Langer Research Associates

Blue Shield of California Foundation is an Independent Licensee of the Blue Shield Association.
empowerment and engagement
among low-income Californians:
enhancing patient-centered care
2012 blue shield of california foundation survey
September 2012
introduction
Beyond the expansion of health insurance to millions of Americans, the
Affordable Care Act also offers new challenges and opportunities to
reshape the way that we deliver health care. Recognizing the need for
improvement in the current health care system and the demands of health
reform, there have been concerted efforts in the public and private sectors
to more fully engage patients in their own care. Many advances have
already been made toward achieving a health system in which patients
are active participants. Much of this work to date has been driven by
providers notions of high-quality care and system-level interpretations of
administrative data. While it is important to engage physicians and the
broader health care system in the conversation around the transformation
of care, we must also include the patients themselves.
The primary goal of this survey was to bring the voices of low-income
Californians into these conversations, to hear and share their perspectives
on some of the key tenets of patient-centered care. The results provide
new empirical data to evaluate the relationships between patients and
their providers, and help us understand how they can lead to a patient
population that is more involved in their own health and well-being. Building
upcn fncing: frcm cur previcu: :urvey cf |cw-inccme Cc|ifcrnicn:, Ihi:
report dives deeper to provide meaningful insight into the kind of care that
underserved populations want, and deserve.
The results of the survey underscore not only the value of a strong patient-
physician connection, but also the role of effective communication in
empowering and engaging patients. Among patients who say they are
well-informed about their health, more than two-thirds report that they
fee| ccmfcrIcL|e c:king ue:Iicn: cnc very ccnfcenI in Iheir cLi|iIy Ic
make healthcare decisions. By engendering a sense of involvement and
providing useful, accessible information, safety net providers can count on
improved patient experiences and, ultimately, better health outcomes for
some of our most vulnerable residents.
As the American health care system continues to transform, it is only by
listening to those we aim to serve that we can ensure that changes will
produce the desired outcomes. We will continue to ask relevant questions of
key audiences to bring us closer to our shared goal of accessible, effective,
and affordable health care for all Californians. Thanks to the team at Langer
Research Associates Gary Langer, Julie Phelan, Greg Holyk, and Damla
Ergun. They are a delight to work with. Thank you to Cecilia Echeverra and
Christine Maulhardt as well, for their tireless efforts to shepherd this project.
In partnership,
Peter V. Long, Ph.D.
President and CEO
Blue Shield of California Foundation
table of contents
executive summary 7
project overview 12
part a: information and engagement
section i: shared decision making 16
section ii: current and desired patient involvement 19
section iii: personal responsibility 21
part b: empowering healthcare consumers
section iv: impacts of information 23
section v: miscommunication and its consequences 27
section vi: information and the internet 28
section vii: fostering empowerment 29
part c: additional information and cultural competence
section viii: desire for greater information 35
section ix; cultural competence and community 37
understanding
part d: conclusions 40
methodology 41
appendices
appendix a: statistical modeling 51
appendix b: topline data report 62
appendix c: full questionnaire 67
appendix d: references 93
enhancing patient-centered care 7
executive summary
Slightly fewer than six in 10 low-income Californians overall want an
equal say in their healthcare, leaving a substantial number who prefer
instead to leave decisions mainly to their care providers. But if guidance
about treatment options is offered, that recalcitrance fades: Given clear
information, many more eight in 10 say theyd like an equal role.
That result is one of several in this Blue Shield of California Foundation (BSCF)
survey that underscores the central role of information and communication
in achieving the goals of patient-centered care. Among other outcomes,
we||-infcrmec pcIienI: cre much mcre |ike|y Ihcn cIher: Ic Le ccnfcenI
about taking an active role in their care decisions, to feel comfortable
asking questions of their care providers, and to report that they understand
their providers explanations.
1

Ihc:e e|emenI: - c|ecr hec|Ih infcrmcIicn, ccnfcence, ccmfcrI c:king
providers questions, and comprehension of providers medical explanations
are the tools with which patients are empowered to take an active role in
Iheir hec|Ih ccre. ln Iurn, Ihe prccucI cf IhcI empcwermenI, Ihi: :Iucy fnc:,
is greater self-reported engagement in healthcare decisions.
Empowerment and engagement are central aims of patient-centered
ccre, Ihe pcrccigm IhcI :eek: LcIh mcre effcienI ccre mcce|:, cnc
improved health outcomes, in large part through a focus on the patient
as an active participant in his or her care. This survey tested some of the
basic principles of patient-centered care from the patients perspective,
producing empirical data with which to evaluate how these concepts may
lead to a more engaged patient population. Results reveal the extent to
which healthcare providers and facilities can encourage empowerment
and engagement by providing patients across the socioeconomic
spectrum with full, clearly explained information about their health
conditions and choices for care.
The role of information and communication described in this study builds
upcn fncing: frcm Connectedness and Continuity: Patient-Provider
Relationships Among Low-Income Californians, a BSCF report earlier
this year. That report found that many patients desire closer personal
relationships with providers and staff at their care facilities than they have
now, and that, when present, such relationships produce greater patient
:e|f-effcccy cnc :cIi:fccIicn c|ike.
Feinfcrcing cnc exIencing IhcI fncing, Ihi: repcrI :hcw: IhcI ccnIinuiIy
(seeing the same care provider regularly) and connectedness (thinking
that someone at the care facility knows you well) foster the relationships
Well-informed
patients are
substantially
more likely to be
ccnfcenI Icking
an active role
in their care.
8 enhancing patient-centered care
IhcI he|p Ic empcwer cnc engcge pcIienI: - imprcving Ihe fcw cf
information, increasing the comfort patients have asking questions of their
prcvicer:, increc:ing Ihe chcnce: pcIienI: wi|| fnc Ihe infcrmcIicn Ihey
are given to be clear and understandable and, ultimately, engaging
Ihem in Iheir ccre ceci:icn:. Ihe:e fncing: prccuce c mcce| cf pcIienI
engagement, based on a series of statistical analyses of the results of this
survey, describing a continuum from connectedness and continuity to
empowerment and then engagement.
2

The data are striking: In terms of information, patients who see the same
provider at least most of the time are 21 percentage points more apt than
those with less continuity in a care provider to feel very informed about their
health. And those who say someone at their care facility knows them well
are more apt to be very informed, by 27 points, than those who lack that
personal connection.
The fundamental role of information in enhancing empowerment also
shows clearly in the survey results:
- Among patients who feel informed about their health, 67 percent say theyre
very comfortable asking questions of their provider. Among those who feel
less informed, comfort asking questions drops by half, to 33 percent.
- Nearly seven in 10 of those who feel very informed about their health
c|:c fee| very ccnfcenI in Iheir cLi|iIy Ic mcke hec|Ihccre ceci:icn:.
SIrcng ccnfcence fc||: Ic 44 percenI cmcng Ihc:e whc fee| |e:: Ihcn
very well-informed.
a model of patient engagement
empowerment
feel informed about your health
comfortable asking
provider questions
provider usually explains things
in a way you understand
con0dent you con moke heo|thcore
decisions
engagement
Controlling for other factors, the results of this survey show that connectedness and continuity predict empowerment
outcomes feeling well-informed, being comfortable asking questions of care providers, understanding providers answers
cnc ce|ng ccn|cent |n tne cc|||ty tc ncke nec|tncc|e cec|:|cn:. Fee||ng we||-|n|c|nec c|:c |ncepencent|y p|ec|ct: tne
ctne| tn|ee enpcwe|nent |ten:. Anc eccn c| tne enpcwe|nent nec:u|e: p|ec|ct: engcgenent. tnct |:. tck|ng c |c|e
|n nec|tncc|e cec|:|cn: - c key gcc| c| pct|ent-cente|ec cc|e.
connectedness
continuity
enhancing patient-centered care 9
- Among patients who feel highly informed about their health, 61 percent
say they always understand their providers advice and treatment plans.
IhcI cec|ine: Ic 34 percenI cf Ihc:e whc fee| ju:I :cmewhcI" infcrmec,
and 18 percent of those who feel less informed about their health.
The next step, from empowerment, is to engagement in care decisions, and
there the results are equally compelling:
- Among patients who report trouble understanding their providers
instructions, 51 percent are involved in decisions about their care.
Among those who report higher levels of understanding, however,
many more, 79 percent, are involved in their care decisions.
- Among patients who say theyre less than fully comfortable asking
questions of their care providers, 59 percent are involved in their care.
Among those who are very comfortable asking questions, instead, 81
percent are involved.
- Involvement in care is 19 points higher among patients who are very
ccnfcenI in Iheir cLi|iIy Ic mcke hec|Ih ceci:icn: Ihcn cmcng Ihe |e::
ccnfcenI, 81 percenI v:. 2 percenI.

