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. Author manuscript; available in PMC: 2014 Jan 1.
Published in final edited form as: J Ambul Care Manage. 2013 Jan-Mar;36(1):2–12. doi: 10.1097/JAC.0b013e318276dc2f

Parents’ Preferences for Enhanced Access to the Pediatric Medical Home: A Qualitative Study

Joseph S Zickafoose 1, Lisa R DeCamp 1, Dana J Sambuco 1, Lisa A Prosser 1
PMCID: PMC3728827  NIHMSID: NIHMS489705  PMID: 23222008

Abstract

Enhanced access services are key components of the patient-centered medical home, but they are resource-intensive and may require significant trade-offs by practices and patients. Using qualitative research methods, we interviewed 20 parents about experiences accessing primary care for their children, priorities for enhanced access, and willingness to make trade-offs. Parents had strong preferences for certain services, such as same-day sick care appointments, and were willing to make trade-offs for high-priority services. Primary care practices and medical home programs should educate families about trade-offs needed to implement new services and engage families in setting priorities for medical home implementation.

Keywords: enhanced access, medical home, pediatrics, primary care

The medical home is a model of primary care that is widely promoted to improve the integration and effectiveness of the health care system (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association, 2007; American Academy of Pediatrics, 2002). Enhanced access is a key component of medical home implementation, encompassing a variety of services intended to expand options for communicating with primary care practices and getting direct care, when needed (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association, 2007; American Academy of Pediatrics, 2002; Blue Cross Blue Shield of Michigan, 2010; National Committee for Quality Assurance, 2011). Enhanced access services range from same-day sick care visits to weekend office hours to e-mail communication. These services could be especially important for vulnerable populations, such as low-income families and minorities, who frequently report difficulty with a variety of access measures (Stevens & Shi, 2003), such as communicating with providers outside of scheduled visits (Coker et al., 2009), getting timely appointments(Shi, 1999), and having enough time during visits (Coker et al., 2009, 2010; Guerrero et al., 2010; Ngui & Flores, 2006). Of the many components of the medical home, enhanced access will likely be among the most obvious and tangible to patients and their families.

As primary care practices consider implementation of enhanced access services, they must prioritize changes, given limited time and resources (Abrams et al., 2010). In recognition of these constraints, practices are often given significant flexibility in implementation within medical home programs (Blue Cross Blue Shield of Michigan, 2010; National Committee for Quality Assurance, 2011). Medical home implementation represents an opportunity to include patients’ preferences in primary care service design. Practices that implement services without input from patients may risk investing in services that will be underutilized because of a lack of interest or practicality for patients (Crawford et al., 2003; Tritter, 2009).

In this study, we address a significant gap in practical and policy dialogues about the medical home by providing a qualitative assessment of parents’ preferences for enhanced access services in their children’s primary care practice. The objectives of this study were to explore (1) parents’ preferences for enhanced access services in a pediatric primary care medical home and (2) parents’ willingness to make trade-offs between enhanced access services and other aspects of primary care.

METHODS

We conducted 20 semistructured interviews with parents during September to October 2011.

Sampling and data collection

We recruited our study sample using 3 methods: (1) in-person recruitment of parents bringing their children to preventive care or influenza vaccine visits; (2) posted research flyers; and (3) a mailing to parents of children who had been seen in a large academic emergency department (ED) for a nonemergent complaint in the prior 2 years. Inperson and flyer recruitment were performed at a single multispecialty satellite clinic of an academic medical center. Most pediatric patients served by the clinic lived in Washtenaw County, Michigan. In 2010, the county had a population of approximately 345 000, with a racial composition of 75% white, 13% black or African American, 8% Asian, and 4% other, and approximately 11% of families with children had household incomes below the federal poverty level (U.S. Census Bureau, 2010). In 2011, approximately 2047 children between ages 1 and 5 years attended a visit at the clinic, and this group had the following demographic characteristics: parent-identified race 64% white, 15% black or African American, 10% Asian or South Asian, 5% multiracial or other races, and 5% unknown; 69% were covered by private insurance, 30% by public insurance, and 1% uninsured. The mailing recruitment targeted parents of children who had attended the ED for a non-emergent complaint in the prior 2 years, regardless of primary care site for their children. Recruitment letters were sent to a random sample of 100 parents from a total sample of 2900 children. The total sample of children who had attended an ED visit had the following demographics: parent-identified race 61% white, 18% black or African American, 13% other, 6% Asian or South Asian, and 2% unknown; 54% were covered by private insurance, 44% public insurance, and 2% uninsured.

