4 Attachment G: Physician/PCMH Leader Interview Protocol

RAND DO NOT CITE OR DISTRIBUTE. 4/15/2016

Form Approved
OMB No. 0935-xxxx Exp. Date XX/XX/2017

RAND CAHPS IV Project: CAHPS PCMH Items QI Demonstration

PROVIDER INTERVIEW PROTOCOL

Thank you for your time today. I’m (say first and last name).

Introduce any other study staff present (i.e. note taker).

Go through informed consent script. (2 minutes)

Explain the general purpose and format of the interview, and RAND’s role in this effort:

• We are researchers from RAND, a nonprofit research institution.

• We are doing a research project funded by Agency for Health Care Research and Policy (AHRQ), which is part of the federal government’s Department of Health and Human Services

• The project is intended to learn about your clinic’s experiences becoming a PCMH and how that may influence patients’ experiences with health care.

• FOR THOSE PARTICIPATING IN THE CAHPS DISTINCTION ONLY: We are also interested in your experience obtaining the NCQA Patient Experience Distinction and administering the CG CAHPS survey plus PCMH supplemental items.

  • Each participating practice will also receive a report of the practice’s mean case mix adjusted CG-CAHPS scores and PCMH items (if relevant) compared to the mean scores of the participating practices with a current CAHPS distinction, past CAHPS distinction, and Recognition only practices in the study. No practices will be identified in these reports.

• We want to learn from you and your experiences. The discussion should take about 45 minutes. If you need to take a break at any time, please let me know.

• Data will be reported so that neither you nor your organization can be identified.

• Your participation is voluntary, and you can decline to discuss any topic that we raise. We will not report your participation to anyone outside the research team.

• [CONFIRM RECEIPT OF PCMH ASSESSMENT DATA]

  • IF PCMH ASSESSMENT DATA RECEIVED: You will receive $150 honorarium for completing the interview today and $50 honorarium for the PCMH assessment data you provided, a total of $200

  • IF PCMH ASSESSMENT DATA NOT RECEIVED: You will receive $150 honorarium for completing the interview today

• [OBTAIN/CONFIRM ADDRESS SENDING THE HONOARIUM TO]

• We would like to record this discussion for note-taking purpose only. We will destroy the tape as soon as the notes have been completed. You can still participate in this conversation if you do not want to be taped.

May we record this discussion? [With permission, turn on the audio recorder.]

Public reporting burden for this collection of information is estimated to average 35 minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0XXX, expires XX/XX/20XX), AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

If you have any specific questions about this project, you may contact:

Ron Hays, Ph.D. Principal Investigator- CAHPS RAND 1776 Main Street Santa Monica, CA 90407 Telephone: 310-794-2294 FAX: 310-794-0732 Email: [email protected]

Jim Tebow Human Subjects Protection Committee RAND P.O. Box 2138 Santa Monica CA 90407-2138 Telephone: 310-393-0411 x7173 FAX: 310-393-4818 Email: [email protected]

Turn on recorder.

Do you have any questions before we begin? Please state your name and your title

Module 1: Respondents’ Background (2-3 minutes)

1. First, I’d like to start by having you tell me a little about yourself.

   1. How long have you been at [name of practice]?

   2. Can you tell me a little bit about your current role/position and long have you worked in this role?

   3. Your practice has NCQA PCMH Recognition. What was your role in the NCQA PCMH Recognition process?

      1. Probe: Did you help with filling and submitting the initial Recognition application? Or any recent ones? Have you been on a team of doctors that have made PCMH changes to the practice? Been on a team that has reviewed data on the practice to decide on PCMH changes?

   4. IF PRACTICE QUESTIONS WERE NOT COMPLETED:

AA How many physicians are in your practice? ________(RECORD actual number)

• Small (=<9 physicians)

• Medium (10-49 physicians)

• Large (50 or more physicians)

AB. Who owns the practice?

