Child CG-CAHPS Survey - Providers’ Use of Information to Coordinate Patient Care (Care Coordination)

The CG-CAHPS Survey measures key components of patient experience, such as provider communication and ease of access, that are consistent with patient-centered care. The CAHPS Surveys focus on aspects of care that consumers have identified as important and for which patients are the best or only source of information. Measuring patients’ perceptions of their healthcare experience is not just a means to improve services—it’s a recognition that the patient’s voice matters in and of itself. Listening to patients affirms their role as active participants in their care, and their insights are essential to truly understanding the quality and impact of healthcare delivery. In 2023, over 238,000 patients completed the CG-CAHPS Survey as part of the PCF PECS survey. It is possible that more practices are administering and using the CG-CAHPS survey beyond the practices participating in PCF. We reviewed the literature on the determinants of patient care experiences measured by CAHPS and their associations with other indicators of health care quality. CAHPS is also an actionable measure that helps clinicians and health plans target interventions that will improve the quality and patient-centeredness of care.

Review of the Evidence

Prior research has identified several features of healthcare delivery structure, including clinic accessibility, patient flow, and management, that are associated with patient experiences. Two major systematic reviews have examined the relationships among patient experience, clinical processes, and patient outcomes. A systematic review performed by researchers in the U.K. found that patient experience is favorably associated with adherence to recommended medications and treatments, preventive care such as screenings and immunizations, patient-reported health outcomes, clinical outcomes, reduced hospitalizations and primary care visits, and reduced adverse events (Doyle et al., 2013). Anhang Price et al. (2014) reviewed evidence on the association between patient experiences and other measures of health care quality in the U.S. They similarly found that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, and less health care utilization. 

Health Care Process and Quality Improvement Influence on Patient Experience

Providers routinely use patient-reported measures such as CAHPS to guide quality improvement (QI) activities to improve their patients’ experience with care (Friedberg et al., 2011; Davies, Shaller, et al., 2013; Quigley et al., 2015). 

For example, to improve scores for “how often the office staff were as helpful as you thought they should be”, Dean Clinic, a large integrated health care delivery system in Wisconsin, further surveyed their patients to ask them what “helpfulness” means to them and to ask how office staff could be more helpful. From this feedback, the Clinic learned about ways that the office staff can be more welcoming, friendly, and appreciative of patients. With input from both staff and management, Dean Clinic developed action plans to improve patient experience. The service department shadowed staff and provided feedback. To improve consistency in service across all sites, the Clinic developed an orientation for all new employees on customer service expectations. They also offered ongoing training in the form of service workshops, videos, and Webinars, as well as targeted interventions for the lowest scoring offices (AHRQ, 2013). Several quality improvement initiatives to improve provider communication and engagement include shadowing, coaching, and training (AHRQ, 2013; Hardee & Kasper, 2008; Quigley, Palimaru, et al., 2017). Lastly, Friedberg et al. (2011) found that physician groups that aim to improve access, communication with patients, and customer service do so by addressing office workflow, providing additional training for nonclinical staff, and adopting or enhancing an electronic health record.

Using data from the CAHPS survey and a newly installed electronic health record system, in 2015, leaders of Northeast Valley Health Corporation (Los Angeles County) pinpointed interventions including reallocating staff resources and not scheduling well-child visits first thing in the morning. System leaders found that when the first appointments of the day ran long, there was a cascading effect on the rest of the day's schedule. By 2015, NEVHC instituted changes systemwide. By 2017, total average cycle time was reduced from 82 minutes to 65 minutes; the proportion of patients with a cycle time under 60 minutes rose from 34 percent to 48 percent; and the proportion of patients seen within 15 minutes of appointment time rose from 38 percent to 47 percent. Case study found at https://www.ahrq.gov/news/newsroom/case-studies/201718.html

More examples of interventions to improve patient experience with primary and specialty care as measured by the CG-CAHPS Survey can be found in the CAHPS Improvement Guide available at https://www.ahrq.gov/cahps/quality-improvement/index.html. The Guide also includes information on analyzing survey results and identifying root causes of performance problems.

The Centers for Medicare and Medicaid Services Merit-based Incentive Payment System (MIPS) Quality Payment Program measures Medicare Part B providers in four performance categories to derive a score that could affect a provider's Medicare reimbursement positively or negatively starting at 4% in 2019 (based on 2017 performance). MIPS has a performance category called “Improvement Activities” that includes an inventory of activities that assess how a physician group can improve care processes, enhance patient engagement in care, and increase access to care. Several of these activities are geared to improve patient experience of care as measured by CG-CAHPS. A list of MIPS activities can be found at https://qpp.cms.gov/mips/improvement-activities.