Parents were eligible for participation if they had at least 1 child between 1 and 5 years of age. Purposeful sampling was used to obtain approximately equal representation between white, non-Hispanic and minority children, as well as publicly versus privately insured children.

The interviewer was a master’s degree–level research assistant with prior training and experience with semistructured interviewing. Interviews lasted 20 to 45 minutes.

Participants signed informed consent in person and received $50 for their participation. This study was approved by the University of Michigan Institutional Review Board.

Interview design

Interviews with participants included 2 sections (Appendix). In the first section, parents were asked open-ended questions about their experiences with accessing sick and preventive care visits for their children, experiences with getting advice outside office visits, and their preferences for enhanced access services. In the second part of the interview, parents were asked to “think aloud” while they answered questions in a paper-based survey under development. The survey included questions on enhanced access services in their children’s primary care office and ratings of different enhanced access services in general. The survey also included 4 scenarios in which parents were asked to choose between 2 hypothetical clinics that differed in terms of enhanced access services, provider continuity, and scheduling wait times for preventive visits. In each scenario, the clinics included different combinations of services. The scenarios included potential trade-offs that practices and patients might need to make to implement enhanced access services, including weekday hours, provider continuity, and wait times for preventive care appointments (eg, <2 weeks vs >1 month). The scenarios helped elicit parents’ relative priorities for enhanced access services by forcing them to make trade-offs among services while choosing between hypothetical clinics.

Open-ended interview questions and survey questions were developed on the basis of literature review and a prior qualitative study of mothers’ experiences with primary care (DeCamp et al., 2012).

Sociodemographic characteristics

Key sociodemographic characteristics of interest were identified from several sources. Child health insurance status was determined through medical record review on the day prior to recruitment. The survey instrument was used to elicit parents’ reports of the number of children in the family, child race/ethnicity, and special health care needs. Special health care needs were defined using the Children with Special Health Care Needs Screener, a 5-item parent-reported survey tool based on the Maternal and Child Health Bureau’s definition of special health care needs (Bethell et al., 2002).

Data analysis

Interviews were audio-recorded and transcribed verbatim. During data collection, the research team identified preliminary themes. A codebook was then developed on the basis of these themes through an iterative consensus process and refined throughout the coding process (Patton, 2002). Each transcript was coded by 2 team members. In place of a measure of intercoder reliability, we used established methods for addressing differences in coding by reconciling them through discussion and consensus (Barbour, 2001; DeCamp et al., 2012; Patton, 2002).

We used NVivo Version 9.2 (QSR International, Doncaster, Victoria, Australia) to apply codes to the transcripts and organize relevant quotes abstracted during analysis. One coder summarized each transcript with input and approval from the second coder. Summaries included key themes and text evidence for those themes. These summaries were used to compare themes across groups with different sociodemographic characteristics.

RESULTS

Of the 20 participating parents, 10 responded to a mailing to parents of children who had been seen in an ED for a nonemergent complaint, 7 were recruited at preventive care visits, and 3 responded to flyers. Fifteen participants were mothers, and most had more than 1 child (Table 1). Slightly more than half of the children were from racial/ethnic minority groups, and half of the children had public insurance coverage.

Table 1.

Demographic Characteristics of Participant Parents (N = 20)

Characteristic
Female respondent, n (%) 15 (75)
Number of children, median (range) 2 (1–6)
Children’s race/ethnicity, a n (%)
White 9 (45)
African American 6 (30)
Multiple/other 5 (25)
Children with special health care needa,b n (%) 6 (30)
Children’s health insurance,c n (%)
Private 9 (45)
Public 10 (50)
Uninsured 1 (5)
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a

Based on parent report.

b

Based on Children with Special Health Care Needs Screener (Bethell et al., 2002).

c

Based on medical record review at time of recruitment.