1. Hospital affiliated practice group

2. Health system affiliated practice group

3. Medical/Academic Health Center

4. Health Management Organization (HMO)

5. Federally Qualified Health Center (FQHC)

6. Privately owned - small (less than or = 9 physicians)

7. Privately owned – med/large (more than 9 physicians

8. Military treatment practice group (NOTE: FLAG THESE FOR VERIFICATION]

9. Other? ____________________

AC. ASK IF NOT A STAND ALONE PRACTICE:

What is the name of your organization? (E.G. we want the name of the network or medical group that the site belongs to)? ___________________________

AD. How many total unique patients does the clinic serve? (ESTIMATE IS FINE)

AE. What is your practice’s estimated number of annual patient visits? (ESTIMATE IS FINE)

AF. How would you describe the clinic’s patient population? (ESTIMATE IS FINE)

1. Patient racial/ethnic Mix:

   1. Percent Minority:

   2. Percent Non-Minority:

2. Patient Language Mix:

   1. Percent English Speakers

   2. Percent Spanish Speakers

   3. Percent Limited English proficiency

3. Patient Insurance payer types- (e.g. uninsured, privately insured, Medicaid, Medicare):

   1. Percentage of revenue from Medicaid

   2. Percent Commercial insurers

   3. Percent uninsured patients

4. Patient Health Care Affiliations:

   1. Significant amount of patients from an independent practice? (Yes/No)

   2. Significant amount of patients from physician-hospital organizations (Yes/No)

   3. Neither of the above (confirm)

Module 2: Practice History of NCQA PCMH Recognition (15 minutes)

2. I would like to talk about your practice’s NCQA PCMH Recogntion and transformation process. First, I would like to confirm the administrative data we have about your practice.

1. Confirm the “Practice Characteristics about PCMH” and “Patient Expreience Data” information that is in GREY on PAGE 2 and 3 above

2. Summarize what is learned/confirmed

{Summarize the PMCH History of the practice, by saying for example, “Your practice is currently a Level XX PCMH and you received that back in XX(Month/Year)}

3. Thank you. Knowing that PCMH history of the practice, I see that you have been at the practice: (Please check one)

a._____ The whole time the practice has pursued PCMH. Is that correct?

b._____ The whole time the practice has pursued PCMH and even before. Is that correct?

c._____ Only part of the time the practice has been a PCMH. Is that correct? Since ______

4. What prompted your clinic to pursue or consider NCQA PCMH recognition? What factors were considered in that decision process? (e.g. internal factors, external factors)

5. How were decisions made about the priorities and strategies for becoming a PCMH? Who was involved in these decisions?

6. What resources, support, or direction has your practice received [from your Medical Group/ Academic Center/ Health System/ Corporate] to help with the PCMH transformation? What has been decided at your site locally?

7. What do you see as the benefits of NCQA PCMH recognition? What are the downsides?

8. What have been your pratice’s major achievements related to becoming a PCMH?

[RECORD OPEN ENDED RESPONSE of up to at LEAST THREE Major Achievements;

USE LIST BELOW IF NEED TO PROMPT OR PROBE]

9. Ask about the specific PCMH changes mentioned from list above: How were these major changes approached or sequenced:

   1. Can you summarize the main PMCH changes that were made? And when (Month/Year)?

10. Does your clinic currently use any type of “team-based” approach to delivering primary care? If so, what does it look like?

Probes: How many and what types of staff are on each team? What roles do they play? Was this part of the PCMH process?

11. Have there been changes in team meetings or team huddles related to becoming a PCMH?

12. What about changes in the process or flow of a patient visit? Such as pre-visit chart review, visit planning? Are these related to PCMH?

13. How does your clinic communication lab tests or procedures results to patients? What have been the changes as you became a PCMH?

