**Transcript of Cyberseminar**

**Timely Topics of Interest**

**A New Survey for Assessing the Primary Care Experience for Homeless Patients, the PCQ-H**

**Presenters: Stefan G. Kertesz, MD**

**June 5, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**Stefan.Kertesz@VA.gov**.*

*Moderator:*Again, we are at the top of the hour, so at this time I would like to introduce our speaker, we have Stefan Kertesz joining us today and he is at the Birmingham VA Medical Center and at the University of Alabama at Birmingham School of Medicine where he is an Associate Professor. We are very grateful to have him joining us today. At this time, I will turn it over to you Stefan. 

*Dr. Stefan Kertesz:*Great, thanks for the opportunity to present to the cyberseminar, which is a diverse group; there are already forty-four people on which is quite an honor. My name is Stefan Kertesz I am at the Birmingham VA, University of Alabama, Birmingham School of Medicine. The title today is “A New Tool for Assessing Primary Care Experience for Homeless Patients, the PCQ-H. I trust that someone will let me know if for some reason the audio gets screwed up or the computer gets screwed up. So I am already at the pointer, I should state that the work I am presenting was supported by VA Health Services Research and Development and obviously I will speak for VA but just for the research process that we were in. Let me go forward a slide, there is a disclosure there which is pretty much the same. 

We are going to be talking about a survey instrument and therefore, I want people to know that if they have not been distributed already, we can provide copies of that survey instrument for people to look at, to use. The NVA we have not gone through the Office of Management and Budget Privacy Act procedures necessary to distribute a survey widely but we will touch on where we are in that process at the end. However, people who are not in VA easily can use it, it is being used outside the VA and this is really, we hope that it will become a VA tool, a recommended and available one. 

I want to acknowledge that the work that resulted in this instrument really comes from multiple collaborating institutions including several VA Medical Centers including the VA of Greater Los Angeles, Pittsburgh VA, Tuscaloosa VA, Birmingham VA obviously as well as collaboration with a variety of institutions. We are probably one of the few VA funded research studies that occur with a complete and total collaboration with the federally qualified health center including appropriate data sharing arrangements and such that the data was used in developing the survey came from not just Veterans but from a somewhat different homeless population cared for on the streets of Boston. 

The aim is to introduce the primary care experience questionnaire designed for homeless experienced patients. We want to show the method for the development and how we combine qualitative interviews, survey testing with patients and psychometric techniques to select the most informative items so that this would be a useful survey and ideally a short one. 

There is a survey question and the poll questions show on the side, my understanding is you can actually respond to them and we can see what kind of folks are participating today it will help us get a sense. We will broadcast the result. 

*Moderator:*Thank you. 

*Dr. Stefan Kertesz:*My ability to anticipate the categories of people who might attend this call is remarkably poor actually; forty-two percent so far said that I failed to anticipate their work category. 

*Moderator:*For those forty-four percent now at the end during the feedback survey we will have a more extensive list where you can hopefully find your specific titles there so just be patient with us. Actually, the responses have stopped rolling in so I will go ahead.

*Dr. Stefan Kertesz:*Okay, so first of all those people are not social workers position, psychologists, other clinical services or healthcare managers. I have a sneaky suspicion it is a mixture of research, staff and quality folks in the mix that I filed to correct, when we get to the Q&A we will actually ask more. 

The next slide is another just a question, how many people on the call have provided direct service to homeless individuals directly. 

*Moderator:*Now this one I am certain you would have gotten their category in. 

*Dr. Stefan Kertesz:*Okay. I guess somebody could respond it depends on how you define homeless. Okay so two-thirds have been involved directly and one-third have not so we will need that. Thank you folks for voting on that. We have a little bit of a sense of the mixture of people participating. 

A little bit of background, why did this project begin? In 2013, the point-in-time account specified greater than six hundred thousand Americans were homeless; fifty-seven thousand or so veterans at the point-in-time obviously more over the course of the year. Tailored primary care programs, these are medical care programs really begin in 1986 and I will define tailored in a moment but there are actually nineteen original healthcare for the homeless programs funded by Robert Wood Johnson and Pew. They are now funded through HHS, Health and Human Services by the Federal Government, two hundred and twenty or more, it keeps on expanding. There are a rising number of VA homeless focused pact delivering primary care services, it is expected to reach fifty in the coming year. This is an initiative led by Dr. Tom O’Toole, I happen to lead one of those pacts although this research is not based on it. These entities are trying to be Patients that are in Medical Homes, that is a mouthful but sort of a single program that coordinates all aspects of medical care. HHS is trying to enable those Healthcare for the Homeless Programs to acquire such designation; VA obviously tries to make sure that Homeless PACTS function as Patient-Centered Medical Homes. All such patients that are medical homes require patient input, usually using the patient experience questionnaire. 

Let us step back a little bit and ask – what is this notion of tailoring of services mean? So tailoring includes aspects of the design of the primary care services, the inclusion of outreach in the homeless context, oftentimes collocating mental and medical care. It can include inclusion of consumers in the governance of the entity providing the care. In the non-VA world, healthcare for the homeless programs are mandated to have consumers on their Board of Directors. It is an example of an article about a VA Health Services Researcher I do not think she was in the VA at the time the picture was taken; she brings health services to skid row. That is actually Lillian Gelberg one of my heroes in Health Services Research convening homeless individuals. 

Another picture, this is an interesting kind of clinic, this is from the Boston Healthcare for the Homeless Program and what you see are three clients seated facing away from us on the Boston Common meeting with three providers. The red haired woman is a psychiatrist for the Department of Public Health, the kneeling gray haired guy is a doctor who has been working with the homeless in Boston for twenty-five/thirty years and then on the left I think is a case manager. So that is actually a kind of group visit for a street homeless population and that certainly is a kind of tailored service, it involves reconfiguring everything to make that possible. 