- Information, in addition to enhancing empowerment, also directly
impacts engagement. Among patients who feel they lack information
about their health, just 55 percent also say they have a role in their
healthcare decisions. Among those who are very informed, by contrast,
the number who report involvement jumps to 83 percent.
Notably, the extent to which patients feel informed about their health
cnc ccnfcenI cLcuI Icking c rc|e in Iheir ccre ceci:icn: precicI: Iheir
engagement independently of and more strongly than their education,
income, gender, race/ethnicity, language spoken at home, and the type
of care facility they use. That suggests that clear information can help level
Ihe hec|Ihccre p|cying fe|c ccrc:: pcpu|cIicn grcup:.
among patients who dont
feel informed
among patients who
feel informed
very comfortable
somewhat comfortable
somewhat uncomfortable
very uncomfortable
no opinion
comfort asking provider questions
33%
35%
16%
14%
2%
67%
26%
6%
1%
10 enhancing patient-centered care
Still, there are socioeconomic barriers in current access to some forms of
hec|Ih infcrmcIicn. Specifcc||y, |cw-inccme Cc|ifcrnicn: cre :uL:IcnIic||y
less apt than Americans more broadly to use the internet for healthcare
infcrmcIicn, refecIing Ihe cigiIc| civice" IhcI ci:ccvcnIcge: Ihe pccr cnc
near-poor in the information age. Fifty-six percent in this population never
have used the internet to obtain health information, and most of the rest do
so only infrequently.
The survey was conducted by landline and cellular telephone interviews
cmcng c rcnccm :IcIewice :cmp|e cf 1,024 Cc|ifcrnicn: cge 1 Ic 4
with household incomes less than 200 percent of the federal poverty level.
Among other results:
- lnfcrmcIicn i: ncI cL:enI: 84 percenI fee| cI |ec:I :cmewhcI infcrmec
about their health and any health problems they may have. But many
fewer, 48 percenI, fee| very" infcrmec, c :ignifccnI :hcrIfc|| in Ihi:
uniquely important indicator.
- CcmmuniccIicn :uffer: :imi|cr chc||enge:. Ju:I 44 percenI :cy Iheir
healthcare provider always explains things to them in a way they can
uncer:Icnc. /nc cne in fve :cy: Ihere hcve Leen Iime: when Ihey cicnI
follow a care providers advice or treatment plan because they didnt
understand what they were supposed to do.
- Misunderstanding providers instructions is especially prevalent among
low-income Californians who feel less than fully comfortable asking
questions about their care, marking the need for providers to encourage
patients to speak up when they feel instructions are unclear. Patients
with chronic conditions, and those who rate their health as less than very
good, also are particularly vulnerable to failing to follow treatment plans
because they havent understood their instructions.
- Helpfully, 73 percent say they themselves, rather than their care
prcvicer:, cre chiefy re:pcn:iL|e fcr mcncging Iheir cwn hec|Ih. Ihi:
cccepIcnce cf per:cnc| re:pcn:iLi|iIy mcy ccn:IiIuIe c u:efu| fr:I :Iep c:
providers seek to move patients down the path to greater engagement
in their care.
- Theres substantial desire for new information about healthcare
options. More than eight in 10 express interest in learning about the
pros and cons of tests or treatments, the training and experience of
health professionals in their area, patient satisfaction ratings of local
facilities, and quality ratings of care providers. The first is especially
ccmpe||ing, wiIh 58 percenI very" inIere:Iec in infcrmcIicn cn
potential tests and treatments.
very informed
somewhat informed
not so informed
not informed at all
informed about health
48%
36%
4%
11%
provider explains things in a
way patients can understand
every time
most of the time
some of the time
rarely
never
44%
31%
4%
17%
3%
enhancing patient-centered care 11
- Fewer, c|LeiI necr|y hc|f {47 percenI), :cy c :ec| cf cpprcvc|" frcm c
national healthcare association would make them more likely to go to
a particular facility. That ranges from 53 percent of patients of community
c|inic: cnc hec|Ih cenIer: {CCHC:) Ic c |cw cf 40 percenI cmcng Kci:er
Permanente patients.
- Cultural, community and linguistic competence also receive broad
interest. Two-thirds of poor and near-poor Californians say its important
for their healthcare provider to understand their ethnic or cultural
background. Three-quarters prefer that their provider know whats
going on in their community (including 86 percent of CCHC patients).
And among those who mainly dont speak English at home, more than
nine in 10 want a provider who can speak with them in the language of
their choice.
In combination with the Connectedness and Continuity report, results of
this survey lend themselves to an action plan for Californias safety net
healthcare providers. The previous study laid out approaches including
team-based care, healthcare navigators, group health programs, and use
of technology that can enhance the personal connection patients feel
with their healthcare facility. This report explores the value of using those
personal connections to provide clear information, thus empowering and
engaging patients in their own care.
endnotes
1 Fhrc:e: :uch c: fee|ing infcrmec," Leing infcrmec," cnc hcving
hec|Ih infcrmcIicn" cre u:ec inIerchcngecL|y IhrcughcuI Ihi: repcrI Ic
describe respondents who report feeling well-informed about their health
and any health problems they may have. For question wording and full
topline results, see Appendix B, question 37.
2 The model of patient engagement we present in this report is based
cn empiricc| re:u|I: cf cur :Iucy - :pecifcc||y, cn mecicIicn mcce|: in
which we produced a series of regression analyses examining underlying
processes in the relationships among the variables of interest. While our
survey questions are based on some of the theoretical principles of patient-
centered care, our model was independently derived from the data
collected for this study. See Appendix A for full details of the mediation
models predicting patient engagement. Separately, for a theoretical,
literature-based model of relationships among patient-centered medical
home concepts, see Agency for Healthcare Research and Quality
Publication No. 10-0083-EF, http://pcmh.ahrq.gov/portal/server.pt/
ccmmuniIy/pcmh__hcme/1483/FCMH_HIMLCcnver:icn_10-0083-EF_v2.
12 enhancing patient-centered care
project overview
This study is the second of two reports based on a 2012 Blue Shield of Cali-
fornia Foundation survey of poor and near-poor Californians. The project
extends a course of research initiated by BSCF with its 2011 study, On the
Cusp of Change: The Healthcare Preferences of Low-Income Californians.
lcenIicc| in :cmp|e ce:ign, Ihi: yecr: :urvey fccu:e: cn Iwc key fncing: cf
the 2011 report: Expressed interest in a traditional doctor-patient relationship,
and hesitancy in some patient groups to embrace the concept of shared
decision making in healthcare matters.
Ihe fr:I 2012 repcrI, Connectedness and Continuity: Patient-Provider
Relationships Among Low-Income Californians, measured experience and
interest among patients in seeing the same care provider on a regular
basis, and the prevalence of having someone at their healthcare facility
whc kncw: ycu preIIy we||." lI exp|crec c|IerncIive pcIh: Ic cchieving Ihi:
connectedness, and analyzed their positive impacts on patient satisfaction
cnc effcccy, Ihe ccpcciIy cnc ccnfcence cf pcIienI: Ic Icke cn ccIive
role in their care.
This second report extends that research by examining low-income
Californians interest in having an equal role with the provider in decisions
cLcuI Iheir ccre :pecifcc||y, cnc Iheir empcwermenI cnc engcgemenI
more broadly, within the context of connectedness and continuity. Among
the questions:
- Why would some patients rather leave health decisions up to their
providers, and would additional information move the needle?
- Hcw cre ccnfcence in mcking hec|Ihccre ceci:icn:, ccmfcrI in c:king
questions, and comprehension of providers instructions supported
by information? To what extent do these, in turn, relate to patients
engagement in their own care?
- How are connectedness and continuity two key concepts from this
yecr: fr:I repcrI - re|cIec Ic pcIienI empcwermenI cnc engcgemenI
- How much health information do patients feel they have, how much
would they like, and in what areas?
- What are patients preferences for cultural, community, and linguistic
competence in their healthcare providers?
enhancing patient-centered care 13
This study, like last years, was produced and analyzed by Langer Research
Associates after an extensive review of relevant literature, listed in
Appendix D, and discussions on questionnaire development with a group
cf prcminenI re:ecrcher: cnc prccIiIicner: in Ihe fe|c: Ccrc| 8ec:|ey,
director of strategic projects, Institute for Healthcare Improvement; Susan
Dentzer, editor, Health Affairs; Rushika Fernandopulle, co-founder and CEO,
Iora Health; Ed ONeil, former director, Center for the Health Professions
at University of California, San Francisco; Dr. Sunita Mutha, interim director,
Center for the Health Professions at University of California, San Francisco;
Lyn Paget, director of policy and outreach, Informed Medical Decisions
FcunccIicn: Ju|ic Fcrcci:e, c::ccicIe cirecIcr, Kci:er Ccmmi::icn cn
Medicaid and the Uninsured; Jane Stafford, managing director, Community
C|inic: lniIicIive: cnc l:cLe||e Vcn Kchcrn, prcgrcm cffcer, ln:IiIuIe cf
Medicine. We are grateful for their insights.
Blue Shield of California Foundation, long a thought leader in safety net
healthcare services, has sponsored this research as part of its mission to
improve the lives of Californians, particularly underserved populations, by
making health care accessible, effective, and affordable for all Californians.
BSCF in particular has a long history of support for the states community
clinic and health centers (CCHCs) through its Community Health Center
Core Support Initiative and Clinic Leadership Institute offerings.
This survey was conducted among a representative, random sample
cf 1,024 Cc|ifcrnicn: cge 1 Ic 4 wiIh hcu:ehc|c inccme: |e:: Ihcn
200 percenI cf Ihe fecerc| pcverIy |eve| {cpprcximcIe|y $4,000 c yecr
for a family of four). Interviews, averaging 22.6 minutes in length, were
conducted by both landline and cellular telephone, in English and Spanish,
from March 12 to April 8, 2012; see details in the methodology section of this
report. Results for the full sample have a margin of sampling error of plus or
minus 3.5 percentage points.
Scmp|ing, fe|cwcrk cnc ccIc IcLu|cIicn were ccrriec cuI Ly SSFS/Sccic|
Science Research Solutions of Media, Pa. SSRS has performed similar
services in a range of prominent healthcare studies, including surveys for
the Harvard School of Public Health under the sponsorship of the federal
Centers for Disease Control and Prevention, the Massachusetts Division of
Health Care Finance and Policy (via the Urban Institute), the Minnesota
Department of Health (through the University of Minnesota and the State
Health Access Data Assistance Center), the Oregon Department of Human
Services, the Colorado Health Institute, The Commonwealth Fund, and the
Henry J. Kci:er Fcmi|y FcunccIicn.
14 enhancing patient-centered care
sections guide
Key re:u|I: cre cuI|inec in Ihe execuIive :ummcry. Ihe fu|| repcrI prcvice:
extensive details, presented as follows:
part a: information and engagement
- section i: shared decision making. Whether or not patients prefer taking
an equal role in health decisions, and the effect of information on that
preference. Differences in initial preference for an equal say and shifting
preference among groups.
- section ii: current and desired patient involvement. Current level of
patient engagement in care decisions, and whether they desire more
involvement or not. The relationship between patient empowerment
and engagement.
- section iii: personal responsibility. Patient perceptions of whos most
responsible for their own health the patients themselves or their
care providers.
part b: empowering healthcare consumers
- section iv: impacts of information. How informed patients feel they are
about their own health, overall and among groups. The central role
information plays in empowering patients and how connectedness and
continuity in healthcare relationships foster empowerment, and through
it, patient engagement.
- section v: miscommunication and its consequences. The number of
patients who have not followed a providers advice or treatment plan
due to misunderstanding, and differences in doing so among groups.
- section vi: information and the internet. A look at the groups most likely to
have used the internet to search for health information, including a brief
ci:cu::icn cf Ihe cigiIc| civice" in inIerneI u:cge.
- :ecIicn vii: fc:Iering empcwermenI. FcIienI ccnfcence in mcking hec|Ih-
related decisions, comfort in asking questions of their care providers,
and how frequently providers explain things in a way that patients can
understand. An examination of the key independent predictors of each
of these three elements of patient empowerment.
part c: additional information and cultural competence
- section viii: desire for greater information. Interest in more information
on the pros and cons of tests or treatments, the training and experience
of health professionals in the area, patient satisfaction ratings of local
facilities, and quality ratings of care providers. The effects of a national
seal of approval on patients choice of facility.
enhancing patient-centered care 15
- section ix: cultural competence and community understanding.
A look at the importance patients place on provider knowledge
of their communities, understanding of their cultural and ethnic
backgrounds, and for non-English speakers, their ability to
communicate in the language of their choice.
part d: conclusions
methodology
/ ceIci|ec ce:cripIicn cf Ihe :urvey: :cmp|ing meIhccc|cgy, fe|c wcrk,
data processing, weighting, response rate information, and procedures for
hec|Ihccre fcci|iIy icenIifccIicn.
The report concludes with appendices explaining the statistical modeling
used in this study, and presenting the topline results for questions included in
this report, the full questionnaire, and source references.
Questions on any aspect of this study, and requests for further data
analysis, should be directed to Cecilia Echeverra, Blue Shield of California
FcunccIicn, 50 8ec|e SIreeI, 14Ih F|ccr, Scn Frcnci:cc, Cc|if., 4105-181,
Ie|. {415) 22-147, ceci|ic.echeverric@L|ue:hie|cccfcunccIicn.crg.
16 enhancing patient-centered care
part a: information
and engagement
section i: shared decision making
Patient-centered care envisions a range of services that enhance patients
involvement in their health care and ownership of their well-being. One
prime element is shared decision making, in which patients are encouraged
to take an equal role with their providers in medical decisions.
FifIy-nine percenI cf |cw-inccme Cc|ifcrnicn: cge 1 Ic 4 :cy Iheyc |ike
that equal say meaning that nearly four in 10, 39 percent, instead would
rcIher |ecve ceci:icn: mcin|y Ic Iheir hec|Ihccre prcvicer:. /I fr:I L|u:h,
having an equal say earns less than the overwhelming interest that might
be expected, given the presumed appeal of a strong role in such personal
mcIIer: - ncIhing cLcuI me wiIhcuI me," c: iI: phrc:ec in Ihe pcIienI-
centered care literature.
Replicating results from the 2011 Blue Shield of California Foundation survey,
On the Cusp of Change: The Healthcare Preferences of Low-Income
Californians, having an equal say appears almost as intimidating as it
cce: cppec|ing Ic :cme :pecifc grcup: wiIhin Ihe pccr cnc necr-pccr
population. This is particularly true among individuals such as those who
are less educated, noncitizens, or who dont primarily speak English who
may be less accustomed to having their voices heard (or, for some, may
have cultural reasons for preferring a less active role).
8uI infcrmcIicn :hifI: Ihe p|cying fe|c. / fc||cw-up ue:Iicn in Ihi: :urvey
asked respondents who prefer to leave decisions to their care provider
whether they feel that way mainly because they dont think they have
enough information to make the right decisions, or because they feel it is
Ihe cccIcr: re:pcn:iLi|iIy, ncI Iheir:. We|| fewer Ihcn hc|f in Ihi: grcup, 40
percent, said its because they feel it is the doctors role. In sum, this means
that a mere 16 percent of low-income Californians reject shared decision
making simply because they see it as the doctors job.
In another follow-up, moreover, patients who expressed reluctance about
taking an equal role in care decisions were asked how they would feel
cLcuI iI if Ihe cccIcr hc: :e|ecIec IrecImenI cpIicn: fcr ycu - c chcice cf
things you might do, any of which is medically appropriate and youve
Leen given infcrmcIicn IhcI ycu uncer:Icnc cLcuI Ihe:e cpIicn:." Uncer
these conditions, interest in shared decision making jumps from 59 percent
overall to 81 percent key evidence of how clear information can increase
patient involvement.
Having an equal
say appears almost
as intimidating as it
does appealing to
some groups within
the poor and near-
poor population.
enhancing patient-centered care 17
decision making among groups
Ihere cre :ignifccnI grcup cifference: in iniIic| inIere:I in :hcrec ceci:icn
making (i.e., before asking about the inclusion of clearly explained
options).
3
As noted, interest in an equal say is lowest among the least-
educated adults; fewer than half of those without a high school diploma
fnc :hcrec ceci:icn mcking cppec|ing, ccmpcrec wiIh mcre Ihcn :even
in 10 college graduates. And about half of Latinos, non-English speakers,
and noncitizens initially prefer to leave decisions up to the care provider,
compared with a third or fewer of non-Latinos (whites and other racial
groups alike), English speakers, and citizens.
/n impcrIcnI fncing i: IhcI iniIic| preference fcr cn euc| rc|e in ceci:icn
making is higher among more empowered patients. As explored in part
L, Ihi: :Iucy fnc: fcur mcjcr inciccIcr: cf pcIienI empcwermenI - fee|ing
informed about your health, being comfortable asking questions of a care
prcvicer, hcving ccnfcence in ycur cLi|iIy Ic mcke hec|Ihccre ceci:icn:,
and understanding your providers explanations and advice. When these
are present, patients tend to be more interested in taking an active role in
their health care.
Specifcc||y, inIere:I in :hcrec ceci:icn mcking i: higher Ly 24 percenIcge
points among patients who feel comfortable asking their healthcare
provider questions, by 12 points among those who feel informed about their
hec|Ih, Ly 11 pcinI: cmcng Ihc:e whc cre very ccnfcenI in Iheir cLi|iIy
to make care decisions, and by 8 points among those who say their care
provider always explains things in a way they can understand, compared,
in each case, with their opposites.
4