Parents’ experiences with and preferences for enhanced access services

Same-day sick care

More than three-quarters of parents placed the highest priority on being able to get their children into their primary care office the same day for sick care visits, when needed (Table 2, quotes 1 and 2). This was a dominant theme as parents discussed ways to maintain or improve access to their children’s primary care office. About half of all parents would not compromise on same-day sick care for increased availability of other services. However, about a quarter of parents expressed a willingness to delay sick visits, especially if they were able to get telephone advice about home management of illness.

Table 2.

Parents’ Experiences With and Preferences for Enhanced Access Services

Most parents placed a high priority on same-day sick care to promptly address their concerns during an acute illness and to avoid ED use.
  Because sick visits are important. If they’re sick—my kids have asthma so if I need to get them in I need to get them in or I’ll end up in the ER or someplace. I usually try to call them before it gets to the emergency room point. And sometimes … I can’t get in. (Quote 1, mother of 5 children)
  If a kid is sick, you have to be able to see them [doctors] … there should be appointments for sick kids all day … a kid calls home to be sent home because they’re sick, you have to be able to bring ‘em in to make sure nothing’s going on. (Quote 2, mother of 6 children)
Most parents also placed a high priority on access to advice by telephone, especially in making triage decisions about acute illnesses
  I think that [advice by phone] would be important because you never know when you gonna have an emergency … when you gonna have questions about your child’s health. It could be any time of the day, any time of the night. So to have somebody there when you have that question or that concern would be great. (Quote 3, mother of 1 child)
  I would say the telephone consultation would be very important ‘cause I feel like I’m hesitant to bring kids to the emergency department and it’d be very nice to be able to do a triage with the office to decide how critical a particular illness is versus what needs to go to the emergency department. (Quote 4, mother of 2 children)
  I feel like they should be able to [give advice over the phone], but they won’t … They just tell you just to come in or go to the ER … if there’s something that I can do at home and they can give me advice then I’d just rather do it at home than sit in the emergency room … (Quote 5, mother of 2 children)
Parents expressed the importance of extended office hours on evenings and weekends due the challenges of negotiating work schedules and other responsibilities
  That’s important [weekend hours] because some people are busy throughout the week and … a lot of people have jobs. In our life you have to have a job so they really can’t just take off when they wanna take off. (Quote 6, mother of 1 child)
  Yeah. Well, I was able to get a hold of the nurse [on the weekend] … but I could’ve saved $50 and an ER visit if we’d been able to go into the clinic ‘cause they ended up not doing anything and sending us home. (Quote 7, father of 2 children)
Parents were ambivalent about options for online communications, such as e-mail
  I have mixed feelings about it [emailing with providers]. I think that in theory I’d really like it and it’s nice to have another way for practitioners to be accessible. But I also think it’s hard to have that back and forth dialogue and the follow up questions necessary to make a proper assessment. (Quote 8, mother of 2 children)
  I think I like talking to people, too, as opposed to email. I mean if it’s like for general stuff it’s okay … maybe just general questions about vitamins or keeping your children well or something. (Quote 9, mother of 3 children)
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Abbreviations: ED, emergency department; ER, emergency room.

Access to advice by telephone

Three-quarters of parents reported a strong preference for being able to contact their children’s primary care office for advice by phone 24 hours a day. These parents discussed how the availability of telephone advice can be very useful in making decisions about where and when to seek care for their children (Table 2, quotes 3 and 4), and a few expressed frustration when they were unable to get advice by telephone (Table 2, quote 5). A few parents reported that access to telephone advice was less important to them because they could make decisions on the basis of experiences with prior children, a background in a health care field, or other sources of information such as family members or the Internet.

Extended hours

Slightly more than half of parents expressed preferences for extended office hours during evenings and weekends. In discussing the importance of extended hours, some parents discussed the challenges of getting in for an appointment due to their work or school schedules (Table 2, quote 6). A few parents discussed how children do not just get sick or injured during weekday and daytime hours, and they related experiences using urgent or emergency care when they would have preferred being seen in the primary care office (Table 2, quote 7). For the few parents for whom extended hours were less or not important, daytime office hours worked well because they had more flexible work schedules or did not work outside the home.