Other aspects of tailoring as I mentioned in the previous slide you might collocate services, adjust the panel size perhaps to be smaller given the demands of the population, having training focused on homelessness mission, focused on homelessness. In the lower left hand is actually a picture of Dr. Thomas O’Toole who runs the National Age Pact Initiative and has been bringing that kind of vision clinically to VA. 

So the question and there is a picture of me at a younger age, on an island in the middle of Boston Harbor, in front of a number of buildings that serve homeless individuals eleven miles from the center of Boston several years ago. The question that we faced let to our survey is - if you thought you were delivering care in a better way, how would you prove it in a measurable way?  We did not have a poll question for this, it is kind of rhetorical question, in smaller groups we often talk about sort of what do you do and people usually say well maybe I could try to show that there is less emergency department visits if the patients use this unique primary care program. Or maybe I could show that blood pressure is better controlled if they use this unique program.  Why does proving it matter? Well typically, these tailored programs involved a separation of function, sometimes a distinct procedures and processes. Oftentimes they require additional resources so no policymaker worth their salt will make a decision about services like this without data to guide it. 

So let us talk about measurements. If you are going to measure that your primary care whatever it is is doing something good, traditionally, the VA’s own EPRP System emphasizes a number of traditional care indicators. They are typically disease-based, for example if you have diabetic patients, the percentage of having a hemoglobin A1C less than eight percent, the percentage of patents who receive that colonoscopy or mammogram. Those are very traditional disease-based care indicators used across the health system to promulgate it within and outside VA. There were some problems with guiding care based on these metrics and deciding if you are doing a good job or not based on them. They are imperfect because they do not take into account the patients context, the factors that might make the given decision different for them or required decision to be different for them, but for another population. They also rarely are designed to take into account the sheer number of illnesses that might apply to given patents. If a patient has, and a very nice paper published by Cynthia Boyd in *JAMA 2005* highlighted how few guidelines are really designed to take into account the coexistence of potentially eight or ten other conditions whose very presence should influence what endpoints you seek. For example, does my failure to obtain a colonoscopy count as a failure of care, poor care when my patient has no escort and no place to recover from a colonoscopy? Should we consider that a sign that my service program is not working well? Obviously, you know where I am headed; I am thinking no it should not count.  

How do we remedy the limitations of existing measures? First of all you refine the measures and I think actually I got the citation off of here, but there is a non-existence citation efforts to refine measures into taking the complexity of the patients. Dr. Saul Weiner, another VA Health Services Research Investigator has worked very hard on efforts to try to assess medical decisions in light of the contextual situation of that patients. For instance the patients living situation, mental illness, believe system etcetera require an alteration of the plan you would otherwise make. And there are standardized methods to measure that and to teach that. Perhaps a more traditional approach in the last twenty-five years has been to enlist patients, survey them “Through the Patient’s Eyes” as it were which refers to the title of a book from 1993. Patient-reported surveys are common they include a model survey called The Primary Care Assessment Survey by Dana Saffron. The Consumer Assessment of Health Plans it is CAHPS is really the industry standard. They are distributed by the Agency for Healthcare Research and Quality. They are central to both VA’s survey of health experiences and to the required surveys for entities funded by Health and Human Services. 

Question for you about asking – what does it mean when you are asked to fill out a survey? What is your internal reaction? Somebody may do a survey at the hotel, at the clinic, grocery store, it is a it is a car purchasing experience. Let us do the survey item, a poll. Do I have to do something to click a poll into existence? Open. I think it is open now. 

*Moderator:*No, sorry I just it is open, I just need to pull it over and sorry about that, had a little technical difficulty. Alright looks like the results are coming in nice and quickly. Sorry about that delay Dr. Kertesz although I must say it was nice to see those pictures of the Boston Common because that is where I am located. 

*Dr. Stefan Kertesz:*Cool. So let me see, let us wait a moment there are about sixty people on it looks like maybe forty-five have voted, five, four, three, two, one and poll. Okay so most people here are pretty constructively minded group and actually fill things out. I have to admit my response is typically number two; I have no time for this. Then there are those interesting things, if you pay me I might fill it out, a prize. What a crummy poll, I mean surveys that I have received when I leave the hotel often look to be awful and qualitative is a nice way to start isn’t it for you. Try to write up a set of questions. I think we have to close off the survey and with that in mind let us talk about designing the survey. 

There is another question. How comfortable are you with designing surveys? Just curious where people are at validating them. Really, some researchers are in the audience because a lot of people do have some comfort with this. 

*Moderator:*These are actually pretty great response rates. 

*Dr. Stefan Kertesz:*Yeah that is great. Apparently this particular fund survey was decently written so I closed it, what we got was a number of people have dealt with surveys try to validate them. I will be presenting in a way that I hope works for all audiences. What about that standard survey? When we first set out to study the question of patient experiences in primary care, we were going to use something off the shelf. The CAHPS is what Health and Human Services requires for federally qualified health centers, a version of it is essentially installed in the VA survey of past experiences. There is a thousand twelve words, got a ninth grade reading level, which is not bad, but certainly could exceed some homeless populations. Of the forty-three items in the CAHPS the VA’s version is longer but the forty-three out of the twelve are actually two/four skips. Essentially, there is really thirty-one content rich items and twelve that are used to steer the individual around the survey, skipping various portions. The survey is fairly complicated in terms of response options; you have to switch from thinking in terms of never, sometimes, usually, always, not at all, a little, a lot. Zero to ten there are four more sets of responses so when we looked at that, we were worried that it would be both difficult practically and really not on topic for a lot of the concerns of our patient population.

