Health Care Homes Pediatric Patient Experience Meeting
Notes, November 5th, 2013
Points of consideration of the CG-CAHPS Child and Adult 12-Month + PCMH Supplemental Questions
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The child and adult PCMH survey is only appropriate for patients seen by primary care providers
(PCPs).
Pediatric surveys generally have a lower response rate compared to the adult survey.
The current practice of surveying adolescents varies greatly in the community. Some medical
groups survey age 11 and younger; some survey 13 and younger; others under 17. The
recommendation of the CAHPS consortium for fielding the Child survey is 17 and younger. The
primary reason for the difference is the main concern over surveying “protected adolescent
visits”. Currently, there is not a consistent way of identifying these visits among the various
certified health care homes.
Certified CAHPS survey modes are more expensive to administer because the requirements are
more prescriptive compared to administering other patient experience surveys. Additionally,
the PCMH CAHPS Child survey is only available in English and Spanish.
Certified health care home clinics cannot effectively plan for HCH patient experience surveying
until final HCH Patient Experience requirements are established (i.e. survey type and survey
specifications).
Most HCH clinics are doing some form of pediatric patient experience surveying. However, the
survey and timeframe are not standardized among certified HCH clinics.
Adult Population
When considering the appropriateness of the PCMH survey for adult patients, it should only be
distributed to patients who had a visit with a primary care provider (PCP). This could present challenges
to a HCH multi-specialty clinic because they would have to separate patient visits with specialists from
those with PCPs to be able to field the PCMH survey to the right type of visit/patient. Additionally,
multi-specialty HCH clinics must also be in compliance with the SQRMS specification in the Rule which
states: “All patients ages 18 and older with face-to-face office visits should be included in the sample.”
So it would not suffice to allow a HCH multi-specialty clinic to only sample PCP visits because they would
be excluding eligible patient visits from specialties, and therefore, not meet the requirements of the
SQRMS rule. Option 1 below presents a possible solution to this problem by requiring the sampling to
occur for all visits within a clinic but then have the survey vendors send the PCMH survey to only those
patients that had a primary care visit to a HCH clinic.
Adult Population Survey Options
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Option 1: Pull the entire clinic’s eligible patient population (all patients, 18 or older, with a
face-to-face office visit with a provider (MD, DO, adv NP, PA) during the measurement period
9/1/14-11/30/14). The record format of this file should include a HCH Clinic (Y/N) field and then
use the provider specialty field to determine whether or not the vendor should add the
supplemental PCMH questions. This sample frame is sent to the survey vendor who selects the
random sample, and sends out the appropriate adult version survey (either 12-Month or PCMH)
based on the HCH Clinic and provider specialty field. For HCH clinics that are only primary care
they would be required to add the supplemental PCMH questions to all surveys.
Advantages:
Simplifies the patient eligibility process based on the provider scaling table
Simplifies the generation of the sample frame
Meets the mandated SQRMS specifications using the core survey data from
both versions
Collects survey data on the PCMH version (randomly for multi-specialty clinics)
Collects patient experience data from a broader array of physicians in the clinic
Disadvantages: PCMH-specific response quantity will be unknown*
Could be adding cost for fielding 2 Adult versions
*an oversample process can be put in place where the survey vendor would oversample
additional HCH-provider patients to “replace” those that are only sent a 12-Month survey.
Option 2: Follow the SQRMS requirements pertaining to the 12-Month Adult survey (i.e. do not
require the PMCH survey for HCH clinics)4.
Advantages:
Simplifies the patient eligibility process even more
Simplifies the generation of the sample frame
Meets the mandated SQRMS specifications
Not an additional cost for 2 adult versions
Disadvantages: Does not give any PCMH question data
Child Population
The SQRMS Rule does not pertain to pediatric patients. However, certified health care home clinics are
expected to do some form of pediatric surveying according to the HCH certification standards. MDH is
currently exploring whether or not to require HCH clinics to conduct the Child CAHPS PCMH survey (this
includes pediatric primary care visits only because it is the PCMH version of the CAHPS survey).
Feedback gathered from the meeting indicated that “counting” patient visits from PCPs for eligibility
assessment might be complicated, especially in a multi-specialty HCH clinic. Counting patients visits is
important because it ultimately will determine whether or not a clinic is required to participate in the
measure (see table 1 below).
