To find out how well the Montgomery Cares (MCares) program meets the needs of current and potential patients, the Montgomery County Department of Health and Human Services and the Primary Care Coalition (PCC) partnered with NORC at the University of Chicago to conduct a Network Adequacy Study and report on the results*. We covered some of those high-level results in an earlier article, but there is more to say about broader lessons learned—especially points of consideration when conducting other studies among safety net patients and additional themes that emerged from our patient population. In other words, what did we learn about the process and our system as we look toward improvement?
Race/ethnicity data capture remains a challenge. This is not new for us, given that recent MCares annual demographic data includes more than 50% of participants with “other” or “unknown” race while up to 82% of the population self-identifies as Hispanic/Latino. The NORC team assessed demographics for patients completing the survey versus MCares patients overall, and their findings suggested white patients were underrepresented in the final results. However, as NORC reporting noted, this finding may be an artifact of using separate race and ethnicity questions in MCares demographic data collection, versus a single race/ethnicity question on the survey tool. New Office of Management and Budget guidance collapses the two categories into a single race/ethnicity question as well, which may improve future data collection results.
“Low-engagement patients” are also difficult to engage in focus groups. Gathering feedback from patients who haven’t established strong ties is very important to understand if we are failing to meet needs. It is easier said than done. NORC analytics strategies helped identify the potential population versus actual population served and the quantitative standards that would impact their access to our provider partners. The NORC team also conducted patient surveys, as well as focus groups to understand some of the nuances a survey couldn’t fully uncover. Those focus groups provided useful information from some of the most engaged system participants: recent patients and our clinic partners. Where the focus group model struggled was with patients who had a longer time since their last appointment and limited patterns of care, what the study called “low-engagement patients.” Even after updating the focus group methodology—such as allowing for virtual sessions rather than in-person only—only two low-engagement patients actually participated in focus groups (versus 29 engaged patients and 31 clinic staff). Future studies could test alternative strategies, such as planning individual interviews, to collect adequate feedback from “low-engagement” patients.*
Expect paper-based data and survey assistance. Patient surveys were written, distributed both online and on paper, avoiding low IT comfort levels as a participation barrier. NORC reported that nearly half of the surveys were completed on paper, and 15% of surveys were completed with help from someone else—generally clinic representatives (41%) or the patients’ own relatives (45%). Future studies take heed of the significant data entry of paper-based responses. Also, consider the phrasing of survey questions with the expectation the patient may be completing the survey with help from someone else.
“Low-engagement patients” are also difficult to engage in focus groups. Gathering feedback from patients who haven’t established strong ties is very important to understand if we are failing to meet needs. It is easier said than done. NORC analytics strategies helped identify the potential population versus actual population served and the quantitative standards that would impact their access to our provider partners. The NORC team also conducted patient surveys, as well as focus groups to understand some of the nuances a survey couldn’t fully uncover. Those focus groups provided useful information from some of the most engaged system participants: recent patients and our clinic partners. Where the focus group model struggled was with patients who had a longer time since their last appointment and limited patterns of care, what the study called “low-engagement patients.” Even after updating the focus group methodology—such as allowing for virtual sessions rather than in-person only—only two low-engagement patients actually participated in focus groups (versus 29 engaged patients and 31 clinic staff). Future studies could test alternative strategies, such as planning individual interviews, to collect adequate feedback from “low-engagement” patients.*
Expect paper-based data and survey assistance. Patient surveys were written, distributed both online and on paper, avoiding low IT comfort levels as a participation barrier. NORC reported that nearly half of the surveys were completed on paper, and 15% of surveys were completed with help from someone else—generally clinic representatives (41%) or the patients’ own relatives (45%). Future studies take heed of the significant data entry of paper-based responses. Also, consider the phrasing of survey questions with the expectation the patient may be completing the survey with help from someone else.
Primary care should address the whole body. When surveyed about the services they would like to see in their primary care clinics, patient responses reflect the range of services they need for health maintenance throughout the body. The top two service categories selected were “dental care” (64.3%) and “eye care” (53.5%). Maximizing service integration would better serve our patients. It also begs the question: what can we learn about how we provide care from patients who are not “native” to the American healthcare system, where there are many service divisions that exist by tradition rather than thoughtful design.
Location matters. We all know this, but network adequacy study analytics helped quantify exactly how much: NORC calculated an overall patient retention rate of 60.5% but only 53% for patients whose drive times were over half an hour. Added travel time has measurable consequences for patient access.
Cultural competence is essential for good care. We are not overstating the value of the culturally competent care we have created through our clinic networks. According to NORC's Survey + Focus Group Summary Final Report, “several patients shared that they experienced fewer communication and translation challenges at MCares health centers, noting that their health center was ‘familiar,’ ‘comfortable,’ and ‘feels like home.’
Location matters. We all know this, but network adequacy study analytics helped quantify exactly how much: NORC calculated an overall patient retention rate of 60.5% but only 53% for patients whose drive times were over half an hour. Added travel time has measurable consequences for patient access.
Cultural competence is essential for good care. We are not overstating the value of the culturally competent care we have created through our clinic networks. According to NORC's Survey + Focus Group Summary Final Report, “several patients shared that they experienced fewer communication and translation challenges at MCares health centers, noting that their health center was ‘familiar,’ ‘comfortable,’ and ‘feels like home.’
Successfully meeting patient needs requires a combination of geographic access considerations and cultural competence. At PCC, we often talk about our local safety net as an improvement on traditional charity care models because it provides access that is systematic, not scattershot. These results highlight some key ingredients for our healthcare access systems.
*Results were reported in the following Montgomery Cares (MCares) Program Final Reports produced by NORC: Network Adequacy Assessment, Patient Voice: Survey + Focus Group Summary, Patient and Encounter Projections for Fiscal Years (FYs) 2025 and 2026, Patient and Encounter Projections for Fiscal Years (FYs) 2025 and 2026 - Patient Administrative Data, and Patient Retention Analyses.
This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.
*Results were reported in the following Montgomery Cares (MCares) Program Final Reports produced by NORC: Network Adequacy Assessment, Patient Voice: Survey + Focus Group Summary, Patient and Encounter Projections for Fiscal Years (FYs) 2025 and 2026, Patient and Encounter Projections for Fiscal Years (FYs) 2025 and 2026 - Patient Administrative Data, and Patient Retention Analyses.
This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.
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