information

LETTER OF INFORMATION

Federally Qualified Health Center Transformation to the Patient-Centered Medical Home Model: A Qualitative Study of Provider Experiences

HSC-SPH-13-0553

Date

Dear _________,

I am inviting you to take part in a research project I am conducting at the University of Texas Health Science Center called Federally Qualified Health Center (FQHC) Transformation to the Patient-Centered Medical Home (PCMH) Model: A Qualitative Study of Provider Experiences. Your decision to take part is voluntary. You may refuse to answer any questions asked at any time. This research project has been reviewed by the Committee for the Protection of Human Subjects (CPHS) of the University of Texas Health Science Center at Houston as HSC-SPH-13-0553.

The purpose of this research study is to gather information regarding transitional lessons that are relevant to FQHC administrators as they consider pursuing medical home recognition from the National Council on Quality Assurance (NCQA). There are many providers that can in turn apply this experience to enhance their own implementation processes in order to deliver a higher standard of health care to individuals in their respective communities.

I would like to ask you a series of questions to which you may respond with as much detail as is comfortable to you. These questions will focus on the experience of your institution during the certification process. This interview will take about 20 to 30 minutes. The only risk of being in this study is the possible loss of confidentiality, and there is no direct benefit to taking part in this study. Your decision to take part is voluntary. You may decide to stop taking part in the study at any time. If you withdraw from the study none of your information or answers will be used in any way. You will not be personally identified in any reports or publications that may result from this study. Any personal information about you that is gathered during this study will remain confidential to every extent of the law. A special number will be used to identify you in the study and only the investigator will know your name. If you have questions at any time about this research study, please feel free to contact me at (512) 669-0658. You can contact me to discuss problems, voice concerns, obtain information, and offer input in addition to asking questions about the research.

Thank you,

David Ashton Masters Candidate School of Public Health, University of Texas Health Science Center

This study (HSC-SPH-13-0553) has been reviewed by the Committee for the Protection of Human Subjects (CPHS) of the University of Texas Health Science Center at Houston. For any questions about research subject's rights, or to report a research-related injury, call the CPHS at (713) 500-7943.

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Appendix C: Baseline Questionnaire PRELMINARY/BASELINE INFORMATION

Provider organization/medical home: How many patients/enrollees in a given time period? How many outpatient visits per year? Ages by age group Preschool: Youth: Teens: Adults under 65: Adults 65+: Specialty services (YES or NO) Vision: YES or NO Dental: YES or NO Behavioral health: YES or NO Other: Payer mix (%) Uncompensated care: Medicaid: Medicare: Private coverage: Covered through additional special program funding (grant to serve specific need, such as Ryan White):

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Appendix D: Semi-structured Interview Questions

QUESTIONS (in order of interview)

1. “Prior to seeking NCQA recognition, what expectations of the process did you have?”

2. “When you began seeking recognition, did you have a clear understanding of what would be

required?”

3. “How did you plan your preparation approach? Did you…”

a. “Form a team?”

b. “Seek and hire a consultant?”

c. “Develop a structured timeline or intermediate goals?"

d. “Develop priorities or an action plan?”

4. “In what ways was that plan adequate?”

a. “How could the plan have been better?”

5. “What were the most difficult parts of preparing for recognition?”

a. “Were you able to anticipate what the most difficult parts would be?”

b. “Was it easier or more difficult than you thought it would be?”

6. “Did you feel satisfied with the preparation information that was provided by NCQA?”

a. “What additional information would have assisted the planning process?”

7. “What aspects of seeking and maintaining recognition appear to require the greatest amount

of resources from your organization?”

8. “Do you think overall quality of patient care has improved since obtaining recognition?”

9. “What will be the most challenging issues for recertification?”

10. “What were the reasons for seeking recognition?”

a. “Meaningful use reimbursement opportunities?”

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b. “Other reimbursement opportunities?”

c. “Marketing purposes: positioning your organization as a leading provider?”

d. “Were there any mandates that you were responding to? (i.e. - from the State)”

e. “Cost-effectiveness savings from better clinical management?”

i. “At what point do you expect to see any operational efficiencies from

improved management of patient care?”

f. “Any other reasons?”

11. “Are there any lessons learned or further information that would be helpful for other FQHCs

that are considering transformation to the medical home model?”

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Appendix E: Coding Template (with quotes)

1 Reasons for seeking recognition (Contextual) 1 External evaluation of organization

1 Community 1 Improve reputation (word of mouth/marketing)

We wanted to be on the forefront and to improve the relationship with the community

1 Attract more insured patients to show that we are not just [serving the] homeless, that we can actually provide care to insured patients

2 Grantors (HRSA, HUD, industry) 1 Sustain current funding levels The number one reason that we have continued to do NCQA, is we are involved in some of the HRSA projects and they require NCQA/PCMH.

2 Eligibility for additional opportunities 3 Payors (Medicare, Medicaid/CHIP, private)

1 Meaningful use in some areas, meaningful use is just staying 50 percent or greater and in most of the areas, we are meeting above 80 percent and getting close to 100 percent in most of our targeted areas.

2 Organizational performance 1 Increase quality of patient care

1 Tx/Rx adherence [We are] better able to manage the patient's illnesses, so we are decreasing the number of medications that we are having to give out; we are decreasing in the number of times that the patient might have to come in within a month

2 Decrease hospitalization rates, ER visits 3 Preventive care

1 Immunizations 2 Increase volume of patient care

1 Decrease wait times/queuing of 43

it is very hard to see somebody who has been sitting out there for three hours and you are telling him, sorry, we have three slots, we can take and can refer you to an emergency room and that's not what we were here for. Our goal was focusing on the patient care and making sure that the patient left here with what they needed.