In evidence of the power of personal connections, initial preference for an
equal say also is 11 points higher among individuals who have a regular
personal doctor, and, in a related result, rises to 70 percent of those with
private insurance (vs. 53 percent among the uninsured, who are less likely to
have a doctor or a personal relationship at their care facility).
Initial preference
for an equal role
in decision making
is higher among
more empowered
patients.
key elements of patient empowerment
- infcrmec cLcuI ycur cwn hec|Ih
- uncer:Icnc Ihe infcrmcIicn ycure given
- ccmfcrIcL|e c:king ue:Iicn: cf ycur prcvicer:
- ccnfcenI mcking ceci:icn: regcrcing ycur hec|Ih
18 enhancing patient-centered care
initial preference for an equal say in care decisions
all 59%
race/ethnicity
white 75
latino 4
other 65
citizenship
citizens 66
non-citizens 47
education
< high school 47
h.s. diploma/some college 65
college graduate 72
personal doctor
have personal doctor 65
lack personal doctor 54
insurance status
private insurance 70
government insurance 56
no insurance 53
the impact of information on shared decision making
There are two informative differences in who shifts their preference from
leaving decisions to their caregiver to wanting an equal say, after its been
:pecifec IhcI c|ecr, we||-exp|cinec cpIicn: wi|| Le prcvicec. Ihc:e whc
see the same care provider on every visit are more likely to move than are
those with less continuity of care (63 vs. 51 percent).
5
Similarly, those who
feel someone at their healthcare facility knows them well are more likely to
shift their preference toward greater involvement than are those who lack
a personal connection, 62 vs. 51 percent. These suggest that even among
those who are initially resistant to having an equal say, continuity and
connectedness two key aspects of care relationships can encourage
more active participation in shared decision making once clear information
is in the mix.
There are few other group differences in the impact of information on
interest in shared decision making. Indeed, the takeaway from these
results is how universally high interest rises when accompanied by clear
information. For example, what started as a stark 25-point education gap
in iniIic| preference: fcr cn euc| :cy :hrink: Ic c ncn-:ignifccnI 7-pcinI
difference when information is provided: Eighty-three percent of those with
a college education express interest in having an equal say, but so do 76
percent of those who lack a high school diploma.
Moreover, racial or ethnic, language, and citizenship differences in
preference for an equal say all are greatly reduced when information is
provided. A 26-point gap in initial interest in an equal say between whites
initial shared decision
making preferences
equal say
leave to the provider
no opinion
1%
59%
39%
3%
81%
17%
shared decision making
preferences when clear
information is provided
enhancing patient-centered care 19
and Latinos is cut in half, with nine in 10 whites expressing a desire to take an
active role in their care and 77 percent of Latinos saying the same. Likewise,
despite their initial reluctance to embrace shared decision making, seven in
10 non-English speakers and three-quarters of noncitizens express desire for a
say in their care when clearly explained options are offered.
section ii: current and desired patient
involvement
Currently more than seven in 10 low-income Californians say they do have
at least a good amount of involvement in decisions about their health care.
8uI mcny fewer, 38 percenI, repcrI hcving c grecI cec|" cf inpuI, mcrking
patient involvement as an area ripe for improvement.
Another question measures whether patients feel their current involvement
i: :uffcienI: c mcjcriIy {58 percenI) rcIe: iI c: cLcuI righI." Cne in Ihree,
Ihcugh, wcnI: mcre cf c :cy, cnc IhcI ri:e: Ic 47 percenI cmcng Ihc:e whc
feel they lack at least a good amount of involvement now.
Statistical modeling shows that the four components of empowerment
- fee|ing infcrmec, Leing ccmfcrIcL|e c:king ue:Iicn:, Leing ccnfcenI
in decision making, and understanding providers explanations are the
strongest independent predictors of patient involvement in healthcare
decisions, controlling for other factors including health status, having
a personal doctor or personal point of connection, and a variety of
demographic variables.
6

