South Florida Physician Survey on Patient-Centered Medical Homes

South Florida Physician Survey on Patient-Centered Medical Homes Allyson Hall, PhD Department of Health Services Research, Management and Policy Unive...
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South Florida Physician Survey on Patient-Centered Medical Homes Allyson Hall, PhD Department of Health Services Research, Management and Policy University of Florida Published 2011

BROWARD

MIAMI-DADE Report to:

www.hfsf.org 305.374.7200



Table
of
Contents
 Executive
Summary ................................................................................................................ 3
 Introduction
and
Background ................................................................................................. 6
 Project
Objective .................................................................................................................. 12
 Methods ............................................................................................................................... 12
 Findings ................................................................................................................................ 14
 Discussion............................................................................................................................. 19
 Recommendations................................................................................................................ 21
 Appendix:
Survey
Instrument ............................................................................................... 25



 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2
 




Executive
Summary
 
 The
concept
of
the
patient‐centered
medical
home
was
brought
to
the
forefront
of
 national
reform
efforts
as
a
mechanism
for
improving
health
care
quality
and
service
delivery,
 reducing
the
growth
in
healthcare
costs,
and
improving
patient
satisfaction
and
outcomes.

 Even
though
the
initial
concept
of
a
medical
home
was
introduced
in
1967
by
the
American
 Academy
of
Pediatrics
(AAP),
it
recently
gained
popularity
as
a
catalyst
for
health
care
delivery
 change
with
its
inclusion
in
the
Institute
of
Medicine’s
Crossing
the
Quality
Chasm:
A
New
 Health
System
for
the
21st
Century
report
as
one
of
the
6
aims
of
quality.1

Medical
homes
and
 patient‐centered
care
is
considered
a
key
approach
to
removing
some
of
the
fragmentation
in
 the
delivery
of
care
and
places
greater
emphasis
on
consumer
involvement
in
their
own
health
 care.
 
 
 During
the
2009
state
legislative
session
in
Florida,
legislators
mandated
the
formation
 of
a
task
force
to
make
recommendations
for
establishing
a
medical
home
pilot
project
for
 Florida
Medicaid.


Although
the
task
force
delivered
its
recommendations
in
February
2010,
 medical
home
legislation
failed
to
pass
during
that
session.

Nevertheless
strong
interest
 remains
among
policymakers
and
others
in
applying
the
medical
home
models
to
physician
 practices
throughout
Florida.
 
 
 This
paper
reports
on
a
survey
of
66
physicians
who
see
Medicaid
patients
in
Miami‐ Dade
and
Broward
counties.
The
intent
of
the
survey
was
to
learn
whether
the
practices
had
in
 place
the
structural
capabilities
necessary
for
medical
home
transformation,
and
also
to
gauge
 their
opinions
about
medical
homes.

Survey
instrumentation
was
guided
by
the
National
 Committee
for
Quality
Assurance’s
(NCQA)
patient‐centered
medical
home
standards
and
on
 recommendations
from
Health
Foundation
of
South
Florida
staff.

To
augment
survey
findings,
 in‐depth
qualitative
interviews
were
conducted
with
physicians
at
3
solo
practices.
 
 Key
Findings
 Health
Care
Accessibility.

A
key
attribute
of
medical
homes
is
accessibility
to
medical
 providers.

The
survey
indicated
that
although
a
significant
majority
of
the
practices
reported
 that
patients
can
get
same
day
appointments,
many
offices
were
not
open
on
the
weekend
(68
 percent),
during
lunch
(57
percent)
or
after
5
pm
(49
percent).


 
 Health
Information
Technology
(HIT).
HIT
is
a
core
attribute
of
the
patient‐centered
medical
 homes.

Seventy‐four
percent
reported
using
some
form
of
HIT.
However,
most
did
not
use
HIT
 3
 


for
two
key
components
of
the
medical
home:
care
coordination
and
clinical
management.

 Only
24
percent
of
practices
using
HIT
said
they
used
it
for
care
coordination
and
36
percent
 used
it
for
clinical
management.


 
 Referrals
to
Counselors
and
Other
Health
Professionals.

There
was
variation
in
practices
 reporting
whether
they
referred
to
allied
health
professionals
for
certain
services.

For
example,
 while
a
majority
of
practices
would
refer
to
a
nutritionist
(87
percent)
or
a
mental/behavioral
 health
counselor
(76
percent),
only
about
42
percent
refer
to
case
managers
or
social
workers.

 
 Following
Patients
across
Systems
of
Care.
Primary
care
medical
homes
should
be
aware
of
 when
their
patients
are
admitted
to
the
hospital
or
visit
the
emergency
room.

However,
only
 about
50
percent
reported
having
a
formal
process
for
indentifying
patients
that
have
an
 unscheduled
hospital
admission
or
emergency
department
visit.
 
 Quality
Improvement
Activities.

Less
than
one‐third
of
practices
said
they
participated
in
 quality
improvement
activities,
and
two‐thirds
do
not
assess
patient
satisfaction.

However,
80
 percent
of
the
practices
said
they
use
evidence
based
guidelines
when
providing
clinical
care.

 
 Participation
in
a
Medical
Home
Demonstration
Program.
Respondents
were
asked
if
they
 would
participate
in
a
medical
home
demonstration
program.

Responses
were
split
evenly
with
 about
51
percent
said
they
would
participate
and
49
percent
said
they
would
not.



Sixty‐five
 percent
of
those
who
indicated
that
they
would
not
participate
in
a
medical
home
 demonstration
said
it
would
cause
additional
administrative
burden
on
the
practice.


Fifty‐eight
 percent
said
that
current
reimbursement
levels
from
insurers
including
Medicaid
were
not
 sufficient
to
support
their
participation
in
a
medical
home
demonstration.




One
of
the
 providers
who
participated
in
the
in‐depth
interviews
indicated
that
he
would
like
to
participate
 in
a
demonstration
program,
but
that
he
does
not
‘have
enough
time
to
even
stop
and
think
 about
it’.
 
 Recommendations
 The
low
response
rate
from
the
survey
necessitates
caution
in
interpreting
findings
and
 generating
conclusions.


However,
although
the
findings
from
this
study
are
not
definitive
or
 conclusive,
they
do
suggest
possible
next
steps
for
furthering
the
medical
home
agenda.


 
 Educate
physicians,
especially
those
in
small
practices
about
medical
homes.

There
are
early
 indications
that
medical
home
transformation
can
result
in
improved
health
care
quality
and
 outcomes.

Strategies
(e.g.
conferences,
webinars)
that
educate
South
Florida
physicians
on:
 the
need
for
and
promise
of
medical
home
implementation
and
successful
transformation
 4
 


strategies
may
help
erase
some
of
the
skepticism
and
uncertainty
associated
with
the
 approach.
 
 Development
of
a
medical
home
learning
collaborative.

Small
practices
often
operate
in
 isolation
without
much
interaction
with
the
larger
delivery
system.



Formalized
learning
 collaboratives
that
bring
together
small
practices
may
help
reduce
some
of
this
isolation,
create
 synergies,
and
provide
resources
to
ensure
sustainability.


 
 Obtain
additional
data
and
information
about
physician
attitudes
and
beliefs
on
medical
home
 transformation.

As
shown
in
this
study,
surveying
physicians
is
difficult
to
do.

To
inform
future
 policy
and
programmatic
work
it
is
necessary
to
continue
to
learn
how
physicians
perceive
the
 medical
home
model
as
well
as
to
identify
the
specific
barriers
and
facilitators
to
 implementation
facing
the
South
Florida
physicians.

Qualitative
study
approaches
can
provide
 a
rich
source
of
information
on
physician
opinions
and
attitudes
towards
medical
homes.

 
 Monitor
health
information
technology
(HIT)
and
electronic
health
record
(EHR)
diffusion
and
 implementation
among
South
Florida
physicians.

HIT
and
EHR
will
serve
as
the
foundation
upon
 which
medical
homes
and
care
coordination
strategies
will
be
implemented.


The
launching
of
 the
Florida
Medicaid
EHR
incentive
program
represents
a
huge
opportunity
for
practices
to
 improve
the
quality
of
care
they
provide.

However,
it
is
unclear
how
successful
the
 implementation
will
be.

Early
monitoring
of
the
diffusion
and
actual
use
of
HIT
will
determine
 whether
the
proposed
strategies
are
successful.
 