 For example, access to care question. Access to care some of the key ones that begin in the CAPHS start out with this, beginning with skip passes it says did you phone this providers office to get an appointment for an illness, injury or condition that needed care right away. If you do not have a phone and did not make a call, two items are skipped, there are certainly no questions about outreach or walking in for care. For homeless healthcare providers that just seems like an awkward fit. We know phones are in possession of many of our clients in the VA but not so much outside the VA and honestly that is just not a number one way of seeking care if you are currently and actively homeless to make a call and hope to get a call back. Control is a more subtle concept, which we are going to come back to. But there was a little bit of query about the relationship in communicating about care and it was decided when you talked about starting or stopping a prescription medicine, this comes after skip item, how much did this provider talk about the reasons you might not want to take a medicine. This is apparently the CAHPS method of assessing whether there is a full-informed conversation about risks and benefits but it does presuppose a lot about what people want and need to discuss compared too many other possible questions you might ask. 

We had concerns with any off the shelf instrument for homeless populations. It is the mandated standard, conceptually it is patient experiences, it is very focused on procedural reports from patients about what happened in specific episodes of care. We worried about fit for the population, it did not seem to always fit with what patient’s might care about. It has never been tested among homeless individuals, and in reality we know now, one of our colleague programs Boston Healthcare for the Homeless they use it but it turns out it leads to an endless round of question and answer from the patients who need help understanding if the question applies to them. 

Our approach to designing a different survey was to construct what I would term the Top Down approach and a Bottom Up approach in taking elements of both in designing this new instrument. From the Top Down, we started with some general constructs, let me say general areas of interest that came from a respected source and to get what we would sort of chase down with survey questions. This is very similar to how the CAHPS was designed, similar to how the Primary Care Assessment Survey, which is one of our models, was designed and how other instruments have been designed. What we are asking about did not emerge wholeheartedly from simple open-ended questions about what people like about care. On the other hand from the Bottom Up, we said let people who are familiar with homeless primary care (both patents and expert caregivers) prioritize what we asked about, add new elements if we are missing something and define the themes that we should ask about so both impetuses are present in the way we approach this. 

To figure out what to ask about we looked at two influential Institute of Medicine Reports. One was the *Crossing the Quality Chasm*Report which has ten rules for quality that defines a very general area of potential interest. The other is the *Primary Care*Report from a few years earlier which had played a bit role in the design of the PCAS of the Primary Care Assessment Survey. We picked out something like sixteen different potential areas to inquire about from these two reports and you are going to see them in a moment, it is going to sort of build up over a few slides. What we knew though was that we had, let me say this, once you have picked sixteen possible topic areas and you decide I want to do qualitative inquiry on maybe access and safety, efficiency. I want to do qualitative inquiry of what these mean for patents we quickly realize that you cannot do a nice open-ended qualitative interview about sixteen separate topics. It is very hard to define a survey that covers sixteen separate topics if you are anticipating two to four items for each topic area or each subscale. It is just going to get very long and no one is going to fill out sixteen times for, seventy-five item survey on patient experiences in primary care. We decided to let patents and some providers help prioritize what we would actually explore in our qualitative research. 

We made a Cardsort exercise and we essentially handed people packs of cards, we sent them out and handed them to patients and providers, twenty-six patients, ten providers or experts in homeless care for multiple states, parts of the country; some in the VA, some not in the VA. The cards had these kind of headings: Primary Care for Homeless Patients Should be—easy to get which is our way of paraphrasing accessibility. Should mean all those who take care of a patient work as a team and talk to each other, which was our way of paraphrasing cooperation; should keep in mind safety that crossing the Quality Chasm survey said that one of the rules for quality should be that it is safe. So we asked people to essentially tell us where to focus our qualitative inquiry using this Cardsort. 

Out of that exercise there were about, waiting for my slide to change, eight or ten items that kind of came up. Accountability whatever that means and we obviously went back to the qualitative to learn what it meant. Patient control; free flow of information and communication; continuity; care being evidence-based; care that is derived by cooperation among caregivers; accessibility and coordination. These are the things that the Cardsort respondents told us to focus our attention on when we did qualitative research meaning open-ended interviews. So that is what we asked about and I am not going to show you very much about those interviews and their results but the typical way we asked about things in our interviews was what do you think about the idea that you should have control in your primary care? I mean that was control was one of the items here. What makes you say that? How about times when you did not have a regular place to live? 

I think in the upcoming slide we are going to show you how many people we interviewed. There were thirty-six patients, both at Boston Healthcare for the Homeless Program and the Birmingham VA. There were twenty-four experts in homeless healthcare who we intentionally balanced frontline providers, administrators, even researchers on homeless healthcare and we pulled those from around the country including VA and non-VA people with telephone recorded interviews. All these interviews were recorded. The transcripts which took up some fifteen hundred pages were coded using, oh gosh, hyper-research software. Our coding approach would not fit with what many qualitative researchers do when they are being wholly sort of grounded, kind of inductive approach. We simply grouped the quotes into the a priori areas that we had already defined as being of interest and that we asked about. Obviously people speak about many things when you ask them questions. You ask about access they start to speak about continuity. You ask about cooperation they start to speak about entirely new concepts that you did not anticipate. Then we had some new constructs that came up, things we did not ask about, but were so prominent in the interviews that we decided those merited attention—homeless specific needs, sometimes including intangible needs like clothing and food; respect and a whole range of concerns related to substance abuse and mental illness. We then identified themes within each of these constructs inductively finding very instructive and illustrative quotes for each of the themes we found, and that was a more Ground Up type of approach. 