In one example, 83 percent of low-income Californians who feel very
informed about their care also say they have a great deal or good
amount of say in their healthcare decisions. That sense of involvement
falls to 65 percent among those who report being just somewhat informed
about their health, and to 55 percent of those who feel less informed.
Similarly, those who say their provider often explains things in a way they
can understand are 28 points more apt to report being involved in their
care decisions than are people who understand their provider less often,
79 percent vs. 51 percent. Among patients who are very comfortable asking
great deal
good amount
just some
only a little
none
no opinion
33%
2%
want more say
about right
want less say
no opinion
desired say in care decisions
58%
7%
current say in care decisions
38%
34%
14%
12%
1% 1%
20 enhancing patient-centered care
questions, 81 percent say theyre involved in care decisions, compared
with 59 percent of those who are less comfortable asking questions of their
prcvicer, c 22-pcinI gcp. /nc pcIienI: whc cre very ccnfcenI in Iheir cLi|iIy
to make healthcare decisions are 19 points more likely to feel involved in
Ihc:e ceci:icn: Ihcn Ihc:e wiIh |e:: ccnfcence, 81 v:. 2 percenI.
7
As noted, lacking current say is, predictably, a strong factor in patients
wanting more of a say in their care than they have now. Desire for more say
is 23 points higher among those who report having little or no current say,
compared with those who have at least a good amount of input.
Thats also expressed in other results. Desire for more say in medical
decisions tops out among people who currently use hospital emergency
rooms as their primary care facility (theyre also more apt to say they lack
input now).
8
And desire for more involvement is 10 points higher among
those who rarely or never see the same care provider when they have a
medical appointment, compared with those who see the same provider on
each visit.
Perhaps not surprisingly, more empowered low-income Californians express
greater satisfaction with their current level of say than do less empowered
groups. Sixty-two percent of patients who feel informed about their health
:cy Ihey hcve cLcuI Ihe righI cmcunI cf inpuI, ccmpcrec wiIh 43 percenI
of patients who feel less informed. Patients who feel their provider always
explains things in a way they can understand, who are very comfortable
c:king Iheir prcvicer ue:Iicn:, cnc whc cre very ccnfcenI in Iheir cLi|iIy Ic
mcke ccre ceci:icn: cre 21, 1, cnc 8 pcinI: mcre |ike|y Ic Le :cIi:fec wiIh
the amount of say they have now than their less-empowered peers.
% currently involved in care decisions
|e:: ccnfcenI mcking ceci:icn:
very ccnfcenI mcking ceci:icn:
less comfortable asking questions
very comfortable asking questions
explanations clear less than often
providers explanations often clear
feel less informed about health
feel very informed about health 83%
62%
81%
62%
81%
59%
79%
51%
enhancing patient-centered care 21
section iii: personal responsibility
Another result illuminates personal responsibility for ones health as a
pathway by which healthcare providers can approach patients about
taking a greater role in their care decisions. When asked whom they feel
is more responsible for managing their health, 73 percent of low-income
Californians say its their own responsibility, many more than the 21 percent
who place the onus on their healthcare providers.
Health status is one important differentiator. Among people who say their
health is very good (or better), 81 percent take personal responsibility
for managing their health; that declines to 68 percent of those in just
good health, or less. Patients who need more care, then, are more apt to
delegate prime responsibility for their health management. Its a result for
providers to keep in mind: As complexity rises, information overload may
reduce patients self-reliance, marking the need for a more concerted
effort to convey even the most complex health information in ways that
are easily understandable. Of course, certain health problems themselves
may reduce patients capacity to manage their own health.
% sot|s0ed w|th the|r current omount o| soy
|e:: ccnfcenI mcking ceci:icn:
very ccnfcenI mcking ceci:icn:
less comfortable asking questions
very comfortable asking questions
explanations clear less than always
providers explanations always clear
dont feel informed about health
feel informed about health 62%
43%
62%
54%
66%
47%
70%
49%
responsibility for patient health
among respondents in...
overall
excellent/very
good health
good/fair/
poor health
me
my provider
both
no opinion
1%
68%
73%
1% 1%
21%
5%
81%
16%
24%
7%
2%
22 enhancing patient-centered care
It follows that young adults (who tend to be in better health) are 11 points
mcre cpI Ihcn Ihc:e 40 cnc c|cer Ic Icke per:cnc| re:pcn:iLi|iIy. Ihere c|:c
is a racial and ethnic gap; 85 percent of whites say theyre responsible for
managing their own health, vs. 69 percent of Latinos and a very similar
67 percent of other racial and ethnic groups.
Ferhcp: mc:I u:efu| i: Ihe fncing IhcI pcIienI: whc Icke per:cnc|
responsibility for their care are more likely than others to express initial interest
in shared decision making, as well as more apt to move to that position if
clear information about healthcare options is provided. That suggests that
providers can encourage patients to take a more involved role in their
health care by appealing to their existing sense of personal responsibility.
endnotes
3 Unless otherwise indicated, all differences described in this report are
:IcIi:Iicc||y :ignifccnI cI Ihe 5 percenI ccnfcence |eve|.
4 Ihe :cmp|e :ize cf Ihc:e whc repcrI fee|ing unccmfcrIcL|e c:king
questions is small, 92. Nonetheless, given the magnitude of the
cifference, Ihe re:u|I i: :IcIi:Iicc||y :ignifccnI cI Ihe 5 percenI
ccnfcence |eve|.
5 Here and in the paragraphs below, desire to have most of the say is
netted with desire to have an equal say.
6 See Appendix A, Model 1 for details of the regression model predicting
patient involvement in care decisions.
7 Regression models do not establish causality. While it is likely that comfort
asking a provider questions impacts the amount of involvement patients
have in decisions about their care, its also possible that the amount of
say patients have impacts their comfort asking questions, or that the
causal arrow points both ways.
8 Ihe :cmp|e :ize fcr hc:piIc| emergency rccm pcIienI: i: :mc|| {N=4),
hcwever Ihi: cifference i: :IcIi:Iicc||y :ignifccnI cI Ihe 5 percenI
ccnfcence |eve|.
enhancing patient-centered care 23
part b: empowering
healthcare consumers
section iv: impacts of information
Whi|e c Lrccc mcjcriIy cf pccr cnc necr-pccr pcIienI:, 84 percenI, fee|
at least somewhat informed about their health, that doesnt mean care
providers can rest in their efforts to improve patient information. Many
fewer pcIienI: - 48 percenI - fee| very" infcrmec. /nc infcrmcIicn i:
uniquely critical. As indicated above, being well-informed on health
issues is a key predictor of patient engagement. It also is a fundamental
precursor of empowerment.
9
Specifcc||y, :IcIi:Iicc| mcce|ing fnc: IhcI hcw infcrmec pcIienI: fee| cLcuI
their health independently predicts three of the basic aspects of patient
empcwermenI icenIifec in Ihi: :Iucy - ccmfcrI c:king ue:Iicn: cf ccre
prcvicer:, ccnfcence in mcking hec|Ihccre ceci:icn:, cnc uncer:Icncing
of providers explanations and advice.
10
Regression models such as those used in this study do not establish
causality.
11
Regardless, the very consistent importance of health
infcrmcIicn, c: we|| c: iI: c|ecr infuence cn inIere:I in :hcrec ceci:icn
making, mark it as essential in advancing patient-centered care.
The very consistent
importance of
information marks
it as essential in
advancing patient-
centered care.
informed about health
very informed
somewhat informed
not so informed
not informed at all
48%
4%
36%
11%
24 enhancing patient-centered care
Fcr excmp|e, pcIienI: whc fee| infcrmec cLcuI Iheir hec|Ih cre 34
points more likely than those who feel less informed to say theyre very
comfortable asking questions of their provider, 67-33 percent; 31 points
more likely to say they always understand their providers explanations and
ccvice, 4-18 percenI: cnc 18 pcinI: mcre |ike|y Ic expre:: ccnfcence in
their ability to make healthcare decisions, 95-77 percent.
connectedness and continuity
An earlier report from this survey found that patients involvement and
satisfaction with their care are positively impacted by their seeing the same
provider on a regular basis (continuity) and by the sense that someone at
Iheir ccre fcci|iIy kncw: Ihem we|| {ccnnecIecne::). Ihi: repcrI, in Iurn, fnc:
that connectedness and continuity also are basic contributors to patient
empowerment, and through it, engagement.
Connectedness and continuity can come from a variety of sources,
whether its a traditional doctor-patient relationship; another personal and
consistent connection with someone at the care facility; or alternative
care relationships through health teams or coaches, group programs, or
technology-based communication via phone, texting, or the internet.
Those who see the same provider at least most of the time, or say theres
someone at their facility who knows them well, are 21 and 27 points,
respectively, more apt to feel very informed about their health than are
patients who lack these kinds of relationships. Similarly, those who have a
regular personal doctor, a healthcare coach, or team-based care all are
mcre |ike|y Ic fee| very infcrmec Ihcn cre Ihc:e whc cc ncI, Ly 22-, 14-,
and 10-point margins, respectively.
67%
33%
engagement by level of information
very comfortable
asking questions
ccnfcenI
making decisions
always understand
explanations
feel informed
dont feel informed
95%
77%
49%
18%
enhancing patient-centered care 25
Continuity and connectedness also have positive impacts, ranging from
10 Ic mcre Ihcn 20 pcinI:, cn ccmfcrI c:king ue:Iicn:, cn ccnfcence in
making healthcare decisions, and on understanding care providers.
Mediation analyses extend these results, showing a progression from
connectedness and continuity to patient empowerment and on to
engagement. In other words, greater connectedness and continuity
:ignifccnI|y impccI pcIienI engcgemenI, ncI cirecI|y, LuI Ly increc:ing
hec|Ih infcrmcIicn, ccnfcence, ccmfcrI cnc ccmprehen:icn. {/: ncIec in
the Executive Summary, and detailed in Appendix A, this model of patient
engagement was independently produced in statistical analyses of the
results of this study.)
% very informed about their health
someone at facility knows you well
yes 64%
59%
56%
37%
37%
35%
have a regular personal doctor
frequency of seeing the same provider
no
yes
no
every/most
of the time
less often
a model of patient engagement
empowerment
feel informed about your health
comfortable asking
provider questions
provider usually explains things
in a way you understand
con0dent you con moke heo|thcore
decisions
engagement
Controlling for other factors, the results of this survey show that connectedness and continuity predict empowerment
outcomes feeling well-informed, being comfortable asking questions of care providers, understanding providers answers
cnc ce|ng ccn|cent |n tne cc|||ty tc ncke nec|tncc|e cec|:|cn:. Fee||ng we||-|n|c|nec c|:c |ncepencent|y p|ec|ct: tne
ctne| tn|ee enpcwe|nent |ten:. Anc eccn c| tne enpcwe|nent nec:u|e: p|ec|ct: engcgenent. tnct |:. tck|ng c |c|e
|n nec|tncc|e cec|:|cn: - c key gcc| c| pct|ent-cente|ec cc|e.
connectedness
continuity
26 enhancing patient-centered care
information among groups
If connectedness and continuity can get the ball rolling, information keeps
it in play. Indeed, even when connectedness and continuity are absent,
information remains a primary driver of empowerment and engagement.
Close examination of self-assessed health information levels among groups
thus is warranted.
12