 Advocate
for
adequate
provider
reimbursement.

It
is
clear
that
a
major
deterrent
to
medical
 home
participation
is
the
perception
that
current
payment
levels
will
not
sufficiently
cover
the
 cost
of
providing
such
care.

One
of
the
physicians
who
provided
an
in‐depth
interview
 expressed
concern
about
already
existing
low
Medicaid
reimbursement
rates.

As
he
explained,
 medical
homes
appear
to
require
that
he
do
more
for
the
patient.
Therefore
he
should
be
paid
 more.

As
policymakers,
program
planners,
and
others
continue
to
call
for
medical
home
 transformation,
part
of
the
discussion
must
focus
on
finding
ways
to
appropriately
reimburse
 providers
for
these
services.
 
 
 
 
 
 
 
 5
 


Introduction
and
Background
 
 The
uncoordinated
and
fragmented
nature
of
the
US
health
care
delivery
system
has
 been
well
documented.3‐6
Commentators
have
concluded
that
care
across
primary,
specialty,
 ancillary,
and
inpatient
providers
is
delivered
in
a
disjointed
way
with
little
connectivity
across
 the
continuum.


Policymakers
and
others
are
championing
various
models
of
care
integration
 that
are
aimed
at
improving
the
quality
of
care
in
general
and
for
chronic
care
in
particular.
4,
5,
7

 
 Patient‐centered
medical
homes
(PCMHs)
speak
to
delivery
system
integration
centered
 at
the
primary
care
practice
level.

PCMHs
were
brought
to
the
forefront
of
national
reform
 efforts
as
a
mechanism
for
improving
health
care
quality
and
service
delivery,
reducing
the
 growth
in
healthcare
costs,
and
improving
patient
satisfaction
and
outcomes.

The
initial
 concept
of
a
medical
home
was
introduced
in
1967
by
the
American
Academy
of
Pediatrics
 (AAP).8

However,
it

gained
popularity
as
a

catalyst
for
health
care
delivery
change
with
its
 inclusion
in
the
Institute
of
Medicine’s
Crossing
the
Quality
Chasm:
A
New
Health
System
for
the
 21st
Century
report
as
one
of
the
6
aims
of
quality.1

In
addition,
interest
in
PCMHs

homes
rose
 dramatically
in
part
due
to
the
efforts
of
the
National
Committee
on
Quality
Assurance
(NCQA),
 the
Patient
Centered
Primary
Care
Collaborative

(a
coalition
of
employers,
consumer
groups,
 and)
health
care
providers,
and
the
Commonwealth
Fund.7,
9,
10



 
 There
are
many
definitions
of
PCMHs.11

The
Agency
for
Health
Care
Research
and
 Quality’s
(AHRQ)
definition
emphasizes
a
‘relationship‐
based’
orientation
that
takes
into
 account
an
individual’s
needs,
culture,
values,
and
preferences;
the
provision
of
comprehensive
 care
using
a
team
of
providers;
coordination
of
care
across
the
continuum
of
providers;
easy
 accessibility;
and
a
system‐based
approach
that
incorporates
evidence‐based
medicine,
clinical
 decision‐support
tools,
and
an
attention
to
quality
and
performance.12


Most
of
the
other
 definitions
mirror
AHRQ’s
and
encompass
the
notion
that
medical
homes
should
provide
high
 quality,
continuous,
coordinated
or
integrated
care
across
a
range
of
clinical
and
community‐ based
services.

Practices
can
provide
these
services
by
ensuring
that
the
care
is
accessible,
 patient‐centered,
and
that
there
are
significant
information
technology
supports.11

 
 
 In
2007,
the
leading
medical
associations
representing
primary
care
physicians
joined
 forces
as
the
Patient‐Centered
Primary
Care
Collaborative
(PCPCC)
and
developed
the
Joint
 Principles
of
the
Patient‐Centered
Medical
Home.
The
American
Academy
of
Pediatrics
(AAP),
 the
American
Academy
of
Family
Physicians
(AAFP),
the
American
College
of
Physicians
(ACP)
 and
the
American
Osteopathic
Association
(AOA)
adopted
the
following
principles
(Table
1)
 which
have
become
the
basis
of
many
PCMH
models
being
tested
today.7
 
 6
 


Table
1.
Core
Features
and
Corresponding
Elements
of
the
Patient‐Centered
Medical
Home
 Core
Feature
 Personal
physician
 Physician‐led
team
 Whole‐person
 orientation
 Coordinated
care
 Quality
and
safety


Alternative
 scheduling
 arrangements
 Payment
reform


Elements
 Each
patient
has
an
ongoing
relationship
with
a
personal
physician
trained
to
 provide
first
contact,
continuous
and
comprehensive
care
 The
personal
physician
leads
a
team
of
individuals
at
the
practice
level
who
 collectively
take
responsibility
for
the
ongoing
care
of
patients
 The
personal
physician
is
responsible
for
providing
for
all
the
patient’s
health
 care
needs
or
taking
responsibility
for
appropriately
arranging
care
with
other
 qualified
professionals
 Care
is
coordinated
and/or
integrated
across
all
elements
of
the
complex
health
 care
system
 Quality
and
safety
are
hallmarks
of
medical
homes
using
evidence‐based
 medicine,
continuous
quality
improvement,
health
information
technology
and
 other
tools

 Enhanced
access
to
care
is
available
through
systems
such
as
open
scheduling,
 expanded
hours
and
new
options
for
communication
between
patients,
their
 personal
physician,
and
practice
staff
 Payment
appropriately
recognizes
the
added
value
provided
to
patients
who
 have
a
patient‐centered
medical
home


Source:
Patient‐Centered
Primary
Care
Collaborative
(PCPCC)7
 
 The
National
Committee
on
Quality
Assurance
(NCQA)
developed
a
recognition
program
to
 provide
standards
consistent
with
the
Joint
Principles
of
the
Patient‐Centered
Medical
Home
 and
is
a
mechanism
for
identifying
PCMH
attributes
of
medical
practices
participating
in
 demonstration
projects.
6
Table
2
shows
the
2011
draft
revised
structural
attributes.13




 
 Table
2:

Summary
of
NCQA
PCMH
2011
Standards
 Standard
 Enhance
Access/Continuity






 Identify/Manage
Patient
 Populations



• • • • • •

Content
Summary
 Patients
have
access
to
culturally
and
linguistically
appropriate
 routine/urgent
care
and
clinical
advice
during
and
after
office
 hours

 The
practice
provides
electronic
access

 Patients
may
select
a
clinician

 The
focus
is
on
team‐based
care
with
trained
staff

 The
practice
collects
demographic
and
clinical
data
for
 population
management

 The
practice
assesses
and
documents
patient
risk
factors

 The
practice
identifies
patients
for
proactive
and
point‐of‐care
 reminders




 Plan/Manage
Care





The
practice
identifies
patients
with
specific
conditions,
 7




Standard




• 
 Provide
Self‐Care
Support/
 Community
Resources



• • •

• •

Content
Summary
 including
high‐risk
or
complex
care
needs
and
conditions
related
 to
health
behaviors,
mental
health
or
substance
abuse
problems

 Care
management
emphasizes:

 – Pre‐visit
planning

 – Assessing
patient
progress
toward
treatment
goals

 – Addressing
patient
barriers
to
treatment
goals

 The
practice
reconciles
patient
medications
at
visits
and
post‐ hospitalization

 The
practice
uses
e‐prescribing

 The
practice
assesses
patient/family
self‐management
abilities

 The
practice
works
with
patient/family
to
develop
a
self‐care
 plan
and
provide
tools
and
resources,
including
community
 resources

 Practice
clinicians
counsel
patients
on
healthy
behaviors

 The
practice
assesses
and
provides
or
arranges
for
mental
 health/substance
abuse
treatment




 Track/Coordinate
Care



• 


Measure/Improve
Performance



• • •



• •

The
practice
tracks,
follows‐up
on
and
coordinates
tests,
 referrals
and
care
at
other
facilities
(e.g.,
hospitals)

 The
practice
follows
up
with
discharged
patients

 The
practice
uses
performance
and
patient
experience
data
to
 continuously
improve

 The
practice
tracks
utilization
measures
such
as
rates
of
 hospitalizations
and
ER
visits

 The
practice
identifies
vulnerable
patient
populations

 The
practice
demonstrates
improved
performance



Source:

NCQA’s
Patient‐Centered
Medical
Home
2011
Standards
 
 The
PCPCC
principles
were
the
basis
of
a
national
demonstration
project
launched
in
 2006
by
AAFP
to
test
how
they
can
be
incorporated
into
primary
care
practices.