Now, I am not going to show all the themes, if somebody wants a sheet of our themes I can send it. But just to give you a sense of how once we had themes and illustrative quotes that led to the design of survey items. We asked a lot of people about this idea of control and care and here is a quote from a patient “I do not necessarily agree I should have control, but to share responsibility, that is what I think. Having a conversation with the doctor, listening to the options available, talking through the possibilities and having a say in what the final outcome is”. Survey item we had many quotes by the way that involved kind of gentle disavow or declining to a certain patient control and saying let me change what that means. Among the survey items we devised based on looking at quotes like that, this is one, “if my primary care provider and I were to disagree about something related to my care, we could work it out”. Items are typically people are asked to state how strongly they agree or disagree with the item, and I will show you that design in a moment, but essentially quotes were used to guide people to design items that would capture the flavor or the spirit of what the quotes had. 

Ultimately we drafted eight hundred and seventy-seven survey items and it was group drafting and group ranking exercise. We were trying to get items to fit each of the eleven construct areas and we originally anticipated that there might be eleven subscales; one, two, three, four, five, six, seven, eight, nine, ten, eleven. In fact we then had after ranking seventy-eight items that we wanted to try out in the field, this is not the final product obviously. They were administered for the purposes of item selection to five hundred and sixty-two persons across four sites. Typically these were primary care patents in VA and at the Boston Healthcare for the Homeless Program who had homeless experience in the medical record. That did not mean that they were homeless the day they did the survey, some were but others were recently homeless or coming out of homelessness or unstably housed. We administrated these seventy-eight items and plenty of other stuff to answer a number of questions, but what we knew was that seventy-eight is not a practical number for a questionnaire to be deployed in a primary care, potentially in the waiting room, potentially by mail. Many of our items were redundant with each other and probably needed to be shaved down but we did not know which ones were the best ones. To reduce the number of items, we started out by dealing with the fact that certain items drew a blank. Asking patients about their, trying to think of a good example, their perceptions of the accessibility of the medical record. We had a fair number of people who honestly had never tried to get the medical record and just kind of looked at us funny and said I do not know what to say to that, it has not come up. So there were probably five to ten items just had to be dropped because there were too many missing. For practical use we did not want to produce a survey that we could send out to people and say all you need to do is administer our survey and then apply multiple imputation with fifty-thousand dollars’ worth of statistician time to make use of the survey. It has to be something that most people can answer and that most people can score. 

We knew we were looking for eleven possible factors and we did allow a more traditional kind of item selection task for confirmatory factor analysis. We essentially said gee if we think we are measuring eleven things do those items tend to correlate with each other and align with factors and we use this confirmatory factor analysis at the start. It seemed like there was reasonable fit except that when we took a look at our little scales, they correlated a lot with each other. We and I am just going to take you back again and you will see why that would make sense. When you ask patents about for instance whether they agree with items about good information flow and care, it turns out that patients who are giving very positive response to that, they also tend to give very positive responses to the notion that there is continuity with their provider, and their belief that their care is evidence-based or based on good knowledge. Patients do not necessarily; we were not able to ask such refined questions that could neatly disentangle communication from say respect. It turns out that people who feel respected often will tell you that they felt like there was good information flow with their provider. We started collapsing our proposed scales and got down to four. 

What are the four? We after the fact said well what can we call these scales. We allowed the scales here now are four, one, two, three, four and they are kind of the post-talk result of saying respect, continuity, accountability, the perception of evidence-based care, the perception of control being favorable. These things are so correlated we are just going to say it is probably a bunch of questions that pertain to the patient clinician relationship. We have three items about perceptions of cooperation amongst one’s caregivers, responses to these we have a lot of dissatisfaction here, and they did not correlate well with the other scales. We said okay, that has to stand on its own even though it is going to be a Kunis Up Scale it is kind of separate. Access and coordination correlated a lot with each other, that created a subscale and finally those homeless specific needs kind of stood apart. So we have now four subscales, but we still had to get rid of items. At this point we embarked on a process mostly using item response theory and looking at items that got high rates of dissatisfaction. I think I originally had a poll question, but I took it out about people’s familiarity with item response theory. 

I do not approach this as a psychomatrician, I had a psychomatrician on the team, but I will tell you what I learned from them. Both traditional analysis and item response theory start with the notion that there is some latent trait that we are trying to assess, that in this case we are using survey questions, the latent trait in this case is essentially the degree of a positive perception of care with respect to access coordination, with respect to the patient clinician relationship. If we were medical school faculty we would talk about the latent trait being knowledge of something we were testing, but it is the same basic concept. A latent trait can reflect presumptions from prior work and in our case, we really had those reports from the Institute of Medicine that define the constructs we were going after. Then we clumped them a bit and some came out of exploration but in essence you add up with the notion that we are trying to measure four scales and four latent traits. A collection of items together makes the mathematic contribution to some latent trait value which you can sort of get out of magical software called MPlus. An item can be more informative or it can be less informative. Items can provide information at different levels of the trait so in principle maybe an item is extremely instructive for people disentangling different levels of satisfaction or maybe an item is particularly helpful at detecting the difference between being merely satisfied versus being mildly dissatisfied versus being totally deeply concerned and upset by one’s care. Items can work along different levels of scale and this works easier mentally if you think about test questions that you write for a class but the same principle applies with experience questionnaires. 