14. How does your practice use an electronic medical record?

Probe: What specific functions are performed? (Yes/No/Don’tKnow)

Patient Specific:

• Electronic patient records

• Direct electronic exchange of information with patients (email or portal)

• Non-visit based care

• Tests and procedures results

• Prescriptions/Electronic prescribing

• Referrals to online resources

Organizational:

• Computerized scheduling

Scheduling models:

• Automated reminders (e.g. medication interaction alerts, allergy alerts)

• Visit summary reports

• Insurance billing

Potential Probe: How long has the practice used this? What was the impetus to make the change – was it PCMH? Are there any changes/improvements you would suggest?

15. Which of the changes (outlined above) in information technology were specifically made to become a PCMH? (NOTE that Meaningful Use standards were beign implemented in the same timeframe).

16. Can you tell us how these changes to the electronic medical record and its functionality impact your ability to do your work?

17. How have your roles and interactions with patients changed as you became a PCMH?

Probe for changes generally associated with PCMH, e.g., staff mix, staff compensation, teamwork, etc.

18. From the perspective of patients and their family and other caregivers, what do you think are the biggest changes they would notice in receiving care from a PCMH versus a more traditional practice model?

19. What are the major challenges you’ve encountered (or foresee) in becoming a PCMH? In attaining NCQA Level 3 recognition in particular?

Probe for things generally expected to be challenging, e.g., staff resistance, new staffing models, introduction of IT systems, costs of new care activities.

20. How much change do you believe is still required for your clinic to become the type of PCMH you’d like it to be? E.g. What steps are you currently undertaking to further implement the PCMH (that we have not discussed)?

21. [If clinic has not yet attained NCQA Level 3 recognition:] How much change do you believe is still required for your clinic to attain NCQA Level 3 recognition as a PCMH?

22. In your opinion, how effective have your PCMH efforts been (and why)?

23. What type of monitoring have you done to assess the progress of the PCMH changes?

Probe: Did you assess the patient experience during your PCMH change process?

Module 3: Patient Experience Survey Data (3-5 minutes)

We’ve been talking about your pratice’s PCMH changes and NCQA Recognition history. Now I’d like to change gears for a few minutes and talk about your patient experience survey data.

24. Does your practice collect any patient experience survey data? (Yes/No/Don’t Know)

IF YES:

1. Since when have you collected your current patient experience survey tool? (month/year)

2. What mode is used (for your patient experience survey tool):

• Phone only

• Mail only

• Mixed mode: Mail with phone follow up

• Email only

• In office, visit-based with tablet only?

• Other (including other types of Mixed mode)? __________________

• Don’t Know

3. Do you collect your patient experience data in a language other than English? (Yes/No/Don’t Know)

If yes, which language(s)? _____________

4. Do you know if you collect the Clinician and Group CAHPS survey (referred to as CG-CAHPS survey)? (Yes/No)

IF Yes [This identifies to research team that we are to follow up about a DUA]:

• Have you been collecting the CG-CAHPS since (MONTH /YEAR FROM ABOVE)? Or when did you start administering the CG-CAHPS survey?

• Does your survey include the supplemental PCMH items?

(Yes/No-Never/ No-in the past/Don’t Know)

25. THEN SUMMARIZE: “You mentioned that you collect the CG-CAHPS data {…. Plus the PCMH supplemental items} since (INSERT MONTH YEAR).”

What do you think about the questions that are asked on your patient experience survey? [Probe: Are they the right kinds of questions?]

NOTE:{Refer to Questions in back to protocol to gain insight into domains and specific items}

26. What was the rationale behind the choices made for your patient experience survey tool (e.g. core CG-CAHPS only, CG-core plus PCMH, 12 month reference vs. visit based, etc.)?

Probe: Do you know the reasons for why the 12-month reference version (or the visit based version) was chosen?

27. Did you have a patient experience survey tool prior to CG-CAHPS? If so, why was the switch made to CG-CAHPS?

28. FOR THOSE THAT USE THE CG_CAHPS DATA: Does your CG-CAHPS survey tool include any supplemental items beyond the core CG-CAHPS survey items?