Access by online communication

About three-quarters of parents placed a low priority on e-mail or Web-portal communication with their children’s primary care office, although many discussed a general interest (Table 2, quotes 8 and 9). Some specific situations when parents thought it could be particularly useful included when they did not have time to wait on the phone or when they thought that the provider might need time to think about or research an answer to their question. A few parents discussed e-mail or a Web site as a means to update parents on illnesses that are “going around” and how to manage them. Parents who were not interested in online communication cited multiple reasons, including not having a computer, thinking it was impersonal, or concerns about privacy.

Parents’ willingness to make trade-offs for enhanced access

In the scenarios forcing choices between hypothetical clinics, parents placed the highest priority on provider continuity and same-day sick care, but all were willing to make some trade-offs between services.

Continuity

Continuity with a primary care provider was a strong preference for nearly all parents, particularly for preventive and chronic care (Table 3, quote 10). About three-quarters of parents were only willing to see a different provider for sick care to promote prompt access to sick visits and recognized that sameday sick care would often necessitate a tradeoff with continuity (Table 3, quote 11).While many parents were willing to compromise continuity for sick care, they appeared less willing to trade-off preventive care continuity for prompt sick care. However, a few parents did not feel that continuity was very important for either well or sick care because they had had good experiences with multiple providers in a practice or felt that good medical records made up for lack of continuity.

Table 3.

Parents’ Willingness to Make Trade-offs for Enhanced Access to Pediatric Primary Care

Most parents placed a high priority on continuity with a provider but were willing to make trade-offs for more rapid access to sick care
  …I’m more comfortable with at least one person knowing my daughter, knowing her health, knowing her history than several other people. So, you know, so I can feel comfortable with someone knowing her actual care and know what’s good for her because they worked with her. (Quote 10, mother of 1 child)
  Now this is one thing I was really big on, child seeing the same doctor. That’s very important, I think. For sick visits is a little different as far as seeing the same doctor ‘cause … your child is sick that day, it’s not guaranteed that your doctor’s gonna be available. … (Quote 11, mother of 1 child)
  Some parents were willing to make trade-offs between same-day sick care and time to the next available preventive care visit, whereas a few parents were less understanding of this trade-off I mean the well checks are kind of just routine anyways, so to me I don’t think it matters that they get in on the week of their fourth birthday. Just if they get in around that time I would say that’s okay. But if that would allow people who did have sick kids to get in on time. … I would be willing to do that. (Quote 12, mother of 3 children)
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Next available preventive care visit

About a quarter of parents recognized the trade-off for practices between rapid access to sick care and time to next available preventive care visit, and these parents were willing to wait longer for preventive care visits to have faster access to sick care (Table 3, quote 12). A few parents did not recognize this trade-off or were unwilling to make it.

Enhanced access and ED use

About half of parents discussed how enhanced access services could help avoid ED use. Some parents discussed how telephone access could help in deciding whether to take their children to emergency care (Table 2, quote 4), and a few parents expressed frustration with instances when a practice was not available or was unwilling to help in making that decision. A few parents described how lack of same-day sick care could result in ED use (Table 2, quote 1). Some parents discussed how extended hours could have been helpful in avoiding ED use for their children (Table 2, quote 7).

Preferences for enhanced access across parent and child characteristics

There were no clear differences in preferences for enhanced access services related to the presence of a special health care need, race/ethnicity, or insurance type.

DISCUSSION

In this qualitative study of a diverse sample of parents with access to pediatric primary care, we found that parents’ strongest preferences among enhanced access services were for the availability of telephone advice and same-day sick care. Preferences for telephone advice and same-day sick care were often connected through parents’ desire for advice on whether their ill children could be cared for at home, needed an office visit, or should be seen in the ED. Parents also showed interest in evening and weekend office hours but only limited interest in options for online communication. In this study, parents placed a high priority on continuity with their primary care provider, and it is important to note that they were hesitant to compromise preventive care continuity for enhanced access but were willing to compromise continuity for same-day sick care.