Structure

Physician clinic hours of operation and availability for appointments have been found to predict patient experience in several studies. In a study with survey data from 61,839 patients of 1729 primary care physicians in California, system-level factors, such as belonging to a larger medical group and the physician’s zip code-based Primary Care Services Areas, explained between 28% to 48% of variation in patient care experience, with the highest proportion explained for the access to care composite (Rodriguez et al., 2009). Improving the infrastructure supporting certain aspects of care may have broad effects because system changes can influence multiple outcomes (Cleary, 2016).

“Expanded practice access” is a highly weighted CMS MIPS improvement activity. To improve the patient experience in access to care, practices may consider providing 24/7 access to clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record). Access expansion can include one of the following: 1) expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care); 2) use of alternatives to increase access to care team by clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or 3) provision of same-day or next-day access to a consistent clinician, group or care team when needed for urgent care or transition management. Another example is implementation of “open access” scheduling, in which some physician time is always reserved for same-day appointments, to improve patient access to care (Murray & Tantau, 1998).

Health-related Patient Behavior and Disease Management

One dimension of the CG-CAHPS measure captures the patients’ perceptions of how well providers communicate with them. Better patient-provider communication promotes healthcare-related patient behaviors (Fuertes, Boylan, et al., 2009). A 2009 meta-analysis of 127 studies assessing the link between patient treatment adherence and physician-patient communication found a 19% higher risk of non-adherence among patients whose physician communicated poorly (Zolnierek and Dimatteo, 2009). Doyle’s (2013) meta-analysis showed positive associations between the quality of clinician-patient communications and adherence to medical treatment in 125 of 127 studies analyzed. Studies using the CAHPS measure have found that better provider communication is positively associated with adherence to hypoglycemic medications among diabetics (Ratanawongsa, Karter, et al., 2013), adherence to tamoxifen among breast cancer patients (Liu, Malin, et al., 2013), and higher rates of colorectal cancer screening among adults in the US (Carcaise-Edinboro and Bradley, 2008). Sequist and colleagues (2008) found that measures of patient experience, including doctor-patient communication, clinical team interactions, and health promotion support, were positively associated with some prevention and disease management clinical process measures in clinical practices and among individual clinicians.

Outcomes

Out of 40 evidence papers with outcome measures, Doyle’s (2013) meta- analysis found 29 studies with positive associations between patient experience and clinical outcomes, 11 with no associations, and none with negative associations. The lack of more evidence may be due to complexity between a patient’s illness level, their level of care, and their likelihood for a poor outcome such as mortality, morbidity or a readmission. Often, such associations have more than one plausible direction of causality. For example, clinicians may be especially attentive to the needs of sicker patients (Kahn et al., 2007) and patients near the end of life (Elliott, Haviland, et al., 2013; Xu et al., 2014). 

Moreover, substantial evidence points to a positive association between various components of patient experience, such as good communication between clinicians and patients, and several important processes and outcomes. These include lower utilization of unnecessary healthcare services; better patient adherence to medical advice; better process of care measures for acute myocardial infarction (AMI), congestive heart failure, pneumonia and surgery; lower inpatient mortality among acute myocardial infarction (AMI) patients; lower infection rates (Anhang Price, et al., 2014); and better clinician and staff perceptions of patient safety culture (Sorra et al., 2012). 

Utilization

Research suggests an association between better patient experiences and lower healthcare utilization. Children with asthma were less likely to visit the emergency department, make urgent office visits, or be hospitalized if their physicians had reviewed a long-term therapeutic plan with their parents (Clark, Cabana, et al., 2008). Among African Americans with Type 2 diabetes, those who reported that doctors or nurses usually listened carefully or spent enough time with them were significantly less likely to visit the emergency department in the 12 months following completion of a patient experience survey (Gary, Maiese, et al., 2005). Children whose parents report longer waits for primary care visits were more likely to visit the emergency department for non-urgent reasons than those who report waiting for less time (Brousseau, Bergholte, et al., 2004).

References

Agency for Healthcare Research and Quality (AHRQ). How Two Provider Groups Are Using the CAHPS® Clinician & Group Survey for Quality Improvement. Brief available at https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvem….