By facility type, rates of feeling very informed are highest among patients
cf privcIe cccIcr: cffce: cnc Kci:er FermcnenIe, cI 58 percenI cnc
53 percent, respectively, and lower among those who rely on hospital
emergency rooms for their care (36 percent). CCHC and non-CCHC clinic
pcIienI: fc|| LeIween Ihe:e grcup: in Iheir |eve|: cf infcrmcIicn, wiIh 47 cnc
43 percenI, re:pecIive|y, fee|ing very infcrmec cLcuI Iheir hec|Ih.
The uninsured report lower levels of health information (just a third in this
group feels very informed, compared with more than half of those with
in:urcnce). /nc Ihere cre :ignifccnI gcp: Ly inccme, wiIh Ihc:e wcr:e
off even within the already-restricted population of poor and near-poor
Californians reporting less information than those with not-quite-so-low
incomes. In addition, whites are roughly 10 points more likely than Latinos
and members of other racial/ethnic groups to report feeling very informed
about their health.
feel very informed about health
facility type
privcIe cccIcr: cffce: 58%
Kci:er FermcnenIe 53
CCHCs 47
non-CCHC clinics 43
hospital E.Rs. 36
insurance status
Medi-Cal 58
private 52
none 34
race/ethnicity
white 55
other 4
latino 45
age
30+ 53
<30 36
gender
women 53
men 42
enhancing patient-centered care 27
There also are gender and age differences: Women are more likely to
repcrI fee|ing very infcrmec Ihcn cre men, 53 Ic 42 percenI. /nc whi|e ju:I
36 percent of younger low-income Californians (i.e., those age 19-29) feel
very informed about their health, that rises to more than half of their elders.
section v: miscommunication and its
consequences
Health information is effective only if clearly communicated, and here
Ihere cre :ignifccnI chc||enge:. Fewer Ihcn hc|f cf pccr cnc necr-pccr
Cc|ifcrnicn:, 44 percenI, :cy Iheir ccre prcvicer c|wcy: exp|cin: Ihing: Ic
them in a way they can understand (as detailed in section vii). And nearly
cne in fve, 1 percenI, :cy: Ihere hcve Leen Iime: when Ihey cicnI fc||cw
a care providers advice or treatment plan because they didnt understand
what they were supposed to do.
The likelihood of misunderstanding medical advice can be reduced by
providers and care facilities making their messages clear and also by
developing relationships in which patients feel at ease asking questions.
13

