The Safety Net Medical Home Scale is a comprehensive, practical scale to measure PCMH adoption in the safety-net setting that adds to strengths in previous scales.14,29,30
The SNMHS has a low response burden, yet still provides a thorough measurement of PCMH domains. Scaled responses provide increased discrimination to detect variation in the sample. While the scale has not been tested in a longitudinal setting, we believe the scaled responses would be more sensitive to change over time than dichotomous responses. In addition, our scale demonstrated reliability as measured by Cronbach’s alpha and convergent validity through correlation with the ACIC and the PCMH-A scales. Overall, we believe our scale is a useful addition because it is brief, comprehensive, publicly available, and suitable for longitudinal analysis.
In our study, the average baseline SNMHS total summary score of 61 suggested that clinics have good foundations for the PCMH model. However, as in studies of PCMH adoption in private practices, room for improvement exists in all domains.31–34
In addition, we found that smaller practices may need special attention to help them succeed in building PCMHs. Some PCMH activities, such as improved access to after-hours clinical advice, may require additional staffing and could be especially challenging for practices with few personnel.35
Going forward, the scale could be used for several purposes. While tools such as the NCQA research version may be appropriate for many PCMH evaluations, we believe our scale is especially relevant for the safety-net setting. The items capturing language services and coordinating care for underserved patients will help evaluate PCMH interventions in safety-net clinics, such as the CMS FQHC Primary Care Practice Demonstration4
. Evaluating this intervention with a medical home tool that does not capture these services could lead to an inappropriate assessment of medical home adoption. In addition, the Safety Net Medical Home Scale may identify areas that require broader coalitions of stakeholders to address. This sample of clinics scored well in the External Coordination domain. However, improving this domain requires external partnerships with other providers in the local health system since the amount of charity care that specialists and non-profit hospitals provide depends on Medicaid reimbursement rates, disproportionate share funding, and legal requirements. 27
Therefore, the Safety Net Medical Home Scale could provide information useful for guiding the wider health care system about how to establish incentives and allocate resources to coordinate care for underserved populations. Finally, the scale should be tested in non-safety-net settings, since the scale has content validity for most outpatient settings.36,37
A good setting to start may be other small practices that may face similar challenges to safety-net clinics.
Our scale has several limitations. First, while the SNMHS has a lower burden than the NCQA recognition process, it relies on self-report. We have validated the SNMHS against the ACIC and PCMH-A surveys, and in the future we will correlate the scale with measures of clinical performance and efficiency. In addition, since the tool only goes to a single respondent per organization, there may be variation in the survey’s reliability across sites. While the survey will go back to the same person over time to increase reliability, it will be difficult to test the reliability of responses since medical home adoption will likely have changed at the end of the intervention. Brevity comes at the price of completeness, and our scale focused on measuring NCQA PPC-PCMH domains plus other domains that seem particularly important for safety-net clinics. Thus, other factors relevant for PCMH development may not be measured. For instance, PCMH domains such as whole person-orientation and team approach to care are not fully captured, and concepts critical for PCMH implementation such as engaged leadership are not completely measured either. Also, the cross-sectional design limited the ability to test specifically for sensitivity to change. However, we did attempt to enhance sensitivity over prior tools. In our convergent validity analyses, the ACIC and PCMH-A do have content overlap with the SNMHS, so some correlation would be expected. However, these instruments were designed for different purposes, include different domains, and the items do not completely overlap. Thus, they are reasonable scales to use to test for convergent validity with the SNMHS.
In addition, the baseline assessment of this clinic sample may not be generalizable. These clinics have established partnerships with regional coordinating centers, which may reflect local policies and culture towards care coordination, and also expressed an interest in PCMH adoption. Also, there are limitations to using UDS data in our analysis of correlates of PCMH adoption. UDS data are center specific, whereas the scale data are site specific, so there is the potential for mismatch when pairing these data sources. However, we used UDS data only for the racial and ethnic composition of the clinics’ patient populations.
In summary, we have developed the Safety Net Medical Home Scale and demonstrated its ability to provide a detailed description of PCMH adoption in a sample of safety-net clinics. The Safety Net Medical Home Scale can be a valuable tool for research evaluations of PCMH adoption in safety-net clinics.