Early
findings
 show
that
transformation
is
slow
and
difficult.14

Nutting
(2009)
and
his
colleagues
found
that
 transformation
to
a
PCMH
requires
epic
whole‐practice
re‐imagination
and
redesign
including
 new
scheduling
and
access
arrangements,
new
coordination
arrangements
with
other
parts
of
 the
health
care
system,
group
visits,
new
ways
of
bringing
evidence
to
the
point
of
care,
quality
 improvement
activities,
institution
of
more
point‐of‐care
services,
development
of
team‐based
 care,
changes
in
practice
management,
new
strategies
for
patient
engagement,
and
multiple
 new
uses
of
information
systems
and
technology.
This
kind
of
transformation
requires
 committed
leadership
and
an
organization
with
an
adaptive,
learning
environment.

In
a
later
 study,
the
authors
continued
to
conclude
that
transformation
to
a
patient‐centered
model
will
 require
significant
external
resources,
motivation
and
leadership.15


 8
 



 Several
studies
have
measured
the
prevalence
of
recommended
structural
capabilities
 to
support
medical
homes
among
primary
care
practices
and
their
impact
on
quality
of
care.

A
 statewide
survey
of
family
medicine
practices
by
Virginia
Commonwealth
University
examined
 the
prevalence
of
medical
home
attributes
using
the
core
features
from
the
Joint
Principles
of
 the
Patient‐Centered
Medical
Home
that

put
forward
by
the
collaborative
of
medical
 associations.16

Their
survey
included
342
office
locations
in
Virginia
and
their
findings
identified
 that
most
practices
reported
continuity‐of‐care
processes
(87%)
and
clinical
guidelines
(77%)
 but
fewer
practices
reported
use
of
patient
surveys
(48%),
electronic
medical
record
for
 internal
coordination
(38%),
community
linkages
for
care
(31%),
and
clinical
performance
 measurement
(28%).

Only
1%
of
practices
surveyed
exhibited
all
elements
outlined
in
the
 medical
home
Joint
Principles.

 
 There
is
some
emerging
evidence
that
medical
homes
improve
patient
outcomes.




A
 review
of
the
evidence
to
date
indicates
that
practice
redesign
focused
on
a
medical
home
 framework
improves
quality
of
care
and
patient
experiences;
and
reduces
emergency
 department
visits,

inpatient
hospitalizations,
and
total
cost.17

Pilot
demonstrations
are
 currently
underway
in
a
variety
of
settings
including
fully
integrated
delivery
systems
and
 community‐based
practices.18

A
study
of
a
pilot
demonstration
program
now
occurring
at
 Group
Health
Cooperative
shows
improvements
in
patient
satisfaction,
lower
costs,
and
a
 reduction
in
hospitalizations
and
emergency
room
visits
in
medical
home
practices
relative
to
 other
practices.19


The

Commonwealth
Fund
surveyed
over
300
primary
care
practices
in
 Massachusetts
to
examine
their
structural
capabilities
and
their
association
with
higher
 performance
on
HEDIS
measures
of
primary
care
quality.20


In
that
study,
Friedberg
and
his
 colleagues
examined
structural
characteristics
such
as
active
use
of
electronic
health
records,
 patient
education
and
reminder
systems,
enhanced
access
to
care
(weekend
hours,
language
 interpreters),
and
attributes
that
demonstrated
a
culture
of
quality
in
the
medical
practice.

 Their
findings
showed
that
frequently
used
multifunctional
electronic
health
records
were
 associated
with
the
largest
performance
differences
on
the
broadest
range
of
HEDIS
measures.
 Some
capabilities,
such
as
physician
awareness
of
performance
results
and
frequent
meetings
 to
discuss
quality,
were
associated
with
smaller
differences
in
performance.

There
is
also
some
 evidence
that
medical
homes
can
reduce
Hispanic
ethnic
disparities
in
the
receipt
of
certain
 preventive
services.21

 
 Several
states,
recognizing
the
value
of
medical
homes
have
initiated
programs
within
 their
Medicaid
programs.


These
states
include
North
Carolina,
Oklahoma,
Pennsylvania,
and
 Washington
State.


The
North
Carolina
program
is
the
oldest,
having
started
in
1998
as
 Community
Care
of
North
Carolina.


Under
this
model,
local
non‐profit
networks
are
formed
 9
 


that
including
primary
care,
specialty
care,
safety
net
providers,
health
departments,
and
 hospitals.

The
primary
care
providers
direct
the
care
provided
to
patients.

They,
along
with
the
 network
receive
a
per
member
per
month
fee
to
implement
various
population
management
 strategies
such
as
disease
management,
care
coordination,
and
health
education.
22,
23



 Evaluations
of
the
North
Carolina
program
found
that
between
2003
and
2006,
the
program
 achieved
significant
savings
relative
to
its
normal
primary
care
case
management
program.

 Yearly
savings
ranged
between
$60
million
and
$162
million
between
2003
and
2006.
23


The
 disease
management
programs
also
proved
to
be
effective.

Between
2000
and
2002,
the
state
 achieved
savings
for
asthma
and
diabetes
patient
of
$3.3
million
and
$2.1
million
respectively.23
 
 
In
Florida,
the
state
legislature
in
2009
mandated
the
formation
of
a
task
force
to
make
 recommendations
for
establishing
a
medical
home
pilot
project
for
Florida
Medicaid.


Although
 the
task
force
delivered
its
recommendations
in
February
2010,
medical
home
legislation
failed
 to
pass
during
that
session.

However,
considerable
interest
remains
in
medical
home
 transformation
in
Florida,
including
amongst
health
care
entities
themselves.

For
example,
in
 2011,
Health
Choice
Network,
a
nation‐wide
collaboration
among
health
centers,
health
center
 controlled
networks
and
partners,
began
the
process
for
NCQA
certification
for
9
community
 health
centers
in
South
Florida
representing
25
primary
care
sites.

Health
Foundation
of
South
 Florida
has
recently
received
requests
from
local
hospital
systems
to
work
towards
adoption
of
 medical
home
standards
at
their
primary
sites.


 
 Below
are
some
of
the
recommendations
from
the
task
force:24
 • Every
Medicaid
recipient
should
have
a
primary
care
provider
(physician,
ARNP,
or
 physician’s
assistant)
who
is
available
on
a
24/7
basis.

 •

Patient
care
should
be
coordinated
–
the
PCP
must
ensure
that
services
to
which
 recipients
are
referred
have
been
received
and
that
appropriate
follow‐up
is
done.
PCPs
 should
address
both
physical
and
behavioral
health
care
needs
of
recipients
and
develop
 strong
referral
relationships
with
local
mental
health
providers.





The
NCQA
Patient‐Centered
Medical
Home
standards
should
be
used
as
a
starting
point
 for
developing
the
requirements
to
qualify
as
a
medical
home.





Pursue
a
3‐tiered
approach
to
levels
of
medical
homes,
similar
to
Oklahoma.

 o Tier
1
–
entry
level
medical
home
 o Tier
2
–
advanced
medical
home
 o Tier
3
–
optimal
medical
home




New
payment
methodologies
and
primary
care
practice
operations
will
need
to
be
 instituted
for
the
medical
home
pilot.

Adequate
physician
participation
in
the
pilot
is


10
 


dependent
upon
the
reimbursement
rates
for
physician
fees
as
well
as
any
case
 management
fee
and/or
incentive
payments.

 
 
 Transformation
to
Patient‐Centered
Medical
Homes:
Potential
Barriers
 Change
in
Physician
Attitudes.
Transformation
to
patient‐centered
medical
homes
will
 require
a
major
change
in
how
clinicians
and
their
staff
think
about
medical
care
delivery.

 Nutting
et
al.
in
their
evaluation
of
a
national
primary
care
demonstration
project
noted
that
a
 practice
must
“embrace
a
different
paradigm
that
moves
it
from
an
efficient
assembly
line
that
 processes
patients
for
the
clinician’s
attention
to
one
that
meets
the
needs
of
individual
 patients,
with
proactive
planning
and
population‐based
care
for
groups
of
patients”.15
Without
 such
a
change
true
patient‐centered
medical
care
may
not
emerge.
 