Among patients who are uncomfortable asking questions, a third say that at
times they have not followed a providers advice or treatment plan because
they didnt understand what to do. Among those who are very comfortable
c:king ue:Iicn:, fewer Ihcn hc|f c: mcny, 14 percenI, repcrI in:Icnce: in
which they didnt follow instructions.
Another result points to a particular need for clarity among people with
chronic conditions or who rate their health as less than very good. These
individuals may have more opportunities to misunderstand their care
providers, and indeed they do: A quarter of those in less-than-good
health, and 31 percent of those with chronic conditions, report times they
didnt follow instructions because they didnt know what to do. That drops
to 15 percent both among those without chronic conditions, and whose
overall health is excellent or very good.
% who have misunderstood medical instructions
disability/chronic condition
yes 31%
no 15
health status
fair/poor 25
good 19
excellent/very good 15
Theres one difference in miscommunication across care facilities: Among
people relying on emergency rooms for care, 26 percent report having not
followed instructions because they didnt understand them; that compares
wiIh 14 cnc 15 percenI, re:pecIive|y, cf Kci:er FermcnenIe cnc CCHC
patients. (Users of other facility types fall in between.)
did not follow providers
advice due to
misunderstanding
no
yes
19%
80%
28 enhancing patient-centered care
Its also notable that poor and near-poor African-Americans in California are twice
as likely as low-income whites and Latinos alike to say they havent followed a
physicians advice or treatment plan because of a lack of understanding.
14

section vi: information and the internet
If communication is one challenge, information access is another.
Most low-income Californians, 56 percent, never have used the internet
to obtain health information, and most of the rest do so only infrequently.
Use of the internet for health information was 17 points higher among all
ccu|I: ncIicnc||y in c Kci:er Fcmi|y FcunccIicn/Wc:hingIcn Fc:I pc|| in 2011:
iI: |cwer |eve| in Ihi: :urvey |ike|y refecI: Ihe :c-cc||ec cigiIc| civice," in
which adults with lower socioeconomic status are less apt to have easy
access to technology, including high-speed internet service.
This divide occurs even within the low-income California population.
15