I wanted to show you a little bit of what happens when you apply item response theory guided analysis to individual items. That involves these graphs and I never had seen them before doing the study but it is worth getting a sense of what happens when you are presented with them. Essentially for every single item we had, the psychomatrician tests the items performance in terms of how informative is it with regard to a latent trait. Here is an item – I feel my primary care provider has spent enough time trying to get to know me. It is something to do with the relationship. Here is another – my primary care provider has known me long enough to see when I am struggling. By the way that item came very closely out of very specific quotes I can almost remember verbatim from our coding exercise. The first thing to know is that not all people, the person’s response is supposed to be: strongly agrees; agree; disagree or strongly disagree. Frankly people do indicate some dissatisfaction, seventeen percent disagreed or strongly disagree with this one and nineteen percent with that one. There is some utility to these items. The test information function puts on the x-axis something called the latent trait. This is essentially the middle of our spectrum of response, the computed, the statistical abstraction that involves combining all of the relationship items that we have. This is the trait of being positively feeling about the primary care relationship this is obviously very negative, most people live somewhere between minus 1.5 and plus 2.5. the information that this particular item gets is in itself a statistical abstraction, but it is not a y-axis from 0.5 to 1.0 to 1.5. I would handle this essentially a set of graphs for initially seventy-eight such items, eventually reading it down. And no of course I do not have any intuitive feeling of what 1.5 means, but I can see that I had graphs where the top was 1.5 or 2.5. Then I have graphs like this one, where the informational value is 0.6. the first thing I notice is that his item performs in a weird way, it has a peak, like somehow it is extremely informative for people who are slightly dissatisfied, that has a valley which suggests that it is apparently not really great at clarifying graduations of mild satisfaction then it has another peak at some high level of satisfaction. So my guess is there is a lot of mushiness when people merely say that they agree with feeling that their primary care provider spends enough time to getting to know them. We did see this double peak curve and the viewers of our journal article asked us to comment and all we could say is that is the output we got. I do see that the curve peaks high and no we do not learn very much about the difference between hating your doctor and merely disliking the relationship you have with your doctor, this item is not going to be helpful for that. This item has a peak that is lower it is 0.6 sometimes we had them as low as 0.3 but the first thing we know is whatever the latent trait is, where we are looking the very best information we get out of this just isn’t quite as strong statistically as this one. Given the choice we would sometimes drop items; typically, we drop items with lower informational value and hold onto ones with higher informational value. 

The other thing we did is we would sometimes hit the situation, it is not shown in the slide where we had almost identically worded items with just two or three words difference and we would look at whether they performed differently. In a few instances they did not perform differently, I will give you an example. My providers are working together to improve my care and I can see that my providers are working together to improve my care, something like that.  Two that are that similar very often did not differentiate statistically and we would just take a look at the distribution of responses, see if there was a better distribution of one versus the other. In some very tiebreaker situations literally ask ten or eleven of our investigative team to talk about which on they think would be more feasible. 

The result is an instrument the survey it is thirty-three items long. Instead of a ninth grade level it has a seventh grade reading level, keep in mind we are not just trying to make this useful for VA but also for non-VA healthcare for the Homeless Program. It is also translated into the Spanish with a seventh grade reading level at this point so it can be used in those HCH programs. We use the very same response option across all thirty-three items. We did not like the idea of skipped items and we did not like the idea of having people have to shift their framework in responses. So it was: strongly agree; agree; disagree; strongly disagree. 

The way it starts off is - We would like to ask you some questions about the person you see for primary medical care here at (introduce place). This is the person you see for a check-up or for a general medical problem when it is not an emergency. This person could be your regular personal doctor, a nurse practitioner, or a physician assistant. We would also like to ask you about receiving 

care here at the Birmingham VA Homeless Pact or at Boston Healthcare for the Homeless Program.  Please indicate how much you agree or disagree with the following statements about the person who provides your primary medical care, make your best guess. Then halfway through we switch to indicate how much you disagree or disagree with the following statements about the place where you are getting care. Some of the items, examples. Here are two items from patient/clinician relationships. I feel my PCP has spent enough time trying to get to know me and seventeen percent of people actually disagreed or strongly disagreed with that. My primary care provider makes sure healthcare decisions fit with other challenges in my life, nine percent of people disagreed or strongly disagreed with that. That is our effort to get the patents perception of whether their care involves contextually appropriate decision-making as Dr. Weiner who I mentioned earlier would put it. We add those three items on perceptions of cooperation among the people who deliver your care. My primary care and other health care providers need to communicate with each other more that is a negatively worded item agreeing with it, is a bad thing, forty-five percent of people say, yep they need to do that more. I am confessed at seeing this had led me to alter my own practice when I am seeing patients I actually make much more of an effort to pick up the phone and call their other providers with the patient in the room. Or say you know last night I was on the phone with your surgeon or last night I reached so and so just to let them know about the situation. It seems to have a subjective effect on the patients. Access and Coordination items - if I walk into this place without an appointment, I have to wait too long for care, twenty-nine percent of people agree with that. By the way these are not all VA this is a mixed population of respondents. Generally the non-VA site which is very of a model, twenty-five years’ experience healthcare did a little better on these items than the VA sites, but these VA sites were not Homeless Pacts these are kind of pre-homeless Pacts, standard primary care. Homeless-Specific Needs, this place tries to help me with things I might need right away like food, shelter or clothing and gain eleven percent said they disagreed with that or strongly disagreed with that. Generally, the same here as simple items, clean language, low reading level and hopefully intuitive. 