2 Better scheduling availabilities you would think that a lot of providers are of the mind-set that if they spend additional time with the patient they will be able to see fewer patients, but it is through overall efficiencies that they have actually been able to increase patient volume

3 Operational consistency 1 Single site because that sets the standards at a certain level and it says that if you are level 3 NCQA-recognized, you will have your standards

2 Multi-site 2 Diagnosis of how approach was taken (Diagnostic)

1 Determination of approach 1 Develop understanding of recognition process the standards are open for interpretation…even with NCQA, their reviewers do not interpret the same. So, we had some things that came back from one reviewer, “no you didn't get these points,” and the next reviewer turned around gave them to us. So, it’s more subjective.

1 NCQA conference/workshops 2 NCQA early site visit, Q&A We did have staff from the NCQA come to meet and they did tell us what would be required. They did have a question and answer session, which was very helpful, and then we went from there

3 NCQA website 2 Readiness preparation and assessment

1 Available budget/resources 1 Seek grant funding for additional personnel

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initially we had no budget and what I did is that I applied for a grant to improve diabetes outcomes based on the PCMH model, so that gave me some money to work with and dedicate the time to initiate the different logs and tracking information that is required

2 Prior accreditations (i.e.- Joint Commission) 1 Possibly meeting many standards it was important to look at the standards and how we aligned it with our practices and our policies that we currently had. So, that gave us an idea as to what we needed to do, if we needed change anything

3 Prior attempts for NCQA-PCMH recognition 1 Level 1 or 2 (trial and error)

3 Formation of team 1 External

1 FQHC network (i.e.- shared resources) 1 Multi-site consultant 2 Training sessions

2 Internal When we told them the importance of NCQA recognition, that our center would be better for all these things, they bought into it. And the fact that they were each given something to do within their department, that did a complete change within our company

1 Executive 2 Medical directors 3 Clinical staff

1 Nursing staff 2 Medical assistants 3 Case managers

4 Other departments 1 Billing/Finance

1 Data tracking 2 IT/Analytics

1 Patient portal 2 Data tracking/reporting

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3 Human Resources 1 Revision of job descriptions, change in focus

2 Approach to meeting NCQA standards 1 Establish timeline and goals at our first three meetings, it was a lot of understanding the process, how it works, and then going over each standard, not understanding them, but knowing that we had the six standards and which one was the most important to meet and what they imply... If you don't pass that mandatory standard, no matter whatever else you have you lose all the points… So, that is what basically, the first three meetings consisted of

1 Must-pass elements 2 Identify unmet standards (i.e.)

1 Preclinic visits 2 Patient education 3 Family participation

3 Triage standards already in process 4 Self-imposed deadlines to stay on schedule we set up target dates and timelines we tried to always go back and reassess and that kind of thing. The days became 12 and 14 hour days. And we had to set up some priorities and procedures and kept that in a log that we reviewed ahead of time

2 Training of personnel 1 Establish clinical teams

1 Physician 2 Nurse/MA 3 Patient service representative

2 Cross training 1 Assist other teams when needed

3 Data collection and assimilation 3 How was approach effective/problematic (Evaluative)

1 Difficulties 1 Patient engagement and education

1 Health or social literacy 2 % of uncompensated care

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1 Possible relation to challenges in patient engagement 2 Staff training and engagement one of the most difficult parts for our PCMH model was finding specific teams to work with. As part of a PCMH model, they were requesting for you to have one specific medical provider, with either a nurse or a medical assistant, and a patient service representative be part of that team. So, when the patients are coming in, they have that knowledge of, okay, [name] is the nurse that works with Dr. [name] and this is my doctor and oh the service representative registering me today is So-and-so, so it would make it more of a friendly environment and he would feel comfortable, especially with the type of population that we deal with.

3 Data gathering and reporting our patient services and our financial department play a big role for this recognition. They tend to want to know exactly how many patients are seen, how many outpatient visits, how many people are coming in that are not compensated, how many are coming in that are Medicaid, and I think that is the most difficult part to maintain. And, what we are doing is we are running reports on a monthly basis, so that at the end of the year, whenever we have to report, we are not pulling the report on 12-month data. We are just doing it month to month to make our life much easier.

4 Lessons learned (Strategic) 1 Interpretation of standards

1 Aligning FQHC interpretation of standards with NCQA expectations 1 Trainings offered 2 Frequent communication with assigned representatives from NCQA

1 Potentially problematic, occasional lapses reported 2 Operational challenges

1 Data gathering/tracking 1 Data intensive getting to a level 3 without having significant ongoing data analytics capabilities, I think would be difficult

1 Collection 2 Reporting

2 Review monthly

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2 Participation at all levels 1 Clinical teams 2 Group huddles 3 Training

1 Initial 2 Continuous When you first hear, create teams, create huddles, meet with the doctors and nurses, improve your no-show rate, call the patient the day before, give them that one-on-one, you know, that human touch… I was one of the ones that said these teams are never going to work, what they are asking for is very difficult, but give it a try. It really does work and it is beneficial.

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http://bphc.hrsa.gov/uds/view.aspx?year=2011

8. National Committee on Quality Assurance. (2011). Standards and Guidelines for

NCQA’s Patient-Centered Medical Home 2011.

9. Ritchie, J, Spencer, L. (1994). Qualitative data analysis for applied policy research. pp.

173-194. A. Bryman and R.G. Burgess [eds.] Analyzing qualitative data, 1994.

10. Rittenhouse DR, Shortell SM. (2009). The patient centered medical home: will it stand

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ashton_mph_thesis_fall2014

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