Development of the Primary Care Quality-Homeless (PCQ-H) Instrument

Abstract

Background Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients' priorities and concerns. Objectives This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients and (b) the methods utilized in its development. Methods Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function curves to eliminate less informative items and devise plausibly distinct subscales. Results The resulting 33-item instrument (Primary Care Quality-Homeless, PCQ-H) has four subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items) and Homeless-Specific Needs (4 items). Evidence for divergent and convergent validity is provided. Test Information Function (TIF) graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (alpha=0.75) and patients frequently reported problems in this aspect of care. Conclusions Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.

A national evaluation of homeless and nonhomeless veterans’ experiences with primary care.

“…National investigations of healthcare experiences among patients with MHSUDs (e.g., patient perceptions of the accessibility of needed services, provider communication skills, and office staff helpfulness/courtesy) have not reported on findings for homeless persons (Burnett-Zeigler, Zivin, Ilgen, Islam, & Bohnert, 2011; Jones et al, 2016; Kilbourne et al, 2006). Studies focused on homeless persons’ experiences have been restricted to a small number of clinics (Chrystal et al, 2015; Zerger et al, 2014), have lacked a non-homeless comparison group (Kertesz et al, 2014), had small samples (Steward et al, 2016), or did not assess patient experiences with care in domains relevant to MHSUD care (e.g., comprehensiveness, care coordination, medication decision-making) (Lebrun-Harris et al, 2013). This is a notable gap in the literature considering that homeless persons disproportionately suffer from MHSUDs and patient experiences with care in general outpatient settings affect MHSUD service use and clinical outcomes (Bauer et al, 2014; Kim et al, 2007; True, Rigg, & Butler, 2015).…”

Experience of Primary Care among Homeless Individuals with Mental Health Conditions

“…We evaluated predictors of a more favorable primary care experience across various care settings for homeless persons with mental health conditions. This is an analysis of data from a larger study that developed and validated a survey, the Primary Care Quality—Homeless (PCQ-H-33), designed to assess perceptions of health care in homeless individuals [ 23 ]. This survey was read aloud to each participant by research associates at five sites, and took 5–10 minutes to complete.…”

“…The five sites differed in the extent to which they were tailored for homeless care services. Homeless-specific tailoring is thought to exist along a continuum [ 23 – 24 ]. The most tailored environments have dedicated program staff, specialized training of staff, heavy emphasis on walk-in availability, the capacity to respond to tangible or competing needs (such as food, washing or clothing), integrated mental health care, and inclusion of homeless individuals in organizational governance.…”

“…Across all five sites, 6371 persons met criteria for two primary care visits between July 2008 and June 2010. Of these, 2584 (41%) were selected for recruitment, 870 (14%) were contacted and screened, and 634 (10%) entered the study [ 23 ]. For analyses, 366 were selected based on having mental health conditions.…”

“…Research efforts to systematically understand what patient or system characteristics help to produce a favorable care experience for homeless patients with mental health conditions are scarce. The present study utilized a new patient-reported 33-item instrument developed specifically to capture homeless persons’ experience of primary care, the Primary Care Quality-Homeless survey [ 23 ]. Drawing on data from a sample of patients receiving care at 5 sites across the country, we sought to identify determinants of primary care experiences for homeless persons with mental health conditions across various delivery models.…”