 No
Change
Strategy
or
Resources.

While
some
practices
may
have
the
desire
to
become
 more
patient‐centered,
the
frenetic
pace
of
primary
care
practices
may
limit
the
ability
to
 transform.

Physicians
and
their
staff
may
simply
not
have
the
time
to
develop
a
systematic
 strategy
or
have
the
resources
to
devote
to
consultants
or
others.

Due
to
this
concern,
most
 practices
that
are
involved
in
transformations
tend
to
be
associated
with
collaborative
or
 demonstration
projects
that
provide
strategic
direction.


 
 Inadequate
Financial
Incentive.
Understandably,
physicians
may
be
concerned
about
the
 additional
work
involved
in
delivering
patient‐centered
care.

Medicaid
payment
in
Florida
is
 currently

on
average
63
of
Medicare
rates
(based
on
2008
data).25

At
these
payment
levels,
 physicians
may
be
reluctant
to
participate
in
medical
homes.

 
 Inadequate
Health
Information
Technology.


Health
information
technology
(HIT)
 supports
certain
key
components
of
patient‐centered
care
including
care
coordination,
clinical
 decision
support
at
the
point
of
care,
and
the
use
of
data
for
population
management
and
 measurement.
10,
26,
27
Recent
national
surveys
have
demonstrated
that
there
is
relatively
little
 adoption
of
electronic
medical
records
(EMR)
and
HIT
among
private
practice
physicians.
28‐35


 For
example,
a
study
of
small
group
practices
(1‐19
physicians)
showed
that
only
26
percent
of
 them
used
electronic
medical
records,
28
percent
used
e‐prescribing,
and
9
percent
used
 chronic
disease
registries.

The
solo
and
two‐physician
practices
were
far
less
likely
to
use
 health
information
processes
relative
to
the
larger
groups.2

There
is
the
possibility
that
there
 may
be
improvements
in
the
adoption
of
HIT
among
physicians.


As
discussed
below,
the
 Federal
government
is
now
providing
incentives
to
encourage
meaningful
use
of
HIT
among
 providers.

A
key
goal
of
this
funding
is
to
promote
the
utilization
of
an
electronic
health
record
 for
each
person
in
the
United
States
by
2014.
 11
 




Project
Objective
 
 This
paper
reports
on
a
survey
of
physicians
in
Miami‐Dade
and
Broward
counties.
The
 survey
sought
to
understand
the
level
of
readiness
among
physician
practices
that
serve
 Medicaid
patients
for
transforming
into
patient‐centered
medical
homes.


Specifically
the
 survey
asked
physicians
about:
 • Characteristics
of
their
practices
 • Elements
associated
with
patient‐centered
medical
homes
 • Their
opinions
and
attitude
towards
primary
care
medical
home,

and

 • Likelihood
of
participating
in
a
medical
home
demonstration
program.


Methods
 
 
Development
of
Physician
Mailing
List.

An
Excel
database
was
created
first
by
compiling
lists
of
 primary
care
providers
from
health
plans
in
Miami‐Dade
and
Broward
counties
that
participate
 in
the
Medicaid
program.

 The
resulting
list
was
sorted
using
the
following
variables:
  Plan
Name

  Provider
Name

  First
Name

  Middle
Name

  Last
Name

  Credentials
  Address
1
(Street
Name)
and
Address
2
(Ste/Bldg
#)

  City,
State
and
Zip
Code

  Telephone
Number,
and

  Specialty
 
 Duplicate
entries
were
removed
to
ensure
that
each
physician’s
office
would
only
 receive
one
mailing.

The
final
unduplicated
list
was
transferred
to
a
Microsoft
Access
database,
 which
facilitated
tracking
by
identifying
the
date
the
surveys
were
mailed,
returned
completed,
 or
deemed
undeliverable
by
the
Post
Office.

Each
provider
was
assigned
a
Provider
 Identification
Number,
which
was
placed
on
the
survey
and
in
their
cover
letter.


 


12
 


Survey
Instrumentation.
Development
of
the
survey
protocol
was
informed
by
the
NCQA
 medical
home
guidelines
with
additional
input
from
Health
Foundation
of
South
Florida
staff.



 See
the
appendix
for
a
copy
of
the
survey.


The
final
mail
packet
included
the
questionnaire,
a
 cover
letter
describing
the
study,
and
a
postage‐paid
return
envelope.

The
survey
was
 presented
in
a
booklet
form,
using
conventional
legal
size
(8
½”
x
14”)
paper,
which
was
then
 folded
lengthwise
to
fit
into
a
regular
business
stationery
envelope.

The
first
page
of
the
 questionnaire
included
the
title
and
instructions
on
completing
the
survey,
and
the
cover
letter
 offered
respondents
the
opportunity
to
either
complete
a
paper
copy
of
the
instrument,
which
 would
be
returned
to
the
University
of
Florida
in
a
stamped
self‐addressed
envelope,
or
to
 complete
the
survey
online
at
SurveyMonkey.
 
 When
the
study
was
originally
designed,
the
intent
was
to
obtain
and
include
 endorsement
letters
from
the
Broward
County
Medical
Society
and
the
Miami‐Dade
County
 Medical
Society.

Despite
numerous
phone
calls
and
emails,
we
were
unable
to
make
contact
 with
society
leaders
or
executives.

 
 Fieldwork.

A
random
sample
of
625
physicians
were
mailed
the
survey
in
November/December
 2010.


Prior
to
the
mailing,
the
University
of
Florida
Post
Office
checked
the
addresses
for
 completeness
(e.g.
ensuring
a
zip
code
was
included).


During
the
first
week
of
January
2011
a
 follow‐up
survey
of
550
was
fielded
to
non‐respondents
(minus
those
that
were
returned
 because
the
practice
had
moved
with
no
forwarding
address).


During
the
third
week
of
 January,
University
of
Florida
students
called
over
100
offices
asking
to
speak
with
the
polled
 physician.

If
the
polled
physician
was
unavailable,
the
students
asked
to
speak
with
a
practice
 manager
or
an
office
manager.

The
intent
was
to
ask
the
manager
to
ask
the
physician
to
 complete
the
survey.

In
many
instances
the
phones
were
not
answered.

In
this
case,
messages
 were
left
on
voicemail.
 
 The
students
encountered
several
problems
when
making
these
phone
calls.

First,
 despite
calling
at
different
points
in
the
day,
the
students
often
encountered
automated
 answering
machines
and
did
not
reach
a
specific
person.

Second,
several
doctors
who
are
listed
 in
the
provider
directories
no
longer
practiced
at
that
location.

Third,
they
had
a
difficult
time
 convincing
office
managers
to
ask
providers
to
complete
the
survey.


Office
managers
said
that
 they
and
their
providers
were
too
busy
to
complete
the
survey.

 
 In
an
effort
to
improve
response
rates
the
study
team
consulted
with
the
University
of
 Florida
Survey
Research
Center.

The
survey
research
center
has
interviewers
who
are
 specifically
trained
in
convincing
reluctant
respondents
to
participate
in
the
survey.

The
survey
 research
center
agreed
to
make
2
call
attempts
to
300
practices
(150
in
each
county).

The
 13
 


intent
of
the
call
was
to
secure
a
commitment
from
the
office
manager
or
a
physician
to
 complete
the
survey
if
it
were
re‐sent
directly
to
a
confirmed
address.


The
office
managers
 were
offered
a
$10
Starbucks
gift
card
for
assisting
with
this
process.


A
telephone
script
was
 developed
to
be
used
as
a
guide
when
communicating
with
the
person
who
answered
the
 telephone.

 
 

 This
portion
of
the
fieldwork
began
in
mid‐March.

During
the
course
of
the
fieldwork,
it
 became
apparent
that
many
of
the
office
managers
had
a
difficult
time
communicating
in
 English.

Therefore,
the
telephone
script
was
translated
in
Spanish.


In
addition,
many
of
the
 individuals
who
answered
the
telephone
were
unfamiliar
with
the
term
‘Medical
Home’.


A
 sentence
describing
the
medical
home
concept
was
added
to
the
script.


The
survey
lab
 secured
a
commitment
from
48
office
managers/receptionists
to
get
a
completed
survey
 returned
in
the
mail
or
via
SurveyMonkey.
 
 A
final
mailing
was
done
on
March
18th
to
these
48
office
managers.

This
resulted
in
10
 additional
responses.