College graduates are twice as likely as non-graduates to say theyve
used the internet to access health information (77 vs. 39 percent), by far
the biggest gap in usage. Young adults, citizens, whites, and non-Latino
respondents also are more likely to have done so than are older people,
noncitizens, and Latinos. Indeed nearly seven in 10 poor and near-poor
Latinos in the state say they never have used the internet for gathering
health information.
Kci:er FermcnenIe pcIienI: cnc Ihc:e wiIh privcIe in:urcnce cre mcre
likely than others to have searched for health information on the internet,
62 and 56 percent, respectively. On the lowest end of the usage spectrum
cre pcIienI: cf CCHC: cnc ncn-CCHC c|inic: c|ike {34 cnc 37 percenI,
respectively) and those who lack private health insurance (38 percent).
Those who take sole responsibility for their health, who desire an equal
say in shared decision making, or who have at least some input in their
current care all are more likely to have used the internet to access health
information than those who do not again underscoring the relationship
between information (whatever its source) and engagement.
16

8SCF, |cw-inccme Cc|ifcrnicn: 1-4
Kci:er Fcmi|y FcunccIicn/Wc:hingIcn Fc:I,
all Americans
have used internet
for health info
have not used internet
for health info
43%
60%
39%
56%
use of internet to access health information
enhancing patient-centered care 29
internet use by groups
education
college grad 77%
non-college grad 39
race/ethnicity
white 57
latino 31
other 59
age
19-29 57
30-39 41
40-4 34
citizenship
citizen 53
noncitizen 25
As noted in the previous report from this survey, use of the internet may be
a way to improve the connectedness patients feel with their care facility,
and substantial numbers express interest in online resources for activities
such as scheduling medical appointments and renewing prescriptions. The
results in this report further suggest untapped potential to use the internet to
enhance health information more generally, and through it empowerment
and engagement to the extent that the digital divide can be bridged.
section vii: fostering empowerment
Whether by clearer delivery of health information, internet resources,
or other means, unquestionably theres room for greater patient
empowerment. While more than nine in 10 low-income Californians are
cI |ec:I :cmewhcI ccnfcenI in Iheir cLi|iIy Ic mcke hec|Ihccre ceci:icn:,
fewer, 5 percenI, cre very" ccnfcenI. /|Ihcugh nine in 10 expre:: ccmfcrI
asking questions about their care, fewer, 62 percent, are very comfortable
in this role. And while three-quarters say their provider explains things in a
wcy Ihey ccn uncer:Icnc cI |ec:I mc:I cf Ihe Iime, cn|y 44 percenI, c:
ncIec, :cy Ihi: hcppen: every Iime."
Results suggest
untapped potential
to use the internet
to enhance
health information
more generally,
and through it
empowerment
and engagement.
con0dence con moke
healthcare decisions
very ccnfcenI 56%
:cmewhcI ccnfcenI 36
ncI :c ccnfcenI 6
ncI ccnfcenI cI c|| 2
comfort asking provider questions
very comfortable 62%
somewhat comfortable 28
somewhat uncomfortable 7
very uncomfortable 3
no opinion 1
frequency provider explains
things in a way you understand
every time 447
most of the time 31
some of the time 17
rarely 4
never 3
30 enhancing patient-centered care
As described above, improving continuity and connectedness in patients
healthcare experiences is one means of improving patient empowerment.
The following section examines additional predictors of each of these
elements, including the common factor of information in each one.
ccnfcence
Regression modeling shows that the most important predictors of self-
ccnfcence in mcking hec|Ihccre ceci:icn: cre fee|ing infcrmec, hcving
clear explanations from providers, and taking responsibility for ones
own health.
17
Cross-sectional data illustrate those results. As noted previously, patients
whc fee| very infcrmec cLcuI Iheir hec|Ih cre 24 pcinI: mcre cpI Ihcn
Ihc:e |e:: infcrmec Ic Le very ccnfcenI mcking hec|Ihccre ceci:icn:.
And among those who say their provider often explains things in a way
Ihey ccn uncer:Icnc, :Ircng ccnfcence i: 15 pcinI: higher, 5 percenI,
than it is among those who report more trouble understanding their care
prcvicer, 44 percenI.
18

Mcving Leycnc mcce|ing, Ihere: c gencer gcp in ccnfcence cmcng
whiIe:: Whi|e 5 percenI cf whiIe wcmen repcrI Leing very ccnfcenI in Iheir
cLi|iIy Ic mcke ceci:icn: cLcuI Iheir ccre, Ihi: cec|ine: Ic 4 percenI cf whiIe
men. Theres no such division among Latinos, 56-55 percent, women-men.
19
FcIienI: cf c|| fcci|iIy Iype: repcrI Leing very ccnfcenI cI re|cIive|y euc|
rcIe:. 8uI Lrcccer ccnfcence {very" cnc :cmewhcI" ccmLinec) peck:
cmcng pcIienI: cf privcIe cccIcr: cffce:, Kci:er FermcnenIe fcci|iIie: cnc
CCHC:, cI , 5, cnc 4 percenI, re:pecIive|y. IhcI: :ignifccnI|y higher
than it is among emergency room users, 79 percent. (It falls in between,
88 percent, among non-CCHC clinic users.)
comfort asking questions
Ccnfcence iI:e|f precicI: pcIienI: ccmfcrI |eve| c:king ue:Iicn: cf Iheir
care providers, as does respondents sense that their providers give clear
explanations, and, again, health information levels.
20
The quality of provider explanations is chief among these predictors.
Patients who say their provider often explains things in a way they can
understand are more than twice as apt to feel very comfortable asking
questions, compared with those whose providers are less clear, 71 percent
vs. 32 percent.
21
Additionally, patients who feel well-informed about
their health show a 26-point advantage in comfort asking their provider
ue:Iicn: v:. Iheir |e::-infcrmec peer:. /nc pcIienI: whc cre very ccnfcenI
mcking ceci:icn: cre 2 pcinI: mcre cpI Ihcn Ihc:e whc cre |e:: ccnfcenI
Ic Le ccmfcrIcL|e c:king ue:Iicn:, 73 percenI v:. 47 percenI.
very ccnfcenI
:cmewhcI ccnfcenI
ncI :c ccnfcenI
ncI ccnfcenI cI c||
among those who feel
very informed
1%
68%
28%
4%
among those who feel
less informed
3%
44%
44%
8%
con0dence con moke
healthcare decisions
enhancing patient-centered care 31
Comfort asking questions also varies by race and ethnicity. Three-quarters of
whites in this low-income population are very comfortable asking questions of
their providers, compared with 55 percent of Latinos, with other groups in the
middle (65 percent).
22
Strong comfort asking questions also is comparatively
low, 50 percent, among those who dont primarily speak English.
8y fcci|iIy Iype, pcIienI: cI Kci:er FermcnenIe cr privcIe cccIcr: cffice:
cre mcre |ike|y Ic :cy Ihey fee| very" ccmfcrIcL|e c:king ue:Iicn: Ihcn
non-CCHC clinic and hospital emergency room patients (69 vs. 56 and
55 percent, respectively). CCHC patients fall in between these groups
(63 percent report feeling very comfortable).
understanding providers
SIcIi:Iicc| mcce|ing fnc: IhcI uncer:Icncing cf prcvicer: exp|cncIicn: i:
best predicted by patients comfort asking questions, how informed they feel
about their health, and how much continuity they have in a care provider.
23
Some of the data on this measure are particularly striking. Among patients
who feel informed about their health, 81 percent say their providers
exp|cncIicn: cre c|ecr cI |ec:I mc:I cf Ihe Iime, inc|ucing 4 percenI whc
say they always understand those explanations. Among those who feel less
infcrmec, Ihe:e crcp Ic 44 cnc 18 percenI, re:pecIive|y.
Likewise, a vast 87 percent of patients who are very comfortable asking
questions also say their providers often explain things in a way they understand.
Among those who are somewhat comfortable, 67 percent report frequent
understanding; among those who are uncomfortable, its just 33 percent.
Patients are well-served when providers put them at ease in asking questions
achieved, to some extent, by those providers giving clear answers and advice.
very comfortable asking questions
a
l
l
62%
75%
55%
65%
71%
50%
71%
32%
67%
33%
w
h
i
t
e
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h
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r
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y