Is this a value survey? Well we used the item response theory and in the end it does not give you a single number it gives you a lot of curves related to something called overall test information functions. I do not think I am graphing those here but essentially it had adequate test information. We did test the convergence of our survey with Dana Saffron’s Primary Care Assessment Survey which is for general populations but actually they do correlate reasonably well. The concept of divergence validity asks – does your item correlate less with something that might be an alternative reason for people to give responses the way they did on your survey. I thought gee if people are really depressed and down in the dumps, maybe they would give that report to their primary are that is kind of a rival hypothesis for how people answered our survey. What we found is that negative psychiatric symptoms meaning being depressed, anxious, not in social withdrawal but more like being paranoid, depressed, anxious etcetera on a standard survey called The Colorado Symptom Index. That did not correlate very much with how people answered our survey. Internal consistency,  apparently lost an ‘I’ there, generally high Cronbach alphas in fact sometimes too high but we will come back to that. Items loaded on their respective factors in ways that were quite comparable to the CAHPS. and we did find in a study we published last year that typically scores were higher at places which had a more greater degree of service tailoring in terms of staff, collocation of services etcetera that is a preliminary finding in the sense that we have only looked at five places and we hope to continue that work. 

I mention that the scales correlate with each other, we got rid of excessive correlations that is obviously a subjective word. Your perception of your relationship with your provider correlates with your perception of whether your providers cooperate with each other; correlates with your perception of access and coordination; correlates with your perception of homeless specific needs. This amount of correlation is pretty much similar or less than what you find among the various upscale used in the consumer assessment health plans. It is a lower degree of correlation that would be found among the subscales in the survey of health experiences used by VA which is based on the same thing. I think there is more redundancy here. You might wonder why we have guns in this, another version of divergent validity is that your survey does not correlate at all with something that has nothing to do with what you were asking about. So we actually were probably the only Homeless Health Researchers to query homeless and formerly homeless individuals about their attitudes towards gun freedom in America. It turns out there is not much correlation between your view of primary care and your views on gun ownership. 

In the field what we found is when this instrument is used side by side with the CAHPS, the patients have an easier time with the Primary Care Quality Homeless Survey. They can get handed the items, they have very few questions, they need very little assistance, at least at Boston where they did this for several hundred people, a lot of them stumble over the items in the CAHPS. The version of the survey, a preliminary version was used in the VA Health Services Research Study, the data has been accumulated we have not analyzed it yet. The PCQ-H instrument I have been describing is being used currently in an e 8-site HRSA-funded Special Project of National Significance focused on medical homes for HIV-Positive Homeless Populations, again outside VA. Our vision and probably my advocacy is showing through here as I would like for the Primary Care Quality Homeless Survey to be the consumer survey of choice for these providers doing primary care for homeless individuals. It is being used, we have briefed it to national leaders and quality measurement and to Dr. O’Toole and essentially our next steps are to test and refine the instrument for real world use. I do not mean that we are going to remove items, but rather that we need to verify that the same kinds of patterns of response are obtainable when you simply hand a survey to people in the waiting room as opposed to introducing them into a study with a twenty dollar payment. All of our developmental work involves face-to-face administration. We know that some programs have used it as a handout because that is how it was designed, but we have not formally tested that so we are trying to do that now. We would hope that over time both central office and Health and Human Services would see this as a desirable way to assess the experiences of patients who are homeless and receiving primary care, particularly if they are paying for programs that are seeking to reach that population. 

Conclusions: My view and hope you will share it is that Homeless Primary Care is unique enough to merit special methods of assessing the quality including patient questionnaires. The use of both kind of a mixed metaphor of Top down and Bottom Up approaches to survey design with help in producing this instrument and we think the resulting survey is practical and available for use. The main version that gives you four scores is thirty-three items. We do have an abbreviated fourteen-item version but it only really validated to get you a general overall scores as opposed to four individual scores. 

Finally, if you want to use the survey, that is totally fine by us, just contact us. I think we are going to distribute the survey, a version of it that allows you to see how the scoring is done for the items. The only reason we want to be contacted in part is to know who has used it and where, that may help us make the case with HHS and VA about the use of this. We also want to know what goes wrong when you try to use the survey. As I said in the VA the step that we are going to be embarking on is that we have to go through the Privacy Act Requirements. You cannot just throw a survey into clinical use in the VA without passing muster under the Office of Management and Budget except if you are a researcher and all to research conditions so we are trying to fix that. I think that is where we are and we would like to open up to questions at this point. 

*Moderator:*Excellent, thank you so very much. 

*Dr. Stefan Kertesz:*There are questions already. 

*Moderator:*Yes we do have some. Before we get to them real quick I just want to let you know that yes, we do have the survey available. It is going to be posted with the archive, it is going to be tacked on to the end of the handouts, you will all receive a follow up email two days from now that has a direct link leading to that archive. You will have access to it, but that should not preclude you contacting Dr. Kertesz if you are going to be using it. Yes we do have some questions. For those of you that joined us after the top of the hour to submit your question and comment just use that Q&A box in the lower left hand corner, I am sorry lower right hand corner of your screen. The first question we have is – how to get the information and latent trait?

*Dr. Stefan Kertesz:*So, first of all I think are phones open at this point in case we need a clarification? 

*Moderator:*No we do not open the phones, however, when there needs clarification they are more than welcome to write in. 

