Relationship Between Patient-Centered Primary Care Provider Communication and Emergency Room Visits in the Medicaid Population in North Carolina, United States.

INTRODUCTION: Medicaid, a joint federal-state program, finances health care for eligible low-income individuals and families in the United States. Medicaid patients use disproportionately more emergency room (ER) services than other patients in the United States. Inadequate provider communication during primary care visits might be one reason for this well-documented phenomenon. The goal of the study was to examine how patient-centered provider communication related to ER use by Medicaid patients in North Carolina. METHODS: A 2015 state-wide cross-sectional telephone survey of NC adult Medicaid patients (n = 2652) was based on the CAHPS methodology. Predictors were 4 patient-centered provider communication characteristics assessed by patients. The outcome was the number of ER visits during 6 months prior to the survey. We used negative binomial regression to examine the relationship. RESULTS: Effective patient-centered provider communication index was associated with 19% fewer ER visits (P < .05). Provider's respect for patients had the biggest impact on the number of visits (37% fewer ER visits, P < .001). Easy to understand provider explanations were associated with 18% fewer ER visits (P < .05). Longer (>1 year) patient continuity with the current primary care provider was associated with 36% to 38% fewer ER visits (P < .001). CONCLUSIONS: Health care quality improvement should focus on training providers how to show respect, give easily understood explanations, and maintain good interpersonal relationships with patients. Relevant agencies should emphasize training and accreditation with a specific emphasis on communication of providers delivering care to Medicaid patients.

The Relationship between Patient-Centered Medical Home Characteristics and Patient Dissatisfaction at a Federally Qualified Health Center.

This cross-sectional study examined the relationship between patients' assessment of patient-centered medical home (PCMH) characteristics and patient experiences at a federally qualified health center. The survey was based on the Consumer Assessment of Health care Providers and Systems (CAHPS) instrument. Patient-centered medical home characteristics include access to care and coordination, provider communication, office staff helpfulness, and discrimination. Outcomes were related to patient experiences reflecting their dissatisfaction and lack of trust. Our sample (N = 257) was 76% female, 39% older than 50, 40% with college education, and 84% African American. We performed multiple logistic regression to examine the association between PCMH characteristics and patient dissatisfaction, adjusting for demographics. Approximately 26% of the participants reported dissatisfaction with at least one outcome. Effective provider communication was the primary contributor to decreased odds of patient dissatisfaction and lack of trust. The study highlights the prominence of provider communication for patients using safety-net providers.

Community Benefit Spending Among North Carolina's Tax-Exempt Hospitals After Performing Community Health Needs Assessments.

CONTEXT: As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every 3 years to incentivize hospitals to provide programs responsive to the health needs of their communities. OBJECTIVE: To examine the distribution and variation in community benefit spending among North Carolina's tax-exempt hospitals 2 years after completing their first IRS-mandated CHNA. DESIGN: Cross-sectional study using secondary analysis of published community benefit reports. Community benefit was categorized on the basis of North Carolina Hospital Association's community benefit reporting guidelines. Multiple regression analysis using generalized linear model was used to examine the variation in community benefit spending among study hospitals considering differences in hospital-level and community characteristics. SETTING: Fifty-three private, nonprofit hospitals across North Carolina. MAIN OUTCOME MEASURE: Dollar expenditures as a percentage of operating expenses of the 2 categories of community benefit spending: patient care financial assistance and community health programs. RESULTS: Study hospitals' aggregate community benefit spending was $2.6 billion, 85% of which was in the form of patient care financial assistance, with only 0.7% of total spending allocated to community-building activities such as affordable housing, economic development, and environmental improvements. On average, the study hospitals' community benefit spending was equivalent to 14.6% of operating expenses. Hospitals with 300 or more beds provided significantly higher investments in community health programs as a percentage of their operating expenses than hospitals with 101 to 299 beds (P = .03) or hospitals with 100 or fewer beds (P = .04). Access to care was not associated with patient care financial assistance (P = .81) or community health programs expenditures (P = .94). CONCLUSIONS: The study hospitals direct most of their community benefit expenditures to patient care financial assistance (individual welfare) rather than population health improvement initiatives, with virtually no investments in community-building activities that address socioeconomic determinants of health.

Patient-centered communication: dissecting provider communication.