    1. IF YES: Was there specific discussion about the rationale for including the supplemental items?

29. FOR CAHPS DISTINCTION PRACTICES ONLY WHO COLLECT THE PCMH ITEMS: Was there specific discussion about the rationale for including the PCMH supplemental items?

30. Are there specific questions or aspects of patient experience that are more important to your practice than others?

31. A. IF THEY COLLECT CG-CAHPS DATA:

THEN ASK FOLLOWING IF WE DO NOT HAVE A NAME OF A PROVIDER TO WORK ON OBTAINING THE DUA:

Finally, we would like to work with your practice to obtain your patient experience –CG CAHPS survey data files for the past several years covering your PCMH history time frame. Would you be the appropriate person to talk to about obtaining your patient experience data (e.g. Clinician Group CAHPS data)? (Yes/No) If not, who would you recommend we talk to?

RECORD NAME AND CONTACT INFO FOR PERSON TO CONTACT ABOUT DUA

IF YES: e.g they are the appropriate person, then provide following information:

We would like to get a copy of your site’s de-identified CG-CAHPS data for the years covering the PCMH transformation. To do this, the first step is to sign a Data Use Agreement executed directly with RAND and your site. Could this be signed by you? If not, who would that be?

RECORD NAME AND CONTACT INFO FOR PERSON TO CONTACT ABOUT DUA

Once a DUA is signe, we could work together to provide RAND with the copy of CG-CAHPS De-Identified Patient level data file(s) for the time period that covers NCQA PCMH Recognition until present. We have a secure method of transferring the data files to RAND.

What is the name of the IT person or data manager that we would work with on obtaining the data files?

RECORD NAME AND CONTACT INFO FOR IT PERSON TO CONTACT ABOUT DATA FILES

• RAND will conduct a de-identified analysis of the your site’s CG-CAHPS data including any PCMH supplemental items for your practice covering the period of time of your PCMH Transformation.

• Each participating practice will also receive a report of the practice’s mean case mix adjusted CG-CAHPS scores and PCMH items (if relevant) compared to the mean scores of the participating practices with a current CAHPS distinction, past CAHPS distinction, and Recognition only practices in the study. No practices will be identified in these reports.

B. IF THEY DO NOT COLLECT CG-CAHPS DATA:

Could we would ask you to send us a copy of the patient experience survey tool that you are currently using??

Module 4: Use of Patient Experience Data during PCMH Transformation Process (10-15 minutes)

Next, I have a few questions about how you use your patient experience data in your practice.

32. Are the patient experience data useful (If so, in what way? If not, why not?)

    1. FOR CAHPS DISTINCTION PRACTICES: Did the PCMH supplemental items add value? (If so, in what way? If not, why not?)

33. Did the patient experience data assist in any specific aspects of the PCMH related changes? If so, which ones?

34. How often do you receive reports on your patient experience scores from your vendor?

1. Record name of Vendor: Who is your vendor? (e.g. Press Ganey)

35. What do you receive from your vendor? Please describe the report including what comparisions are made to your practice data?

    1. Probe: Does the data report include aggregation by provider, by practice? Trend analyses comparing recent to previous performance? Understanding drivers of composite scores? Benchmarking between and within pratices?

• If benchmarking: How are comparison pratices identified for benchmarking? For instance, is it by region? By similarity of service mix? By local competitors?

2. How are the results of the analysis presented? For example, do you receive reports from vendors?

   1. If yes: Are the reports in some standard form or are they customized for your practice or group? What information and measures are contained in these reports?

36. When you receive a new report of your clinic’s performance on patient experiences, how do you make use of these data?

    1. QI intiatives and change efforts

    2. Specific PCMH change efforts

    3. Performance reporting and monitoring

    4. Other?

37. For these change intitiatives (QI or PCMH), what areas of patient experience do you focus on? Why did your practice pursue these particular activities to improve paitent experience?

    1. Probe: Do you focus on areas that are low? Of high priority? Related to PCMH?

38. Was it useful to you while making these QI or PCMH changes to have the patient experience data to trend and monitor? If yes, how?