*Dr. Stefan Kertesz:*What I think this is saying in a sense is how is this computed, that is I have a bunch of items, a bunch of items produced in MPlus, was it MPlus that they used? Yeah it was MPlus software, the psychomatrician is able to compute this abstraction. In fact I have a PDF that explains conceptually the computation. In essence it is still a statistical abstraction, however, it says given all that I know from all the items how much does each item tell me about that latent trait. There are a few different mathematical solutions for this, I think ours is called the two-factor solution. It forces certain assumptions into that modeling approach, essentially an overall factor and a partial factor. It is ultimately a statistical abstraction out of MPlus and for Ace Cowan and anybody else, if you wanted an excerpt from what our psychomatrician wrote us, just email me, and I will share it. He explains his math a little bit better than I can do orally but I kind of have a document he wrote for us so that we could write our own method section. There is a manuscript in press at Medical Care on this which will explain a little bit better his write up is not bad.  The same individual asks what is the difference between the CAPHS and the PCQ-H. so I think the cardinal things I have advertised in a sort of advocacy minded way. In general there are many CAHPS questionnaires so if you hear the word CAHPS, there is a hospital questionnaire, primary care questionnaire, there are one’s that have patient center or medical home items attached and one’s that do not. Keep in mind there is kind of a range there, but I am always comparing us to the CAPHS Primary Care item with the Patient-Centered Medical Home add in. Conceptually the approach taken, CAPHS emerged in a sense from twenty or twenty-five years of background work. It did not involve, it involved probably some early, early qualitative work with patients, twenty or thirty years ago. A lot of focus groups and testing of the items among consumers later, but it does not represent a fresh and recent open-ended look at what patents want and certainly not a fresh and recent open-ended look at what homeless patients want. There are decades of experience built into it. It does reflect a view about what you should be asking patents. It is a little bit different from ours, because the CAHPS is heavily focused on the notion of getting the patients report a particular care experiences and then even when they ask about the relationship a lot of the items are very procedural. When the doctor talked to me about A, such and such happened or such and such did not happen. That reflects a notion in the sense that patients are more reliable reporters if you demand that they be specific about something. Somebody who knows CAHPS can correct me, but in essence we took a pretty different approach in a sense we asked global questions that say when I ask about things I need quickly like test results I can get them. It is a general question, it can apply to what has been going on in the last three months, it can apply to two years. We ask our questions in a broad way that involves a kind of global judgment and there are some down sides to that and positive sides t that. 

There are a ton more relationship questions in our instrument then there is in the CAPHS. We get questions about honesty, perceptions of respect, the patents perception of communication, about their perceptions of time control in the visit. There is just way more that is particular to relationship development than the CAPHS would try. There is way less probably on the specifics of what happened at your last visit. There are no questions about what happened at your last visit. Certainly I actually administered our instrument to my mother who is not homeless as far as I know, but other than the homeless specific items, she kind of liked the questions. We also have questions about stigma, keep in mind we are interested I knowing whether patients in a homeless primary care setting feel that they are negatively judged for substance use. This is a very, very, very big issue and in primary care for homeless individuals the feeling that you are being adversely judged, particularly with the conversation turns to pain. Well, we did not want to have skip patterns so we did not design questions to ask people hey do you have an addiction and if you do answer question five if you do not skip it. That was not going to be a solution for us. We had to come up with questions that got perceptions of stigma on those issue without anybody owning up to have an addiction issue. Here is one question – people who use drugs or alcohol tend to be treated worse t this place. Here is another addiction related item, I think it is something like I feel I can be honest with my provider about issues related to alcohol and drugs. Do you feel you can talk about it? There is a question about whether you think patients are negatively judged if they have mental illness. Those perceptions of stigma questions do not occur in the CAHPS. 

Another question, how did you pull the patients with experience of homelessness and CPRS? We had a database person who pinged the VA’s national patient treatment files at Austin, now in the VSSC. Those databases have a V-60 code which indicates that there has been an encounter with VA related to something to do with homelessness. Most of the time that means they are not homeless at the time you finally reach them. I think these days if you were trying to poll your local facility you might be able to get something out of the homeless screening questions that are administered nationally. I have not tried to pull it myself but there is an emergency department and frontline are using a mandated screener but a V-60 code certainly gets you a population. When you look at it though you find a lot of them are past homeless or they are now in VA housing. 

Alice Burnett, asks – has this work been published? Can you send the citation? Absolutely, there is one major publication which is a comparison of the five sites in the study that we used to develop the instrument. We also using the final instrument compared the experience across five places. The first publication now is actually the less informative about the instrument and more informative about how you can use it. That I can send out and have everyone distribute today right after the call. The most important article to follow up this presentation is the one that is in press at medical care. Obviously it takes a few months we have specifically requested it be open access so whether you are in VA or not VA, you can download it and anybody who I think I am allowed, am I allowed to distribute my own private copy now. If you make a private inquiry with me I can share a copy of my private work presuming you are not going to send it around. I think I am allowed to connect with any individual colleagues with my copy of the manuscript that has been accepted for publication but I cannot submit it broadly. 

Dr. Omar Ramadan asks – what do you think is a realistic timeline for PCQ-H as adaptation to a broader scale? What I have been advised is that it is more work than I would like, but it is work that I have to do. We need to do some refinement in terms of making sure that this thing works when you hand it to someone in a reading room and we have to know what happens when you mail it to people because that is a normal way of getting these questionnaires. Does everything get screwed up if you do mail versus handing it to people in the waiting room? We are trying to do that piece of work in the next three to four months and we are planning that out now it is an IRB amendment. 

The second question though – what will it take to get through the Office of Management and Budget authorization and permission so that anybody can use it regardless of whether VA is mandating it in any general way. On that I need help, I need help from VA central office. I imagine that it is going to be longer than I would like. If anybody has done one of these before I think there are a few on the call who have go ahead and text in what time it took you to get one through Office of Management and Budget. That is an ambiguous answer Omar I am sorry, my guess is that there are several months to get through OMB maybe six to twelve unfortunately. If you are outside VA you have lots of options, if you are inside VA, I think that we are kind of boxed a little bit except that you can do this with a small number of patents like nine or less I think easily. 