PURPOSE: The purpose of this paper is to examine the relationship between patients' provider communication effectiveness and courteousness with patients' satisfaction and trust at free clinics. DESIGN/METHODOLOGY/APPROACH: This cross-sectional survey (n=507), based on the Consumer Assessment of Healthcare Providers and Systems instrument, was conducted in two Southeastern US free clinics. Latent class analysis (LCA) was used to identify patient subgroups (clusters) with similar but not immediately visible characteristics. FINDINGS: Across the items assessing provider communication effectiveness and courteousness, five distinct clusters based on patient satisfaction, trust and socio-demographics were identified. In clusters where communication and courteousness ratings were consistent, trust and satisfaction ratings were aligned with these domains, e.g., 54 percent rated communication and courteousness highly, which was associated with high patient satisfaction and trust. When communication effectiveness and courteousness ratings diverged (e.g., low communication effectiveness but high courteousness), patient trust and satisfaction ratings aligned with communication effectiveness ratings. In all clusters, the association was greater for communication effectiveness than for provider courteousness. Thus, provider courteousness was important but secondary to communication effectiveness. PRACTICAL IMPLICATIONS: Investment in patient-centered communication training for providers will improve patient satisfaction and trust. ORIGINALITY/VALUE: The study is the first to examine individual provider communication components and how they relate to patient satisfaction and trust in free clinics. LCA helped to more fully examine communication constructs, which may be beneficial for more nuanced quality improvement efforts.

Did Performing Community Health Needs Assessments Increase Community Health Program Spending by North Carolina's Tax-Exempt Hospitals?

As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every 3 years. This study assessed whether the IRS CHNA mandate incentivized North Carolina's tax-exempt hospitals to increase investments in community health programs. The authors gathered the 2012-2016 community benefit reports of 53 North Carolina private, nonprofit hospitals from the North Carolina Hospital Association. Community benefit spending data from the year of the first CHNA were compared to that 2 years later using paired t tests among matched subjects. No significant increases were found in hospitals' community health programs spending (P = 0.6920) or in providing patient care financial assistance (charity or discounted care) (P = 0.0934). In fact, aggregate community health programs spending effectively decreased by 4%, from $393.3 million to $377.5 million. Among all community benefit items, only the unreimbursed cost for treating Medicare patients increased significantly (P = 0.0297). The proportion of spending on community health programs relative to patient care financial assistance decreased significantly (P = 0.0338). Performing CHNAs did not incentivize North Carolina's tax-exempt hospitals to progressively invest in community health programs. The hospitals continue to spend heavily on patient care financial assistance and little on disease prevention and community health improvement activities. These findings suggest that tax-exempt hospitals continue to function as a safety net for the poor and the uninsured rather than as active partners in population health management initiatives. At present, performing CHNAs may be more a demonstration of compliance than a tool to improve population health.

Patient assessment of primary care physician communication: segmentation approach.

PURPOSE: The purpose of this paper is to examine how patient assessment of primary care physician (PCP) communication is related to patient satisfaction with the PCP, patient perception of PCP professional competence, patient assessment of the relationship with the doctor and patient demographic characteristics using a segmentation approach. DESIGN/METHODOLOGY/APPROACH: The authors surveyed 514 adult patients waiting for appointments with their PCPs in two US primary care clinics. A latent class analysis was used to identify mutually exclusive unobserved homogeneous classes of patients. FINDINGS: The authors identified three distinct classes/groups with regard to patient assessment of physician communication and the physician-patient relationship. The largest group (53 percent of the sample) assessed their PCP communication and other doctor-patient relationship aspects as excellent. However, 37 percent provided mostly negative assessments, expressed high general dissatisfaction with the physician and disagreed with the statement that their PCP was well qualified to manage their health problems. These patients were on average more educated and affluent and the group included more males. About 10 percent of patients expressed generally lower satisfaction with the PCP, though their dissatisfaction was not as extreme as in the highly dissatisfied group. RESEARCH LIMITATIONS/IMPLICATIONS: Further studies are needed to help physicians develop skills to communicate with different patients. ORIGINALITY/VALUE: Patient segmentation can be an important tool for healthcare quality improvement particularly for emerging approaches to primary care such as patient-centered care.

Innovative human resource practices in U.S. hospitals: an empirical study.