The
total
number
of
responses
received
was
66.

Accounting
for
37
bad
 addresses,
the
response
rate
was
11.2
percent.
(625‐37=588.

66/588=11.2
percent).
 
 
 To
augment
survey
findings,
in‐depth
qualitative
telephone
interviews
were
conducted
 with
three
physicians
from
Miami‐Dade
and
Broward
counties.

The
interviews
asked
the
 physicians
to
describe
their
practice
and
to
provide
opinions
about
medical
homes.


Findings
 
 Practice
Characteristics.


Approximately
56
percent
of
responding
physicians
were
 pediatricians,
39
percent
were
family
medicine
providers,
and
30
percent
were
internists.

All
 respondents
see
Medicaid
beneficiaries.

For
about
48
percent
of
the
practices,
over
30
percent
 of
the
patients
are
Medicaid
beneficiaries,
while
for
about
26
percent
less
than
10
percent
of
 patients
were
on
Medicaid.




Seventy
percent
were
in
one
or
two
person
physician
practices
 and
another
14
percent
were
in
3
to
4
person
groups.


 
 Accessibility.


The
survey
indicates
that
there
may
be
some
limited
access
to
physician
 practices.

As
shown
in
Figure
1,
68
percent
do
not
open
on
the
weekend,
and
57
percent
close
 for
lunch,
and
50
percent
do
not
open
after
5
pm.
 


14
 



 However,
the
majority
of
reporting
practices
indicated
that
patients
can
get
same
day
 appointments
for
routine
or
urgent
care
(Figure
2).

And,
all
practices
said
that
a
clinician
can
be
 contacted
any
time
of
the
day
or
night.




 
 Health
Information
Technology.
Health
information
technology
(HIT)
is
a
core
attribute
 in
the
operationalization
of
patient‐centered
medical
homes.


Almost
74
percent
of
practices
 15
 


indicated
that
they
use
some
form
of
HIT.


Of
those
indicating
that
they
use
HIT,
a
vast
majority
 use
it
for
patient
scheduling
and
collecting
patient
demographic
information.

However,
 considerably
fewer
use
HIT
for
other
key
functions
associated
with
medical
homes,
including
 care
coordination
(24
percent),
reminder
systems
(11
percent),
electronic
medical
records
(31
 percent)
and
patient
registries
(22
percent)
(Figure
3).

 







Provision
of
Medical
Care.

Eighty‐six
percent
of
the
practices
surveyed
(n=65)
said
that
they
 routinely
conduct
comprehensive
health
status
assessments
of
their
patients.

Furthermore,
a
 majority
of
those
surveyed
indicated
that
they
refer
or
recommend
patients
to
a
counselor
or
 health
educator
(Figure
4).

However,
only
about
50
percent
have
a
formal
process
for
 indentifying
whether
patients
have
had
an
unscheduled
hospital
admission
or
emergency
 department
visit.


 


16
 



 Quality
Improvement.

As
shown
in
Figure
5,
not
all
practices
engage
in
formalized
 quality
improvement
activities.


Sixty‐seven
percent
do
not
assess
patient
satisfaction,
and
 only
32
percent
reported
participating
in
quality
improvement
activities.

However,
80
 percent
of
the
practices
said
they
use
evidence
based
guidelines
when
providing
clinical
 care.






 17
 


Opinions
on
Medical
Homes.

The
survey
described
the
general
concepts
associated
with
 medical
homes
and
the
specific
attributes
described
by
the
National
Committee
for
Quality
 Assurance
(NCQA).



Respondents
were
then
asked
to
indicate
whether
they
thought
their
 practice
adhered
to
each
of
the
NCQA
medical
home
components.


As
shown
in
Figure
6,
 there
is
variation
in
the
degree
to
which
practices
thought
they
adhered
to
the
standards.

 Seventy‐eight
percent
thought
they
adhered
to
the
access
and
communication
standard,
 and
63
percent
thought
they
adhered
to
the
care
management
standard.

However,
only
16
 percent
thought
they
provided
advanced
electronic
communication.



 The
physicians
were
also
asked
if
they
thought
their
practice
was
organized
as
a
medical
 home
(n=62).

Fifty‐three
percent
of
respondents
did
not
think
their
practice
was
organized
as
a
 medical
home
while
11
percent
were
unsure.



When
asked
if
they
thought
that
medical
homes
 could
improve
overall
quality
of
care
(n=66),
fifty‐seven
percent
responded
affirmatively.

 However,
23
percent
did
not
know
if
medical
homes
improved
quality,
and
20
percent
said
 medical
homes
would
not
improve
quality
of
care.


 
 Respondents
were
asked
if
they
would
participate
in
a
medical
home
demonstration
 program.

Responses
(n=57)
were
split
evenly
with
about
51
percent
said
they
would
participate
 and
49
percent
said
they
would
not.



Sixty‐five
percent
of
those
who
indicated
that
they
would
 not
participate
in
a
medical
home
demonstration
said
it
would
cause
additional
administrative
 burden
on
the
practice.


Fifty‐eight
percent
said
that
current
reimbursement
levels
from
 insurers
including
Medicaid
were
not
sufficient
to
support
their
participation
in
a
medial
home
 demonstration.




 18
 


The
question
was
then
asked
in
a
slightly
different
way:
if
being
in
a
medical
home
was
a
 requirement
for
participating
in
Medicaid,
would
the
physician
consider
adopting
the
medical
 home
model.


Of
those
who
responded
to
this
question
(n=30)
47
percent
said
they
would
not
 participate
in
the
program,
while
30
percent
indicated
they
were
unsure.

Of
those
who
said
 they
would
not
become
a
part
of
a
medical
home
even
if
required
by
Medicaid
or
unsure
they
 would,
89
percent
thought
it
would
create
an
additional
administrative
burden,
and
83
percent
 indicated
that
they
were
not
sure
if
reimbursement
would
be
adequate
in
a
Medicaid
 demonstration.


 
 
 Interestingly,
the
three
physicians
interviewed
were
not
particularly
familiar
with
the
 term
‘medical
home’.

However,
when
a
description
was
provided
to
them,
all
three
indicated
 that
they
were
a
medical
home.


In
fact,
 For
Future
Surveys
of
South
Florida
Physicians:
 all
three
performed
key
medical
home
 Lessons
Learned
 functions
including
coordinating
referrals
 Provider
Directories
may
not
be
a
reliable
source
on
 to
specialists,
enrolling
patients
in
disease
 which
to
build
a
sampling
frame:


Addresses
can
be
 wrong,
physicians
close
their
practices
or
cease
to
 management
programs,
and
EHR/HIT.



 practice
or
work
at
the
listed
location.

Consider
using
 One
individual
indicated
that
while
he
 lists
that
can
be
obtained
for
a
fee
from
the
American
 Medical
Association,
or
the
Florida
Department
of
 would
like
to
participate
in
a
medical
 Health.
 home
demonstration
program,
he
is
too
 Reaching
a
‘live
person’
via
telephone
proved
to
be
 busy
to
even
think
about
it.

However,
the
 more
difficult
than
expected.

Many
offices
have
 ‘phone
trees’
requiring
that
several
buttons
be
 other
practices
indicated
that
 pushed
before
a
receptionist
can
be
reached.


 participation
might
improve
the
quality
of
 Furthermore
many
offices
are
closed
during
lunch,
 care
provided
to
their
patients.


 open
late,
or
close
early
on
certain
days.

 Communicating
in
English
was
difficult
for
many
of
 the
receptionists
who
answered
the
phone.

 Explaining
the
purpose
of
the
survey
and
what
we
 wanted
was
hard
to
convey
to
non‐English
speakers.
 Ten
dollar
gift
cards
did
not
provide
a
sufficient
 incentive.

We
had
hoped
that
by
securing
a
 commitment
from
the
receptionist
and
providing
 them
with
a
gift
card
would
have
increased
the
 number
of
responses.
However,
this
did
not
occur.

 We
suspect
that
practices
are
simply
too
busy
and
are
 not
interested
in
completing
the
survey.

We
note
that
 other
surveys
of
physician
practices
provide
at
least
 2 $100
incentives. 


 


Discussion



As
noted
above
obtaining
 physician
participation
in
the
survey
 proved
to
be
challenging.

Despite
several
 different
approaches
we
only
obtained
66
 responses
out
of
a
total
588
good
 addresses,
resulting
in
a
11.2
percent
 response
rate.

