Healthcare for the Homeless: Improving Patient S atisfaction S urvey A Qualitative Study

1. Healthcare for the Homeless:Improving Patient Satisfaction SurveyA Qualitative Study

2. Team Members Janel Diehr Jodi Mayer Donna-Marie Mecca Darin Principe Emily Smith

3. Objectives • Supply staff and providers at the healthcare facility a qualitative patient satisfaction tool to help them better serve their patient population • To provide a one page easy to follow qualitative survey to measure patient satisfaction

4. Background • Approximately 10,000 people a year will experience homelessness in Orange, Osceola and Seminole Counties • Healthcare Center for the Homeless is a 501(c)(3) non-profit organization • This facility provides primary care services, dental care, mental health and substance abuse counseling, vision services, on-site pharmacy, TB shelter, mobile health care and street outreach program

5. Population served • Homeless and uninsured residents with income below 200% of poverty guidelines in Orange, Osceola and Seminole county • To be eligible one must provide • Proof of household income • Verification of Residency • Medicare or Medicaid cards • Referral form if appropriate

6. Demographics • Patients seen in 2010- total 8836 • Ages 0-19: 546 Male, 409 Female. Total- 10.8% • Ages 20-64: 4,440 Male, 3154 Female. Total- 85.9% • Ages 65+: 140 Male, 147 Female. Total- 3.2% • Language other than English: 2.6% • Race • Asian: 0.92% • Pacific Islander: 0.32% • Native American: 0.62% • Black/African American: 51.3% • White: 40.2% • Other/Not reported: 6.68% • Primary Diagnoses by Number of Visits. Total 10,746 • Hypertension/HrtDz: 36.2% • Mental Health/Substance Abuse: 35.1% • Diabetes/Obesity: 20.6% • Asthma/Bronchitis/Emphysema: 4.7% • Infectious Disease: 1.7% Reference: Uniform Data System (UDS) Report. (2010). Health care center for the homeless, inc. (BHCMIS ID: 0413580). Orlando, Fl. Retrieved from https://grants.hrsa.gov/webExternal//login.asp?rURL=https%3a%2f%2fgrants2.hrsa.gov%2fWebUDSExternal%2fPlatf orm%2fInterface%2fReviewPage.aspx%3fsoid%3d1ea8

7. Previous Patient Satisfaction Tool • Only offered in one language • Language used may be difficult to understand • Services are rated with “X” and no space for for extra comments • Survey is lengthy at 2 pages long • Questions are closed ended • Little incentive for patient population to complete the survey

8. Current Quantitative Survey

9. Barriers of patient population and current survey • About 14% of Americans or 1 in 7 can’t read • About 2 million in the US don’t speak English • About 70% of adults on welfare have low literacy rates • Financial obligations to get back to work

10. Literature Review • Using a mixed quantitative and qualitative approach to measuring patient satisfaction allows a statistical view of the data in addition to a detailed investigation of the rational behind the results. • Identifying patient’s expectations is helpful in designing a survey which will address them. • Concept of comparison by degree were found to be unfamiliar to the less literate & non native speakers due to difficulty finding equivalents for “slightly”, “fairly”, “extremely”, etc.

11. Literature Review (cont.) • Pictorial rating scales, i.e., Smiley Face, for use in in a non-acute setting with semi-literate adults and non native English speakers were seen as belittling and resulted in negative attitude to the survey process. • Short Verbal Rating Scales were found to be the most valid and reliable measure to use than nonverbal rating scales (numerical, pictorial or graphics), all of which tended to cause confusion in less literate clients due to need for greater explanation.

12. Literature Review (cont) • A qualitative evaluation allows analysis of identified themes, issues, and concerns raised in the comments (Bingener, Sloan, McConico, & Mariani, 2012) . • Qualitative surveys focus their attention identifying a phenomenon (Thomas & Magilvy, 2011). • The purpose of qualitative research is not to generalize to other subjects or settings, but to explore deeply a specific phenomenon or experience on which to build further knowledge (Thomas & Magilvy, 2011).