Contemporary organizations increasingly recognize human resource (HR) capabilities as a source of sustained competitive advantage; about 80% of an organization's value is attributable to intangible assets, including human assets and capital. Some scholars consider effective human resource management (HRM) the single most important factor affecting organizational performance. This study examined (1) the extent to which HRM strategies were included in organizational strategic planning and (2) the association between the involvement of senior HR professionals in strategic planning and the use of innovative HR practices in U.S. hospitals employing strategic HRM theory. A survey was administered to 168 chief executive officers and HR executives from 85 hospitals during spring 2005. Binary logistic regression was conducted to determine whether HRM involvement was associated with the use of innovative HRM strategies in the hospitals. We found significant associations between HRM strategy inclusion in the strategic planning process and senior HR professionals' involvement in organizational strategic planning and in three innovative HR activities: finding talent in advance for key job openings (odds ratio [OR] = 4.61, 95% confidence interval [CI]: 1.10-7.38), stressing organizational culture and values in the selection process (OR = 3.97, 95% CI: 1.01-3.97), and basing individual or team compensation on goal-oriented results (OR = 6.17, 95% CI: 1.17-3.37). Our data indicate that innovative HR practices were underused in some U.S. hospitals despite their potential to improve overall hospital performance. Hospitals that emphasized effective HRM were more likely to use some of the innovative HR approaches. In this article, we discuss this research and the practical implications of the findings.

Medical home and pediatric primary care utilization among children with special health care needs.

INTRODUCTION: The medical home model seeks to improve health care delivery by enhancing primary care. This study examined the relationship between the presence of a medical home and pediatric primary care office visits by children with special health care needs (CSHCN) using the data from 2005-2006 National Survey of Children with Special Healthcare Needs. METHOD: Survey logistic regression was used to analyze the relationship. RESULTS: When CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home [odds ratio = 1.60, 95% confidence interval = (1.47, 1.75)]. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more likely to have a larger number of visits. DISCUSSION: By controlling for child sociodemographic characteristics, this study provides empirical evidence about how medical home availability affects primary care utilization by CSHCN.

Hospital-level variation in the percentage of admissions originating in the emergency department.

PURPOSE: Well over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED. BASIC PROCEDURES: This was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005. MAIN FINDINGS: Hospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition. CONCLUSIONS: The increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research.

Primary care patient satisfaction segmentation.

PURPOSE: The aim of this study is to examine patient satisfaction with non-physician staff as related to patient demographics, satisfaction with physician, and intentions to recommend their physicians to others. DESIGN/METHODOLOGY/APPROACH: A survey was conducted at two internal medicine primary care clinics affiliated with a major university health system. A latent class analysis was used to detect patient subpopulations based on profiles of response for five satisfaction-with-staff indicators. FINDINGS: The response rate was 86.46 percent (479 of 554). Analyses revealed four patient subpopulation segments. Segment I (n = 241) patients uniformly indicated a high level of satisfaction across the five satisfaction-with-staff indicators. These patients tended to be older and less educated, and have lower incomes relative to patients in other segments. Patients in Segment II (n = 83) expressed satisfaction with staff caring and need accommodation, but dissatisfaction with access to their physicians. Patients in Segment III (n = 51) indicated high levels of satisfaction with access and low levels of satisfaction with staff caring and need accommodation. Segment IV (n = 104) patients uniformly expressed low levels of satisfaction across all indicators and generally were younger and more educated, as well as hadhigher incomes than other patients. ORIGINALITY/VALUE: Patients have different expectations from their non-physician staff, e.g. younger, more affluent, and educated patients expressed dissatisfaction with staff. This suggests that non-physician staff should provide extra/further responsiveness to have these patients' needs met. Generally, approaches that are differentially targeted to specific patient subgroups are likely to be more efficient and patient-oriented than undifferentiated approaches.

Study of the relationship between organizational culture and organizational outcomes using hierarchical linear modeling methodology.

This study examines how perceptions of organizational culture influence organizational outcomes, specially, individual employee job satisfaction. The study was conducted in the health care industry in the United States. It examined the data on employee perceptions of job attributes, organizational culture, and job satisfaction, collected by Press Ganey Associates from 88 hospitals across the country in 2002-2003. Hierarchical linear modeling was used to test how organizational culture affects individual employee job satisfaction. Results indicated that some dimensions of organizational culture, specifically, job security and performance recognition, play a role in improving employee job satisfaction.