1. Probe: Can you give me a concrete example of how the patient experience data was useful?

2. (Is this true for changes related to QI or PCMH initatives or both)?

39. Are there actions that your clinic has taken based on your review of the patient experience data? (e.g. probe for changes in processes, started QI intiative, changed structural environment of the clinic), discussion of best practices, sharing data with staff members)

40. Who specifically uses the patient experience data and sees the reports/data?

    1. Probe: In what types of meetings are the patient experience data shared and discussed?

• Daily huddle

• Leadership meetings

• Staff meetings

• QI implementation meetings

• PCMH team meetings

• Regional or medical group meetings (with multiple practices present)

• Other?

41. What is the process you use for reviewing your patient experience data and how has this changed overtime? Has this process been influenced by your PCMH transformation? If so, how? Why?

42. Did you use the patient experience data as you made PCMH changes? If so, How? (If not, why not?) [IF NOT ALREADY ANSWERED]

43. In general, what are your views of patient experience scores/reports and how they are used?

Probe: Why do you believe these performance reports are produced?

44. What are their primary purposes (for patient experience performance reports) in your practice?

ASK ONLY OF STUDY ARMS’ CURRENT CAHPS AND PAST CAHPS ONLY (No Control Sites)--

Module 5: Patient Experience Distinction from NCQA (5 minutes)

Now I’d like to take our conversation back to the fact that your practice sought out NCQA Patient Experience Distinction . [Remind provider of the specific details of CAHPS Distinction they discussed from Page 2 and 3]

45. What was the attraction in obtaining NCQA Patient Experience Distinction?

46. What have been the benefits? Any down sides?

47. Are you planning on obtaining Patient Experience Distinction again?

48. What might some of the barriers or challenges be to obtaining Distinction again?

    1. Probe: Lessons learned in the past?

ASK ONLY OF STUDY ARMS’ CURRENT CAHPS AND PAST CAHPS ONLY (No Control Sites)—

49. What do you think about the content of the PCMH supplemental items? Is there content that you would change or add? (Refer to Appendix for FULL List of Items)

PCMH ITEMS (2.0) - Three Composities:

• Attention to your mental or emotional health (adult only) (3 items

  • Talked about personal or family problem/ahcohol or drug use

  • Talked about worry and stress in your life

  • Talked about feeling sad or depressed

• Talking with you about taking care of your own health (2 items)

  • Provider worked with you to set specific goals for your health

  • Provider asked you if there were things that make it hard for you to take care of your health

• Talking about medication decisions (adult only) (3 items)

  • Provider talked about reasons to take a medicine

  • Provider talked about reasons not to take a medicine

  • Provider asked what you thought was best for you regarding medicine

PCMH ITEMS 2.0 Stand Alone Items:

• Access to care (2 items)

  • -  Got needed care on evenings, weekends, or holidays

  • -  Days you had to wait for an appointment for urgent care

• Attention to care from other providers (3 items)

  • Provider’s office followed up to give you results of blood test, x-ray, or other test

  • Provider seemed informed and up-to-date about care you got from specialists

  • Talked with you about your prescriptions

• Information about care and appointments (2 items)

  • Got information about what to do if you needed care on evenings, weekends, or holidays

  • Received reminders between visits

50. Are the PCMH items actionable in making changes for PCMH? {Are specific items more actionable than others?}

Module 6: Trends in Patient Experience (10 minutes)

Next, I would like to ask you about your patient experience trends overtime since you have embarked on being a PCMH.