13. Action Plan • Adapt an existing patient satisfaction survey that is culturally appropriate, concise, and easily understoodfor use at the Health Care Center for the Homeless. • Organize focus groups to interview patients using our qualitative survey • Provide staff with our findingsand discuss which items on the survey are necessary or erroneous. • Organize a post focus group survey to determine if needs have been met and satisfaction has increased, if time allows. • Provide incentives to encourage patients to attend the focus groups, such as dental hygiene kits, bus passes, and Publix coupons.

14. Implementation • A focus group of 20 randomly selected patients were brought into a conference room in groups of 3-5. • They were provided the current survey as well as the revised survey and were asked to fill out both. • Incentives including coffee and donuts were provided • Surveys were provided in both English and Spanish • One participant did not complete the survey with questionable literacy issues.

15. Results • Survey Responses

16. Survey Results • 40% preferred the old survey • 25% preferred the new survey • 35% were neutral

17. Feedback • Pros: Enjoyed being able to freely write their comments • Cons: too much writing and preferred to only circle a number • Those that were neutral like to be able to write their comments for the revised survey and the ease of circling numbers on the current survey. • All participants felt their needs were being addressed on both surveys.

18. Recommendations • The survey should include both qualitative and quantitative items • Surveys should be provided in English, Spanish, and Creole • Using appropriate literacy levels for the patient population

19. References • Bingener, J., Sloan, JA., McConico, A., and Mariani, A. (2012). Qualitative and quantitative analysis of women’s perceptions of transvaginal surgery. Surgical Endocopy, 26( 4), pp.998-1004. • Carlson, B., Eden, J., O'Connor, D., & Regan, J. (2001). Primary care of patients without insurance by community health centers. Journal Of Ambulatory Care Management, 24(2), 47-59. • Chow, M., Quine, S., & Li, M. (2010). The benefits of using a mixed methods approach -- quantitative with qualitative -- to identify client satisfaction and unmet needs in an HIV healthcare centre. AIDS Care, 22(4), 491-498. doi:10.1080/09540120903214371 • Gertz, A., Frank, S., & Blixen, C. (2011). A survey of patients and providers at free clinics across the united states. Journal Of Community Health, 36(1), 83-93. • Land, L. M., Jobanputra, P., Webber, J., & C. (2012). Patient satisfaction in three clinics managing long-term conditions. British Journal Of Nursing (BJN), 21(3), 186-188 • Miles, K., Penny, N., Power, R., & Mercey, D. (2003). Comparing doctor- and nurse-led care in a sexual health clinic: Patient satisfaction questionnaire. Journal of Advanced Nursing, 42(1), 64-72. doi:10.1046/j.1365-2648.2003.02580.x • O’Toole, TP., Conde-Martel, A., Gibbon, JL., Hanusa, BH., Freyder, PJ., Fine, MJ., (2007). Where do people go when they first become homeless? A survey of homeless adults in the U.S.A. Health & Social Care in the Community, 15(5), 446-453.

20. References • Thomas, E,. and magilvy, JK. (2011). Qualitative rigor or research validity in qualitative research. Journal for Specialists in Pediatric Nursing, 16(2), 151-155. • Uniform Data System (UDS) Report. (2010). Health care center for the homeless, inc. (BHCMIS ID: 0413580). Orlando, Fl. Retrieved from https://grants.hrsa.gov/ webExternal//login.asp?rURL=https%3a%2f%2fgrants2.hrsa.gov %2fWebUDSExternal %2fPlatform%2fInterface%2fReviewPage.aspx%3fsoid%3d1 • Van der Reis, A.P. Problems in the use of rating scales in cross-cultural research. Symposium on International Marketing, ICC/ESOMAR, Paris, France, 26-28 November 1984. Retrieved from http://onlinepubs.trb.org/onlinepubs/ circulars/ec008/session_g.pdf