*Moderator:*May I interrupt. 

*Dr. Stefan Kertesz:*Go ahead. 

*Moderator:*Just a few things, the next question you are about to answer I believe came in during the addiction portion when you were talking about those questions. Also, this is the last opportunity for people to write in their questions or comments because in about one minute, I am going to put up the feedback survey and then we will continue with the Q&A. Go ahead Dr. Kertesz.

*Dr. Stefan Kertesz:*So Ronald Christopher asked – what if a peer asks those questions.  So, when we tested this in research development, we administered a battery of questions that included this one and several other instruments that was face to face. But we never wanted for it to be face to face, we really wanted to design something that was not going to require those kind of resources. Ideally you have paper and pencil in the waiting room or maybe one day in a tablet that they hand you to fill it out. I hope that we do not have information as to what happens if a peer asks those questions but the hope is that it does not normally require that. We figure clinicians are busy in clinical programs, really want things where you can hand it to the patient, they have a good experience and it is over. That is probably the best we can say on that. 

Daniel Headeote asks – is it possible to review the latent trait versus information graphs produced by MPlus about the different items used in PCQ-H. Daniel, email me and I think I can get that to you. You can look at our overall information graphs, you can even look at the packet. Essentially the exercise, everyone would like to believe that when you hand things off to psychomatrician’s they sort of sprinkle some statistical fairy dust and you get the best items out of it. Well, you get a big list of here is what you learned from this item, here is what you learn from that item. Some look manifestively better than the other so you take them, but there is still a mixture of well, we need some items that are informative at the high end and the low end. Gee there are these items that seem totally redundant with each other and it would be kind of offensive to ask the two in the row, even if they are both informative. In the end it is never just purely statistical output that gives you the answer. 

Something about evaluation is coming up. 

*Moderator:*Yep I am going to put up the evaluation so please take the time to fill it out and we do have one more question so I will go ahead and read that aloud because Stefan I have blinded you from seeing the eval report. How do you think social desirability bias affects the survey responses and how long does the survey take on average to complete?

*Dr. Stefan Kertesz:*Completing thirty-three items with identical format across all the items has typically been probably two to four items a minutes, thirty-three divided, to five to ten minutes. As I said there is a fourteen-item version that can be done if that looks like it is going to be a problem. Social desirability I am trying to think if we asked if we directly tested that question. I do not think we did, what we know is that in the research context where we administered this with the population of people who we recruited to the study, we also administered substance abuse items and found very high rates of self-reported substance use and substance misuse. That paper is also under submission now. There did not seem to be a lot of shyness about describing those difficulties and we obviously offered every level of confidentiality protection. Then when the survey was used for purely clinical practical purposes at Boston Healthcare for the Homeless Program, across multiple sites ranging from shelters to their main clinks, their scale scores and the responses they got were slightly worse than what they obtained when they administered to their research subject participants. I think it was because they were working with the more unstable population and people who had greater challenges in their lives in one way or another and had less experience with the Healthcare for the Homeless Program. It also does suggest that people did not hold back in sharing concerns on that survey. There is a general problem is that whatever you are using regularly for a service including a homeless primary care program if you are still going back there, and you are filling out surveys for it, you probably think it is at least half-decent because you would not be there anymore if you hate it. All these questionnaires I have looked through many ours and others, only answers tend to be kind of on the satisfied end and what we prize is finding at least enough items to get negative reactions or dissatisfied responses. Because frequent customers at any service tend to be more favorable than unfavorable about the service. Yet, we want to know what is difficult and where things fall short. 

*Moderator:*Thank you so much. A few things, I know we are at the top of the hour I just want our attendees to know I am going to leave this survey up for the next half an hour so take your time and there is no submit button, once you fill out the poll it automatically comes to us. Dr. Kertesz I would like to give you this opportunity to make any concluding comments you would like to. 

*Dr. Stefan Kertesz:*Yeah, first of all I am going to send an article to you so that everybody has a copy of the article that is already published. If anybody individually wishes read about the instrument a little bit and its methodology with some more statistical detail, email me at either skertesz@uabmc.edu sorry about my name having an s and a z in it but that is what it is. Or it is Stefan.Kertesz@VA.gov and I can send you my private copy of the manuscript that I have for your review. I am also happy to share that statistical extract with people who request it. The first five pages are clear to anyone and then the rest gets into lots of graphs and may be harder to interpret. That is fair game if people would like to look at that and sort of see what we get back from a psychomatrician. 

Thank you for your attention by the way I am so pleased that so many people are willing to listen to this. 

*Moderator:*yeah we still have most of our audience still on. I just want to mention I am watching the feedback come in and a lot of people are saying it would be nice to see the survey. Once again, I do have a copy of the survey, it is immediately going to be posted with the archive in fact it may already be up there. You will receive a follow up email in two days with a link leading directly to that, you can pass that along to colleagues, have them watch the video or look at the handouts. It is available to you I promise and I will also get that paper out that has already been published. With that Dr. Kertesz I cannot thank you enough for sharing your expertise, we did have a very engaged audience and it was a great presentation. As always thank you to our attendees for joining us and please do fill  out the survey as it is your responses that guide which topics we have presented for us and where we go with the program. 

Once again thank you so much to everybody for joining us today, I am going to leave up the survey so take your time but this does conclude the presentation portion of our cyberseminar. Thank you again. 

*Dr. Stefan Kertesz:*Okay that sounds great, thank you. 

*Moderator:*Thank you bye, bye. 

*Dr. Stefan Kertesz:*Okay take care bye, bye everybody. 

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