The
accompanying
text
 box
summarizes
lessons
learned
that
can
 be
applied
to
future
surveys
of
South
Florida
physicians.



Due
to
the
low
response
rate,
 findings,
conclusions,
and
interpretations
from
this
survey
must
be
done
cautiously.

 Nevertheless,
this
data
does
provide
a
good
qualitative
assessment
of
the
readiness
of
South
 Florida
physicians
for
primary
care
transformation.



 
 19
 



 Recall
the
6
standards
that
NCQA
recommends
as
key
components
of
patient‐centered
 medical
homes:

access
and
continuity
of
care,
the
ability
to
identify
and
manage
patient
 populations,
planning
and
managing
care,
the
provision
of
self‐management
care
supports
and
 community
resources,
the
ability
to
track
and
coordinate
care,
and
the
ability
to
measure
and
 improve
performance.

Survey
results
appear
to
indicate
that
many
physician
practices
in
South
 Florida
will
have
to
undergo
significant
transformation
to
meet
these
standards.

Among
the
 respondents
to
this
survey
many
lacked
fundamental
components
of
the
PCMH
model,
notably
 extended
operating
hours,
certain
HIT
capabilities,
use
of
health
educators
and
counselors,
and
 participation
in
certain
quality
improvement
activities.

Clearly,
certain
elements
are
relatively
 easy
to
achieve
such
as
ensuring
access
to
care.

Other
elements
are
likely
more
complicated
to
 achieve
and
will
require
significant
monetary
and
other
resources
to
implement
change.



 
 HIT
is
the
most
apparent
example
in
this
regard.

It
is
expensive
to
implement
and
 requires
a
significant
amount
of
time
to
learn
how
to
use.
Perhaps,
then,
it
is
not
surprising
that
 about
25
percent
of
the
practices
have
no
form
of
HIT.

And,
even
among
the
practices
that
use
 HIT,
the
capabilities
and
functions
employed
are
some
of
the
most
basic
and
will
only
minimally
 address
the
needs
of
a
patient‐centered
practice.



Recognizing
that
the
implementation
and
 use
of
HIT
is
critical
to
current
medical
practice,
the
Federal
government
has
enacted
the
 Medicare
and
Medicaid
Electronic
Health
Records
Incentive
program
as
part
of
the
American
 Recovery
and
Reinvestment
Act
(ARRA)
of
2009.


These
programs
provide
a
financial
incentive
 to
providers
and
facilities
for
adopting
‘meaningful
use’
certified
EHR
technology.1

Meaningful
 use
is
broadly
described
in
the
ARRA
as:
 
 • The
use
of
a
certified
EHR
in
a
meaningful
manner,
such
as
e‐prescribing.

 • The
use
of
certified
EHR
technology
for
electronic
exchange
of
health
information
to
 improve
quality
of
health
care.

 • The
use
of
certified
EHR
technology
to
submit
clinical
quality
and
other
measures.
 
 A
key
goal
of
this
program
is
the
use
of
an
EHR
for
every
person
in
the
United
States
by
 2014.
 
 Florida’s
Agency
for
Health
Care
Administration
was
awarded
$1.6
million
by
the
 Centers
for
Medicare
and
Medicaid
Services
to
support
the
implementation
and
adoption
of
 meaningful
use
EHR
among
Medicaid
providers.

The
program,
scheduled
to
begin
in
August
 2011
will
provide
professionals
up
to
$63,750
over
six
years
if
they
implement
the
appropriate
 




























































 1


See
Centers
for
Medicare
and
Medicaid
Services

EHR
Incentive
Programs
Overview
at:


 https://www.cms.gov/EHRIncentivePrograms/01_Overview.asp#TopOfPage



20
 


technology.2
This
program
should
result
in
significant
adoption
of
HIT
capabilities
among
 providers
in
the
coming
years.
 The
survey
also
appears
to
indicate
that
the
physicians
are
not
uniformly
convinced
that
 they
should
undergo
medical
home
practice
transformation.

Of
those
surveyed,
57
percent
 thought
the
medical
homes
could
improve
quality
of
care
and
health
outcomes
for
individuals.

 The
remaining
43
percent
were
either
unsure
of
the
benefits
of
medical
homes
or
did
not
think
 quality
of
care
could
be
improved.


Furthermore,
only
50
percent
would
consider
participating
 in
a
medical
home
demonstration
program.

The
three
top
reasons
for
not
participating
 included
the
belief
that
this
would
lead
to
an
additional
administrative
burden,
reimbursement
 levels
are
not
sufficient,
and
that
the
physician/practice
did
not
have
the
time
or
resources
to
 undergo
transformation.



These
findings
suggest
that
even
if
significant
Federal
and
state
 resources
are
expended
to
support
HIT
development,
attention
must
also
be
placed
on
 convincing
physicians
of
the
value
of
PCMHs
and
to
ensuring
that
they
receive
suitable
 reimbursement
for
their
efforts.


Recommendations
 
 While
the
findings
from
this
study
are
not
definitive
or
conclusive,
they
do
suggest
possible
 next
steps
for
furthering
the
medical
home
agenda.


 
 Educate
physicians,
especially
those
in
small
practices
about
medical
homes.

The
literature
on
 the
implementation
and
outcomes
of
medical
homes
is
expanding
rapidly.

As
noted
above
 there
are
early
indications
that
medical
home
transformation
can
result
in
improved
health
 care
quality
and
outcomes.

Strategies
(e.g.
conferences,
webinars)
that
educate
South
Florida
 physicians
on:
the
need
for
and
promise
of
medical
home
implementation
and
successful
 transformation
strategies
may
help
erase
some
of
the
skepticism
and
uncertainty
associated
 with
the
approach.
 
 Development
of
a
medical
home
learning
collaborative.

Small
practices
often
operate
in
 isolation
without
much
interaction
with
the
larger
delivery
system.



Formalized
learning
 collaboratives
that
bring
together
small
practices
may
help
reduce
some
of
this
isolation,
create
 synergies,
and
provide
resources
to
ensure
sustainability.

It
must
be
recognized
however,
that
 the
implementation
of
a
collaborative
will
require
thoughtful
approaches
to
ensure
successful
 implementation
as
articulated
in
the
evaluation
of
the
National
Demonstration
Project
on
 Practice
Transformation
to
a
Patient‐Centered
Medical
Home.14

Some
of
the
recommendations
 




























































 2


See
Agency
for
Health
Care
Administration
EHR
Florida
Medicaid
Incentive
Program
at:
 http://www.ahca.myflorida.com/medicaid/ehr/


21
 


include:

assuring
adequate
financial
resources,
tailoring
the
approach
to
the
practice,
providing
 practices
with
assistance
their
personal
transformation,
and
the
establishment
of
initial
realistic
 expectations
of
the
time
and
effort
involved.14
 
 Obtaining
additional
data
and
information
about
physician
attitudes
and
beliefs
on
medical
 home
transformation.

As
shown
in
this
study,
surveying
physicians
is
difficult
to
do.

To
inform
 future
policy
and
programmatic
work
it
is
necessary
to
continue
to
learn
how
physicians
 perceive
the
medical
home
model
as
well
as
to
identify
the
specific
barriers
and
facilitators
to
 implementation
facing
the
South
Florida
physicians.

As
an
addendum
to
this
study,
in‐depth
 qualitative
interviews
with
3
physicians
were
conducted.


However,
a
larger
more
formal
 qualitative
study
of
both
physicians
and
their
administrative
staff
could
inform
the
 development
of
a
collaborative
and
other
strategies.
 
 Monitor
HIT
and
EHR
diffusion
and
implementation
among
South
Florida
physicians.

HIT
and
 EHR
will
serve
as
the
foundation
upon
which
medical
homes
and
care
coordination
strategies
 will
be
implemented.


The
launching
of
the
Medicaid
EHR
incentive
program
represents
a
huge
 opportunity
for
practices
to
improve
the
quality
of
care
they
provide.

However,
it
is
unclear
 how
successful
the
implementation
will
be.

Early
monitoring
of
the
diffusion
and
actual
use
of
 HIT
will
determine
whether
the
proposed
strategies
are
successful.
 
 Advocate
for
appropriate
provider
reimbursement.

It
is
clear
that
a
major
deterrent
to
medical
 home
participation
is
the
perception
that
current
payment
levels
will
not
sufficiently
cover
the
 cost
of
providing
care.