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One potential solution is to provide clinics an “estimated sample count” by using the monthly HCH
provider file submitted by MDH that is uploaded to the data portal. A behind the scenes portal analysis
of the number of HCH providers (by count only, not FTE) would be displayed along with the pediatric
eligibility question. For example, a clinic may get this prompt message: “Your clinic currently has 10
HCH certified primary care providers. Based on this PCP count, did your clinic see 575 unique pediatric
patients for a visit during September 1, 2013 to November 30, 2013? <yes> or <no>.” This serves both
as an assessment for the measure, and the estimated sample size (for 2014 dates).
The lower response rate generally seen with pediatric surveys was considered when the provider scaling
table was modified. The “estimated sample size” could have been increased to account for a lower
response rate, but was not, due to:
a. A higher initial sample size would make more clinics drop out of eligibility for the survey
b. Since the HCH results are not publicly reported, the reliability threshold does not have
the same importance.
If a HCH clinic with 3 PCP obtains a 20% response rate, about 90 Child surveys would be received. This is
a sufficient number of surveys to garner QI information on, but not publicly report which is appropriate
at this time.
One issue with the CAHPS PMCH Child survey is the lack of availability of Hmong and Somali translated
surveys (CAHPS does have a Spanish version available). Not having surveys in these other languages is
counter to the HCH goal of providing patient-centered care. While it is possible to translate the CAHPS
surveys into other languages it would require a significant amount of time and resources.
Finally, there was discussion about adolescent visits and appropriateness of surveys for 13-17 year olds.
There is extensive research showing the correlation between confidentiality and the adolescent’s
utilization of treatment. Polling of the workgroup showed that variability exists in the community in the
pediatric ages that medical groups use to survey (e.g. some groups survey 12 and under, some 17 and
under some 11 and under). Workgroup members agreed that there is not a clean way in the EHR to
designate “confidential visits” for adolescents.
Child Population Survey Options
Recommendations on the Child HCH survey can be different than what is recommended on the Adult
HCH survey due to the absence of SQRMS Rule application. MNCM would recommend the use of the
provider scaling table (see table 1 below) as a means to assess eligibility for the measure. Although
arguments for reduced response rates have been raised, the survey is not going to be publicly reported
and thus used only for QI purposes at this time.
Also, MNCM would recommend that the Child survey be distributed only on pediatric patients that are
0-12 years old. This would standardize the current sampling practices while addressing the adolescent
confidentiality concern.
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The options for surveying the pediatric HCH population are stated below.
Option 1: Use the Child 12-Month + PCMH Supplemental Items survey on the population of the
patients, 0-12 years old, that saw a PCP for a face-to-face encounter during 9/1/14-11/30/14.
Advantages:
Obtains data for the PCMH supplemental questions
Disadvantages: Makes the measure eligibility process more complex
Does not generate a patient sample from all providers in the clinic (affects
multi-specialty clinics which account for 2/3 of the HCH clinics)
Makes the generation of the sample frame more complex
Option 2: Use the Child 12-Month survey without the PCMH Supplemental Items with the same
measure specifications. The patient population would then be all patients, 0-12 years old, that
saw a provider (MD, DO, adv NP, PA) for the same period.
Advantages:
The sample is across all pediatric patients and all provider types
Simplifies the measure eligibility process
Simplifies the generation of the sample frame
Disadvantage: Does not collect data on the PCMH questions
Option 3: Postpone requiring HCH clinics to do a standardized Pediatric Patient Experience
survey
Supporting Information
The Health Care Homes (HCH) program is a provider-based program; primary care physicians are
certified within the clinic. The program has recertification requirements that state clinics must show
that quality improvement efforts are in place, can be measured, and show improvement from year to
year. This includes measuring patient experience for both adults and pediatric populations.
The results from the MN state mandated 2012 Patient Experience of Care survey were used to
supplement the HCH Adult Patient Experience requirement. Since the state mandate only covers adults
there is not currently a standardized requirement for HCH pediatric patient experience surveying. The
requirement that MDH is considering in 2014 is for eligible HCH clinics to field the CG-CAHPS 12-Month
Survey with PCMH Supplemental questions for both the Adult and Child versions.
The Statewide Quality Reporting and Measurement System (SQRMS) mandates ambulatory physician
clinics to complete a CG-CAHPS survey every other year. The recommendation for the 2014 Rule is that
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eligible clinics use the CG-CAHPS 12 –Month Adult survey. There is no mandate for clinics to complete a
Child Patient Experience survey.
The SQRMS requirement must be met for eligible clinics- whether those eligible clinics are HCH or not.
Since the Adult 12-Month + PCMH survey has the same core questions and domains as the Adult 12Month survey, a HCH clinic could fulfill the SQRMS mandate using the Adult PCMH survey.
Table 1: 2014 Patient Experience Sampling and Eligibility
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