Although enhanced access is a central component of medical home implementation (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association, 2007; American Academy of Pediatrics, 2002; Blue Cross Blue Shield of Michigan, 2010; National Committee for Quality Assurance, 2011), patients’ and families’ preferences for these services have not been previously explored. The results of this study contribute to the growing literature on including patients and families in setting priorities for medical services, in general (Crawford et al., 2003; Tritter, 2009), and for medical home implementation, specifically (Bechtel & Ness, 2010; Berenson et al., 2008). Importantly, we found that parents’ preferences for enhanced access and willingness to make trade-offs did not differ significantly in the limited comparisons we were able to make across race/ethnicity and public versus private insurance coverage. This suggests, as others have postulated, that models of enhanced access may be acceptable, and potentially successful, in a variety of practice settings, including those with high proportions of vulnerable populations (Bodenheimer, 2011; O’Connor et al., 2006).

Medical home implementation is very time and resource-intensive (Reid et al., 2009; Stewart et al., 2010), and information on patient priorities could be helpful to practices in choosing which services to implement and prioritizing the order of implementation. Although parents often valued many of these resource-intensive services, they were able to prioritize specific services during discussion. Parents were willing to make tradeoffs between different enhanced access services, continuity of care with their children’s provider, and wait times for the next available preventive care visit. There is rarely discussion about the potential trade-offs primary care practices need to make in implementing new services (Reid et al., 2009; Stewart et al., 2010), and patient-centered information could be helpful to practices making these decisions. We found that parents had specific priorities for access to care, and some did not recognize the inherent trade-offs that practices must make to provide these services. This suggests that practices should consider methods to directly engage their own patient populations to set priorities for medical home implementation (Bechtel & Ness, 2010; Berenson et al., 2008).

In this study, parents frequently spontaneously discussed thoughts on how enhanced access primary care services could help decrease unnecessary ED use and, in some cases, cited specific personal situations illustrating this. Access to primary care is frequently cited as a contributing factor to levels of ED use (Brousseau et al., 2007, 2009). However, the specific forms of access that could help reduce unnecessary ED use have rarely been investigated beyond the presence of a usual source of care (Stanley et al., 2007). Future empiric work is needed to explore whether enhanced access services have population level effects on ED use, individually and in combination.

In this study, we found few differences in preferences for enhanced access services between parents from different sociodemographic groups. Although certain groups may have different expectations for primary care, there is growing evidence that diverse groups of parents share the same core priorities for characteristics of pediatric primary care (Coker et al., 2009; DeCamp et al., 2012). In this study, parent showed nearly universal preferences for access to telephone advice, same-day sick care, and provider continuity for preventive care and care of chronic conditions.

The results of this study should be considered in the context of several limitations. First, although we recruited a diverse sample in terms of sociodemographic characteristics, the parents were from a limited geographic area and thus may represent a more limited range of experiences and preferences. Second, the families that participated in our study had access to and utilized pediatric primary care. Thus, their preferences may not reflect preferences of families that currently experience access and utilization barriers. Finally, we did not explore parents’ preferences for other models of primary care that have been discussed in the context of enhanced access, such as group visits or school-based services (Coker et al., 2009; Friedberg et al., 2010; Goldberg & Kuzel, 2009). We chose to focus on enhanced access services that are most commonly included in current medical home programs (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association, 2007; Blue Cross Blue Shield of Michigan, 2010; National Committee for Quality Assurance, 2011).

In conclusion, parents in this study expressed strong preferences for services that enhance access to primary care for their children, especially advice by telephone and same-day sick care. These parents were able to express priorities for enhanced access services, and most were willing to make some trade-offs with other aspects of primary care. Primary care practices and medical home programs should educate patients about the trade-offs needed to implement new services and engage patients and families in setting priorities for medical home implementation.

Acknowledgments

This work was supported by a grant through the Michigan Institute for Clinical and Health Research at the University of Michigan (UL1RR024986). Dr Zickafoose was supported by a training grant from the National Institute of Child Health and Human Development (T32 HD07534). The authors acknowledge the assistance of the staff and administration at the University of Michigan’s Briarwood Center for Women, Children, and Young Adults in making this study possible.

APPENDIX

Parents’ Preferences for Enhanced Access to the Pediatric Medical Home

Interview Guide

Thank you for agreeing to participate in our study. We are interested in learning about the ways you prefer to get advice or schedule an appointment when you have a question about your child or when your child is sick. We plan to use your responses to help primary care offices meet the needs of families in better ways.