As
policymakers,
program
planners,
and
others
continue
to
call
for
 medical
home
transformation,
part
of
the
discussion
must
focus
on
finding
ways
to
 appropriately
reimburse
providers
for
these
services.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 22
 


1.
 2.


3.
 4.
 5.
 6.
 7.
 8.
 9.
 10.
 11.
 12.
 13.
 14.
 15.


16.
 17.


18.
 19.


20.


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21.


Beal
A,
Hernandez
S,
Doty
M.
Latino
access
to
the
patient‐centered
medical
home.
J
Gen
Intern
 Med
2009;24
Suppl
3:514‐20.
 Kaye
N,
Takach
M.
Building
Medical
Homes
in
State
Medicaid
and

CHIP
Programs:
National
 Academy
for
State
Health
Policy;
June
2009.
 The
Henry
J.
Kaiser
Family
Foundation.
Kaiser
Commission
on
Medicaid
and
the
Uninsured.
 Community
Care
of
North
Carolina:
Putting
Health
Reform
Ideas
into
Practice
in
Medicad;
May
 2009.
 Agency
for
Health
Care
Administration.
Medicaid
Medical
Home
Task
Force
Report.
In.
 Tallahassee,
Florida;
2010.
 Zuckerman
S,
Williams
AF,
Stockley
KE.
Trends
in
Medicaid
physician
fees,
2003‐2008.
Health
Aff
 (Millwood)
2009;28(3):w510‐9.
 Marchibroda
JM.
The
impact
of
health
information
technology
on
collaborative
chronic
care
 management.
Journal
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Managed
Care
Pharmacy
2008;14(2
Suppl):S3‐S11.
 Reid
RJ,
Wagner
EH.
Strengthening
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care
with
better
transfer
of
information.
CMAJ
 2008;179(10):987‐988.
 DesRoches
CM,
Campbell
EG,
Rao
SR,
Donelan
K,
Ferris
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et
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Electronic
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ambulatory
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New
England
Journal
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Medicine
 2008;359(1):50‐60.
 Simon
JS,
Rundall
TG,
Shortell
SM.
Drivers
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medical
record
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 groups.
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Quality
and
Patient
Safety
2005;31(11):631‐639.
 Simon
SR,
Kaushal
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Cleary
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2007;167(5):507‐512.
 Ford
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Menachemi
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Predicting
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 physicians:
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 Menachemi
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Charting
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2006;6:1471‐ 2431.
 Menachemi
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 urban
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 Shields
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22.
 23.


24.
 25.
 26.
 27.
 28.


29.
 30.
 31.


32.


33.
 34.


35.
 2008.
 



 
 
 
 
 
 
 
 
 24
 


Appendix:
Survey
Instrument
 



 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Medical
Home
Survey
for
South
Florida
Physicians
 Health
Foundation
of
South
Florida
and
the
University
of
Florida
are
surveying
 primary
care
physicians
to
assess
their
understanding
and
readiness
to
establish
a
 medical
home
model
within
their
practices.

Efforts
are
underway
at
the
national
 level
and
in
many
states
across
the
country
to
support
the
adoption
of
a
patient‐ centered
medical
home
delivery
model
which
is
believed
to
result
in
more
 integrated
and
coordinated
care
for
the
patient.



 
 Given
the
recent
interest
and
push
for
patient‐centered
medical
homes,
we
want
to
 know
what
you
know
about
medical
homes,
your
opinions
on
the
extent
to
which
 they
can
improve
quality
of
care
for
patients,
and
readiness
to
adopt
this
delivery
 system
model.
 
 Your
participation
in
this
survey
is
entirely
voluntary.

Please
be
aware,
however
 that

the
information
collected
will
be
used
to
inform
state
planning
efforts
towards
 adopting
a
medical
home
model
and/or
inform
state
policy
regarding
medical
 homes
as
a
cost‐effective
option
under
Medicaid
Reform.

There
is
no
harm
to
you
 or
your
practice
associated
with
your
participation.
All
of
the
findings
from
this
 study
will
be
reported
in
aggregate
and
directly
to
you.


 
 Please
complete
this
survey
and
mail
it
back
in
the
self
addressed
stamped
 envelope.

Alternatively
you
can
go
online
at
 www.surveymonkey.com/s/medicalhomesurvey
to
complete
the
survey.
 If
you
have
any
questions
or
concerns
please
contact
Allyson
Hall,
PhD,
Project
 Director
at
the
University
of
Florida,
at
[email protected]
or
352‐273‐5129.


25
 


First,
we
would
like
some
information
about
your
practice.
 1. How
many
physicians
are
there
in
your
practice?

 
 
 2. How
many
nurse
practitioners
are
there
in
your
practice?
 
 
 3. What
clinical
specialties
are
practiced
in
your
office?
(Check
all
that
apply)
 
 a.

Internal
Medicine
 b.

Family
Medicine
 c.

Pediatrics
 d.

OB/GYN
 e.

Other:




4. 
What
year
did
the
oldest
member
of
the
practice
graduate
from
medical
school?














































5. Does
your
practice
provide
services
to
Medicaid
patients?




a.

Yes
(go
to
question
6)
 b.

No
(go
to
question
7)
 c.

Don’t
know
(go
to
question
7)




6. What
proportion
of
your
practice’s
patients
are
Medicaid
patients?




a.

Less
than
10
percent
 b.

Between
10
and
30
percent
 c.

Over
30
percent
 d.

Don’t
know
 
 


7. Does
your
practice
have
office
hours
on
the
weekends?


a.

Yes
 b.

No
 c.

Don’t
know
 
 
 
 
 
 
 26
 


8. Does
your
practice
close
for
lunch?






a.

Yes
 b.

No
 c.

Don’t
know
 
 
 
 9. Does
your
practice
have
office
hours
after
5
o’clock?

 
 a.

Yes
 b.

No
 c.

Don’t
know
 
 10. 
Are
patients
able
to
obtain
same‐day
appointments
for
routine
care?
 
 a.

Yes
 b.

No
 c.

Don’t
know
 11. 
Are
patients
able
to
obtain
same‐day
appointments
for
urgent
care?






a.

Yes
 b.

No
 c.

Don’t
know
 
 12. Can
patients
contact
a
clinician
any
time
of
the
day
or
night?
 

 a.

Yes
 b.

No
 c.

Don’t
know
 
 13. Do
you
use
any
form
of
electronic
health
information
technology
(i.e.
computer
 systems)
in
your
practice?

 
 a.

Yes
(go
to
question
14)
 b.

No
(go
to
question

19)
 c.

Don’t
know
(go
to
question
19)
 
 


27
 


14. What
functions
are
served
by
the
electronic
health
information
technology
in
your


office?
(Check
all
that
apply)


a.

Patient
scheduling





c.

Electronic
claims
submission




e.

E‐Mail
 




b.

Financial
data
 management
 d.

Patient
clinical
 management
 f.

General
clinical
 information
searches
(on
the
 internet)
 h.

Electronic
prescribing
 j.

Electronic
transmission
of
 lab
results




g.

Patient
communication
 i.

Referrals
to
other
providers
 




k.

Patient
registries
or
lists
of
 patients
with
specific
diseases


l.

Electronic
medical
or
 health
records




n.

Reminder
systems
(e.g.
 alerting
clinician
that
patient
 needs
a
lab
test
or
 prescription)


m.

Coordination
of
care
(such
as
 with
other
providers,
hospitals,
 
 care
managers)
 
 o.

Other
(please
indicate):



 
 15. Does
the
electronic
health
information
technology
collect
patient
demographic
 information?
 
 a.

Yes
(go
to
question
16)
 b.

No
(go
to
question
17)
 c.

Don’t
know
(go
to
question
17)
 
 16. What
patient
demographic
information
is
collected?
(Check
all
that
apply)
 
 a.

Date
of
birth
 b.

Gender
 


c.

Marital
status


e.

Preferred
language
of
the
patient
 


f.

Patient’s
home
address


g.

Patient’s
email
address




h.

Current
and
past
 diagnoses


i.

Dates
of
previous
clinical
visits




j.

Legal
guardian
or
proxy




l.

Health
insurance
 information


k.

Presence
of
advance
directives
 
 m.

Other
information:
 
 28
 


d.

Race/ethnicity


17. Does
the
health
information
technology
collect
patient
clinical
information?




a.