Anhang Price, R, Elliott, MN, Zaslavsky, AM, Hays, RD, Lehrman, WG, Rybowski, L, Edgman-Levitan, S, Cleary, PD. (2014). Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 71(5), 522-54.

Brousseau, DC., Bergholte, J., et al. (2004). The effect of prior interactions with a primary care provider on nonurgent pediatric emergency department use. Archives of Pediatrics & Adolescent Medicine. 158(1), 78-82.

Carcaise-Edinboro, P. and Bradley, CJ. (2008). Influence of patient-provider communication on colorectal cancer screening. Medical Care. 46(7), 738-745.

Clark, NM., Cabana, MD., et al. (2008). The clinician-patient partnership paradigm: Outcomes associated with physician communication behavior. Clinical Pediatrics. 47(1), 49-57.

Cleary, PD. (2016). Evolving concepts of patient-centered care and the assessment of patient care experiences; optimism and opposition. J Health Pol, Policy & Law. 41(4), 675-696.

Davies, E, Shaller, D, Edgman-Levitan, S, Safran, DG, Oftedahl, G, Sakowski, J, Cleary, PD. (2008). Evaluating the use of a modified CAHPS survey to support improvements in patient-centered care: lessons from a quality improvement collaborative. Health Expect. 11(2), 160-76.

Doyle, C., Lennox, L., et al. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 3(1). http://bmjopen.bmj.com/content/3/1/e001570.full

Elliott, MN., Haviland, AM., et al. (2013). Care experiences of managed care Medicare enrollees near the end of life. Journal of the American Geriatrics Society 61(3), 407-412.

Friedberg, MV, SteelFisher, GK, Karp, M, and Schneider, EC. (2011). Physician groups’ use of data from patient experience surveys. J Gen Intern Med. 26(5), 498-504.

Fuertes, J N., Boylan, LS., et al. (2009). Behavioral indices in medical care outcome: The working alliance, adherence, and related factors. Journal of General Internal Medicine. 24(1), 80-85.

Gary, TL., Maiese, EM., et al. (2005). Patient satisfaction, preventive services, and emergency room use among African-Americans with type 2 diabetes. Disease Management. 8(6), 361-371.

Hardee, JT, Kasper, IK. (2008). A clinical communication strategy to enhance effectiveness and CAHPS scores: The ALERT model. Perm J. Summer. 12(3), 70-4.

Kahn, KL., Tisnado, DM., et al.  (2007).  Does ambulatory process of care predict health-related quality of life outcomes? Health Services Research. 42, 63-83.

Liu, Y., Malin, JL., et al. (2013). Adherence to adjuvant hormone therapy in low-income women with breast cancer: The role of provider-patient communication. Breast Cancer Research and Treatment. 137(3), 829-836.

Murray, M and Tantau, C. (1998). Must patients wait?  Jt Comm J Qual Improv. 24(8), 423-5.

Quigley, DD, Mendel, PJ, Predmore, ZS, Chen, AY, Hays, RD. (2015). Use of CAHPS™ patient experience survey data as part of a patient-centered medical home quality improvement initiative. J Healthc Leadersh. 7, 41-54.

Quigley, DD., Palimuru, AI., Chen AY., & Hays, RD. (2017). Implementation of practice transformation: Patient experience according to practice leaders. Quality Management in Health Care. 26 (3), 140-151.

Ratanawongsa, N., Karter, AJ., et al. (2013). Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA Internal Medicine. 173(3), 210-218.

Rodriguez, HP, Scoggins, JF, von Glahn, T, Zaslavsky, AM, Safran, DG. (2009). Attributing sources of variation in patients' experiences of ambulatory care. Med Care. 47(8), 835-41.

Sequist, TD., Schneider, EC., et al. (2008). Quality monitoring of physicians: linking patients' experiences of care to clinical quality and outcomes. Journal of General Internal Medicine. 23(11), 1784-1790.

Sorra, J, Khanna, K, Dyer, N, Mardon, R, Famolaro, T. (2012). Exploring relationships between patient safety culture and patients’ assessments of hospital care. Journal of Patient Safety. 8(3), 131–139.

Xu, X., Buta, E., Anhang Price, R., Elliott. NN., Hays, RD., & Cleary, PD. (2014).  Methodological considerations when studying the association between patient-reported care experiences and mortality. Health Services Research. 50(4), 1146-61.

Zolnierek, KB. and Dimatteo, MR. (2009). Physician communication and patient adherence to treatment: a meta-analysis. Medical Care. 47(8), 826-834.