51. In what areas of patient experience does your practice currently excel?

IF NEEDED: REFER TO THE CG CAHPS 2.0 - 12 month reference survey content areas:

Composites and global rating:

• Getting timely appointments, care, and information (composite of 5 items)

• How well providers communicate with patients (composite of 6 items)

• Helpful, courteous, and respectful office staff (composite of 2 items)

• Patients’ rating of the provider (1 item)

• Followup on test results (1 item)

• Rating of provider (1 item) – Global Rating

PCMH Supplemental Items:

• Attention to your mental or emotional health (adult only) (3 items

• Talked about personal or family problem/ahcohol or drug use

• Talked about worry and stress in your life

• Talked about feeling sad or depressed

• Talking with you about taking care of your own health (2 items)

  • Provider worked with you to set specific goals for your health

  • Provider asked you if there were things that make it hard for you to take care of your health

• Talking about medication decisions (adult only) (3 items)

• Provider talked about reasons to take a medicine

• Provider talked about reasons not to take a medicine

• Provider asked what you thought was best for you regarding medicine

PCMH ITEMS 2.0 Stand Alone Items:

• Access to care (2 items)

  • -  Got needed care on evenings, weekends, or holidays

  • -  Days you had to wait for an appointment for urgent care

• Attention to care from other providers (3 items)

  • Provider’s office followed up to give you results of blood test, x-ray, or other test

  • Provider seemed informed and up-to-date about care you got from specialists

  • Talked with you about your prescriptions

• Information about care and appointments (2 items)

  • Got information about what to do if you needed care on evenings, weekends, or holidays

  • Received reminders between visits

IF NOT CG-CAHPS USER: ASK for main topics on pnt exp survey (or refer to tool provided)

52. Are these the same areas in which your practice has always done well?

53. (PAST AREAS) What are the areas of patient experience that you have focused on improving since becoming a PCMH? In which of these have you succeeded in improving? Which have been hard to improve?

54. (CURRENT AREAS) What areas of the patient experience are you continuing to work on improving?

55. (FUTURE AREAS) Are there areas that you need to improve, but have not yet focused attention to? If so, what are the challenges involved?

56. How well has your practice done over time in terms of the global ratings? Or the likelihood of recommending the practice or the provider?

57. How important is it to your practice that your patient experience scores improve?

    1. What do you think will happen to [name of practice] if patient experience does not improve? [if confused: Do you think there would be any bad consequences for the group? What kind of consequences?]

2. [If making any improvement efforts] How confident are you that the efforts of [name of practice] will improve patient experience/satisfaction?

3. Do you sense pressure on your group to “do something” about patient experience/satisfaction whether or not these efforts are important or likely to succeed? _____Yes ______No

4. [If Yes] Where does this pressure come from?

58. Thinking more broadly about all of the different pressures on medical groups/practices these days, which are the most important pressures for you group?

List them:

1. Where do patient experience/satisfaction ratings rank in this list?

59. Over the past few years, for your practice do you think performance on measures of patient experience has become more important over the past few years, become less important, or stayed at the same level of importance?

______ Become more important ______ Become less important _______ Stayed the same

1. Why?

2. [If change is reported] What has been driving this change in importance, in your opinion?

60. Does your practice publicly report data on:

    1. Patient satisfaction or patient experience? (Yes/No)

    2. Data on clinical quality? (Yes/No)

61. Does your practice’s have the opportunity to receive additional income from external entities based on:

    1. Its clinical quality (on quality measures like HEDIS)? (Yes/No)

    2. Use of information technology? (Yes/No) and

    3. Efficient use of resources? (Yes/No)

    4. Utilization or costs of care? (Yes/No)

62. Does your practice face any financial incentives that are specifically tied to performance on patient experience? _____Yes ______No

Could you please describe the incentives.

[If in a network or group] Do these incentives come from payers or from [name of network]… both?

________From Payers _______ From Network _____ Both ________ Hard to tell

Closing (2 minutes)

Finally, I have two closing questions:

1. Is there anything that we haven’t talked about that we should include in our thinking about how pratices are using patient experience data during the PCMH transformation process?

2. In summary, what has been the value-added of using the CG-CAHPS patient experience survey ? Value-addin in including the PCMH items?

Thank you for taking the time to talk to us today, and all the time you and your clinic are spending to transform into a PCMH.

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