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Disparities in Patient Experiences with Care in a Patient-Centered Medical Home (PCMH)
Patient experience is an indicator of quality of care, and its assessment is a requirement for recognition as a PCMH. Although some literature shows that PCMH generally enhances patients’ experience, there has been no investigation to date on whether the extent of primary care transformation to implement a PCMH affects racial and ethnic disparities in experience with care.
The aim of this paper is to compare the experiences of racial/ethnic populations with care across domains of the PCMH using the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS-PCMH). A customized version of the CAHPS-PCMH survey was administered by mail. Patients with at least one visit to one of 10 University-owned community clinics between June 2010-June 2013, were considered. Respondents were categorized as non-Hispanic White and Hispanic based on self-report. Their experiences with care were categorized as positive or not positive in each of the nine PCMH domains (i.e. access to care, communication, coordination of care, shared decision making, comprehensive care, self-management support, continuity of care, whole person orientation, and office staff interactions). An internally developed tool was used to measure the level of implementation of PCMH in three domains: appropriate access to care (AA), planned care (PC) and Care Team (CT). Implementation score ranged from 0 to 4, where a higher value indicates higher implementation in the domains.
Study Population and Method
Patients 18 years and older with a diagnosis of one or more of three chronic conditions (diabetes, heart failure, and/or coronary artery disease) or with a visit for preventive care services within the previous 12 months comprised the sample (n=2282; non-Hispanic White=1978 and Hispanic=304). Logistic regression with clustering effect was used to test for associations between race/ethnicity and experience outcomes after adjusting for covariates including age, gender, number of visits in the past 12 months, years of education.
Results
Hispanics had less positive experiences than non-Hispanic White patients with respect to access to care (odds ratio (OR)=0.63; p=0.015), self-management support from provider (OR=0.74; p=0.047), and interactions with office staff (OR=0.52; p=0.006). Patients exposed to clinics with high levels of transformation, regardless of race/ethnicity, were more likely to have higher positive experience in almost all domains as compared with patients exposed to clinics with low levels of transformation. Compared with non-Hispanic White patients exposed to clinics with high levels of transformation, Hispanic patients in clinics with low transformation had lower odds for positive experience in most domains. There was no difference in experience between Hispanic patients and non-Hispanic White patients who had exposure to clinics with high levels of transformation. However, for patients exposed to clinics with low levels of transformation, Hispanic patients had lower odds in access to care (OR=0.62; p=0.027) and courtesy of office staff (OR=0.46; p=0.003) than did non-Hispanic White patients.
Implication
This paper suggests that high levels of PCMH implementation may reduce racial and ethnic disparities in care.