Yes
(go
to
question
18)
 b.

No
(go
to
question
19)
 c.

Don’t
know
(go
to
question
19)
 
 18. If
yes,
what
patient
clinical
information
is
collected?
(Check
all
that
apply)
 
 a.

Over
the
counter
medications,

 b.

Allergies
and
adverse
 
 prescription
drugs,

and
 drug
reactions
 supplements
 c.

Results
of
screenings
and
risk
 
 d.

Blood
pressure
 factor
assessments
 e.

Height
and
weight




f.

Laboratory
test
results



 g.

Imaging
results
 h.

Care
in
other
facilities
 
 19. Does
your
practice
conduct
and
document
a
comprehensive
health
status
 assessment
routinely
for
all
patients?
 
 a.

Yes
 b.

No
 c.

Don’t
know
 
 20. Indicate
whether
you
refer
or
recommend
to
your
patients
the
following
types
of
 counselors
and
health
educators.
(Check
all
that
apply).

 
 
 a.

Nutritionist
 b.

Diabetes
counselor
 c.

Exercise
counselor




d.

Smoking
cessation
counselor


e.

Asthma
counselor




f.

Substance
abuse
counselor




h.

Case
managers/social
workers
 


g.

Mental/behavioral
health
 counselor
 
 i.

Other
(please
indicate):

 
 
 
 
 
 


29
 


21. Does
your
practice
have
a
formal
process
to
identify
patients
with
an
unscheduled




hospital
admission
or
emergency
department
visit?
 
 a.

Yes
 b.

No
 c.

Don’t
know
 
 22. Does
your
practice
have
a
formal
process
for
evaluating
patient
satisfaction
and
 patient
experiences
with
care?
 
 a.

Yes
 b.

No
 c.

Don’t

know
 
 23.

Does
your
practice
use
evidence‐based
guidelines
for
treating
patients?


a.

Yes
 b.

No
 c.

Don’t
know
 
 24.

Has
your
practice
participated
in
any
quality
improvement
projects
within
the
 last
5
years?
 
 a.

Yes
(go
to
question
25)


 b.

No
(go
to
question
26)
 c.

Don’t
know
(go
to
question
26)
 
 
 25. 
Please
describe
the
focus
of
your
quality
improvement
activities:

 
 
 
 Now,
we
would
like
to
get
your
opinions
on
medical
homes.


 
 In
the
past,
some
state
legislators
have
called
for
creating
medical
home
 demonstration
projects
within
the
Florida
Medicaid
program.


Medical
homes
would
 consist
of
groups
of
primary
care
practices
who
come
together
under
one
 administrative
structure.

In
each
medical
home
a
physician
or
other
medical
provider
 would
lead
an
interdisciplinary
team
of
professionals
who
would
share
responsibility
 for
the
ongoing
care
for
a
specific
panel
of
patients.


 
 
 The
patient‐centered
medical
home
would:
 30
 


• 
 • 
 • 
 
 •

Provide
primary
care,
coordinate
services
to
control
chronic
illness,
provide
 disease
management
and
patient
education
 Ensure
care
through
direct
service
to
the
patient
or
by
coordinating
care
to
 other
providers
 
Provide/arrange
for
pharmacy
services,
diagnostic
and
specialty
services,
 inpatient
services,
behavioral
and
mental
health
services,
and
rehabilitative
 services.
 Use
information
technology
and
electronic
medical
records
would
be
used
to
 enhance
clinical
performance
and
monitor
patient
outcomes.



 26.

Does
your
practice
adhere
to
the
following
standards?

(Check
all
that
apply)
 a.

Access
and
Communication

 
 b.

Patient
Tracking
and
Registry
 d.

Patient
Self‐Management
 
 c.

Care
Management
 Support
 e.

Electronic
Prescribing




f.

Test
and
Referral
Tracking



g.

Performance
Reporting
and
 Improvement




h.

Advanced
Electronic
 Communications



 27.

Do
you
think
your
practice
is
currently
organized
as
a
medical
home
as
described
 above?
 
 a.

Yes
 b.

No
 c.

Don’t
know



 28.

Do
you
think
medical
homes
can
improve
the
quality
of
care
and
health
 outcomes
for
individuals?
 



 a.
Yes
(go
to
Question
30)
 b.

No
(go
to
Question
29)
 c.

Don’t
know
(go
to
question
30)



 29.

Why
do
you
think
medical
homes
will
not
improve
the
quality
of
care?
(Check
all
that
 apply)
 
 a.
The
practice
already
provides
quality
care.

There
is
not
much
more
that
 we
can
do
 b.

Medical
homes
will
just
make
health
care
delivery
more
complicated
 c.

There
are
concerns
about
patient
compliance
 d.

Other
reasons:

 
 31
 



 





 30.

If
asked,
would
you
participate
in
a
medical
home
demonstration
program?
 
 a.

Yes
(go
to
Question
35)
 b.

No

(go
to
Question

31)
 
 31.

Why
would
you
not
participate
in
a
medical
home
demonstration?
(Check
all
that
 apply)
 a.

Already
organized
as
a
medical
home
 b.

Additional
administrative
burden
on
practice
 c.

Unsure
of
clinical
and
quality
benefit
of
a
medical
home
 d.
I
prefer
to
focus
on
patients
only
when
they
are
here
for
a
visit.
I
do
not
 think
I
should
be
responsible
for
their
care
coordination
across
providers
and
 services
 e.

Medical
homes
require
too
much
from
a
primary
care
provider
 f.

Current
reimbursement
from
Medicaid
and
other
insurance
companies
is
 not
sufficient
 g.

Health
information
technology
needed
is
too
expensive
 h.

I
(we)
do
not
have
the
time
or
financial
resources
to
convert
the
practice
 i.

I
am
not
sure
how
I
would
go
about
implementing
changes
 j.

Other:

 
 


32.

What
would
it
take
for
you
to
participate
in
a
medical
home?

(Check
all
that

 










apply)
 
 a.

Adequate
reimbursement
structure
for
medical
home/care
coordination
 services
 b.

Grant
funding
to
support
health
information
technology
infrastructure
 development
 c.

Use
of
consulting
services
to
support
transformation
 d.

Additional
information
on
the
value
of
medical
homes
 e.

Mechanisms
to
support
development
of
relationships
with
outside
 providers
and
services
 f.

Other:

 
 
 
 
 
 32
 



 
 


33.

What
if
being
in
a
medical
home
was
a
requirement
for
participating
in
the
 










Medicaid
program,
would
you
consider
adopting
the
medical
home
model?
 
 a.

Yes
(go
to
question
35)
 b.

No
(go
to
question
34)
 c.

Don’t
know
(go
to
question
34)
 
 
 
 34.

If
no,
why
not?
(Check
all
that
apply)
 
 
a.

I
do
not
currently
participate
in
Medicaid
and
do
not
want
to
 
b.

I
would
expect
additional
administrative
burden
on
the
practice
 
c.

Not
sure
if
reimbursement
would
be
adequate
in
a
Medicaid
 demonstration
 
d.

Unsure
of
clinical
and
quality
benefit
of
a
medical
home
 
e.
I
prefer
to
focus
on
patients
only
when
they
are
here
for
a
visit.
I
do
not
 think
I
should
be
responsible
for
their
care
coordination
across
providers
 and
services
 
f.

Medical
homes
require
too
much
from
a
primary
care
provider
 
g.

Current
reimbursement
from
Medicaid
and
other
insurance
companies
 not
sufficient
 
h.

Health
information
technology
needed
is
too
expensive
 
i.

I
(we)
do
not
have
the
time
or
financial
resources
to
convert
the
practice
 
j.

I
am
not
sure
how
I
would
go
about
implementing
changes
 
k.

Other:
 
 35.

Are
the
clinicians
in
your
practice
primarily:
 
 
 
a.

White
 
b.

Black
 
 
c.

Asian
 d.

Hispanic
 
e.

American
Indian/Alaskan
 
f.

Native
American/
 
 Native
 Pacific
Islander
 
 
g.

Not
Determined
 
h.

Other:
 
 36.

Are
the
clinicians
in
your
practice
primarily:
 
 a.
Male
 b.
Female
 


33
 


37.

Thank
you
for
your
time.

Please
provide
additional
comments
below,
or
give


us
your
 contact
information
if
you
are
interested
in
receiving
resources
pertaining

to
medical
homes.
 
 
 
 



 


34