We will begin with asking a few questions about your experiences with getting advice and appointments for your child. Then, we will finish with having you fill out a survey while “thinking out loud” about the questions you are answering.

Your participation in this study and the answers you give will be completely anonymous. Your participation and your answers will not affect the care your child or you receive. Your participation is completely voluntary. You can ask to stop at any time. If you prefer not to answer a question, you can ask to skip the question and move to the next one.

Semistructured Interview

We are very interested in your thoughts about getting advice and scheduling appointments in your child’s primary care office.

A child’s primary care office is the office where they receive most of their regular health care, such as checkups, physical examinations, and immunizations and regular sick visits.

We are interested in your experiences with anyone in the office, including your child’s doctoror nurse practitioner, office nurses, and any other staff you might speak with to get advice about your child.

Please know that there are no wrong answers. Your answers are confidential and will not affect the care your child receives.

  1. Can you tell me about the last time you contacted the office because your child was sick?

    IF NO RECENT CONTACT DUE TO CHILD BEING SICK→Skip to QUESTION 2

    Probes:
    1. Is there anything you think would make it easier to get advice when your child is sick?
    2. Can you tell me about a time when it was easier to get advice when your child was sick? Any other times?
    3. Can you tell me about a time when it was harder to get advice when your child was sick? Any other times?

  2. Can you tell me about the last time you contacted your child’s primary care office to get advice for other questions or concerns when you child was not sick? For example, you may have been concerned about how your child was eating or your child’s development.

    IF NO RECENT CONTACT FOR QUESTIONS OR CONCERNS→Skip to QUESTION 3

    Probes:
    1. Is there anything you think would make it easier to get advice about your child from the office?
    2. Can you tell me about a time when it was easier to get advice when your child was sick? Any other times?
    3. Can you tell me about a time when it was harder to get advice when your child was sick? Any other times?

  3. Sometimes clinics give advice about children’s health outside of appointments. Can you tell me about ways you would like to get advice about your child’s health when you don’t have an appointment?

    Probes
    1. What do you think about getting advice over the phone as compared with advice during an appointment?
    2. What do you think about getting advice by e-mail?
    3. What do you think about getting advice through a clinic Web site?
  4. Sometimes parents would prefer to get an appointment when their child is sick or they have another concern. What are the most important things an office can do to help you get an appointment for your child when your child is sick or you have a concern?
    1. Are there specific hours or days when it is important to have the office open?
    2. How long are you willing to wait for an appointment when your child is sick?
    3. How long are you willing to wait for an appointment when your child is not sick but you have a concern?
    4. Would you be willing to wait longer for checkup appointments if it was easier to get in for appointments when your child is sick or you have a concern?

Cognitive Interviewing

Now, I am going to ask you to fill out a survey about your preferences for different ways to get advice and schedule appointments. As you fill out the survey, I would like you to think out loud, telling me anything you are thinking about as you answer the question. I, especially, want you to tell me about:

  • Any instructions that are hard to read or hard to understand

  • Any questions that are hard to read or hard to understand.

Page 1: First, I would like you to read the introduction and tell me whether there are any parts that are difficult to read or do not make sense.

Page 2–3: Please fill out these questions while thinking aloud about why you are choosing your answers and any parts of the question that are hard to understand.

Page 4: Next, please read the instructions on page 2.

Probes:

  • Are there any services important to you that are left out?

  • Are there any services that are included that you think are not important?

Page 5–8: Now we are going to go through 4 questions asking you to choose between imaginary offices for your child. As you answer the question, I want you think out loud and tell me a few things:

  • Which practice would you choose?

  • Why would you choose that practice over the other practice in the question?

  • Any thoughts on what might change your choice.

Probes for discrete choice questions:

  1. Can you tell me what you are thinking about as you answer the question?

  2. Why did you pick that clinic?

  3. What part of the question was most important in making your choice?

  4. Did you think about other parts of the office in making your choice?

  5. Were there parts you did not think about at all?

Pages 9–14: Please fill out these questions while thinking aloud about why you are choosing your answers and any parts of the question that are hard to understand.

Footnotes

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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