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e
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l
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m
e
d

a
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t

h
e
a
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t
h
32 enhancing patient-centered care
Theres also differentiation in clear communication across care facilities.
/mcng pcIienI: cf Kci:er FermcnenIe cnc privcIe cccIcr: cffce:, 8 cnc
81 percent, respectively, say their providers explanations are usually clear;
that compares with 79, 72, and 69 percent, respectively, among patients
of public clinics, private/other clinics and CCHCs. The lowest rates, again,
are among hospital emergency room users, 59 percent of whom say they
generally receive clear information from their care providers, and just 28
percent of whom say they always do.
Related to this result, those who lack insurance entirely are less likely than
those with Medi-Cal to usually understand their care provider 63 vs. 75
percent. Comprehension rates are highest among low-income Californians
with private insurance, with 85 percent saying they usually understand their
ccre prcvicer, inc|ucing 54 percenI whc :cy Ihey c|wcy: cc.
In one other difference, understanding is higher among patients who
report being in better health 83 percent among those who describe
their health as excellent or very good, vs. 71 percent among those who
:cy Iheyre in gccc, fcir cr pccr hec|Ih: Ihi: cgcin mcy refecI Ihe grecIer
amount and complexity of information needed by patients in less robust
health as well as the possibility that some health problems can reduce
patients cognitive capacity.
Those with a college degree are 12 points more apt to say they usually can
understand their providers explanations than are low-income Californians
with a high school diploma or less. In addition, citizens and English
speakers are 13 and 12 points more likely to say they usually understand
care providers instructions, compared with noncitizens and non-English
:pecker:, re:pecIive|y. ln Icncem, Ihe:e fncing: :ugge:I Ihe neec fcr c|ecr
instructions that can overcome educational and language barriers.
% who understand providers explanations
usually understand
sometimes understand
rarely/never understand
87%
very comfortable
asking questions
somewhat comfortable
asking questions
uncomfortable
asking questions
9%
67%
27%
33%
38%
29%
3%
6%
enhancing patient-centered care 33
endnotes
9 There are cultural differences in norms about empowerment, and while
patient empowerment is an essential component of patient-centered
care, it may not be universally desired by all patients.
10 While health information is directly related to greater patient
engagement in making care decisions, it takes an important indirect
rc|e c: we||. Specifcc||y, invc|vemenI in ccre ceci:icn: i: precicIec Ly
ccnfcence, ccmfcrI, cnc ccmprehen:icn - Ihree iIem: IhcI, c: ncIec,
c|| cre enhcncec Ly grecIer infcrmcIicn. See /ppencix /, Mcce| 3, 4
and 5 for details of the model predicting how informed respondents feel
about their own health.
11 Its logical, for instance, that the clarity of explanations given by
providers will affect how informed patients feel about their health, just as
the amount of information patients have about their health will impact
their ability to understand their providers. See Section VII for further
ceIci|: cf Ihe precicIcr: cf ccmfcrI, ccnfcence cnc ccmprehen:icn.
12 See Appendix A, Model 2 for details of the model predicting how
informed respondents feel about their own health.
13 A review of effective patient-provider communication methods
i: Leycnc Ihe :ccpe cf Ihi: repcrI. Specifc :IrcIegie: hcve Leen
demonstrated to improve patients understanding of medical
explanations, such as the teach-back method. See Schillinger, D,
FieIIe, J., GrumLcch, K., eI c|. {2003). C|c:ing Ihe |ccp: phy:icicn
communication with diabetic patients who have low health literacy.
Archives of Internal Medicine, 163, 83-90. Other resources include http://
www.nchealthliteracy.org/toolkit/tool5.pdf and http://pilot.train.hrsa.
gov/uhc/pdf/module_02_job_aid_teach_back_method.pdf.
14 Ihe :cmp|e :ize cf /friccn-/mericcn: in Ihi: :urvey i: Icc :mc|| fcr preci:e
population estimates (N = 87), however, this difference is statistically
:ignifccnI cI Ihe 5 percenI ccnfcence |eve|.
15 See Appendix A, Model 7 for details of the model predicting the
frequency patients use the internet for health information.
16 The difference between those who have little or no say in current
decisions compared with those with at least some say is statistically
:ignifccnI cI Ihe 0 percenI ccnfcence |eve|. Ihe cIher cifference:
repcrIec in Ihi: pcrcgrcph cre :IcIi:Iicc||y :ignifccnI cI 5 percenI
ccnfcence.
17 See Appendix A, Model 3 for details of the model predicting patient
ccnfcence in mcking ceci:icn: cLcuI Iheir cwn hec|Ih.
34 enhancing patient-centered care
18 As with other regressions presented in this report, causality is not assured;
hcving ccnfcence cnc uncer:Icncing Ihe prcvicer: in:IrucIicn:, fcr
example, may be self-reinforcing.
19 The sample size among other ethnic/racial groups is too small to
separately analyze results by gender.
20 See Appendix A, Model 5 for details of the model predicting patient
comfort in asking questions of their care provider.
21 Again, this is a case in which the causal arrow likely points both ways.
Providers who explain things well may invite questions from the patient
to ensure clarity (as noted in Model 5), but comfort asking the provider
questions also may improve the clarity of the advice and instructions of
Ihe prcvicer {c: :een in Mcce| 4).
22 The sample sizes of other racial/ethnic groups (e.g., African-Americans,
Asian-Americans) are too small for precise population estimates.
23 See /ppencix /, Mcce| 4 fcr ceIci|: cf Ihe mcce| precicIing hcw
frequently the provider explains things in a way patients understand.
enhancing patient-centered care 35
part c: additional
information and
cultural competence
section viii: desire for greater information
Helpfully, whatever the level of information patients feel they currently
possess about their health, there is substantial desire for more information
about treatments and healthcare providers alike. Anywhere from 83 to
88 percent of low-income Californians express interest in a variety of
information resources: learning about the pros and cons of relevant tests
or treatments, the training and experience of health professionals in their
area, patient satisfaction ratings of local facilities, and quality ratings of
care providers in their community.
Enccurcging|y, Ihi: inc|uce: ccn:icercL|e high-|eve| inIere:I, wiIh 45 percenI
cr mcre very" inIere:Iec in ecch cpIicn. /I Ihe Icp enc, 58 percenI cre
very interested in information on potential tests and treatments.
Strong interest peaks among patients who feel they currently have at least
a good amount of say in care decisions, but would still like to have more.
Anywhere from 61 to 69 percent in this group are very interested in each of
the information options tested, much greater than the interest levels among
patients who either dont feel involved, or who dont seek greater involvement.
interest in more information
pros/cons of
tests/treatment
provider training/
experience
patient
satisfaction ratings
provider
quality ratings
very interested somewhat interested
30%
58% 52% 45% 48%
32%
38% 35%
36 enhancing patient-centered care
Because interest in one item is related to interest in another, all four were
combined in an index of interest in health-related information. Higher
scores on this index strongly relate to indicators of patient empowerment
cnc engcgemenI c|ike - IhcI i:, hcving ccnfcence, Leing ccmfcrIcL|e
asking questions, current involvement in care decisions, and desire for
more involvement in care decisions all predict greater interest in additional
health-related information.
24
Ihi: fncing pcinI: Ic c pc:iIive feecLcck |ccp: Fccr cnc necr-pccr
Cc|ifcrnicn: whc fee| mcre ccnfcenI, ccmfcrIcL|e, cnc invc|vec cre mcre
likely to be interested in obtaining further information, which in turn can
lead to still greater empowerment and engagement.
Modeling shows that connectedness and continuity, or if they are lacking,
a desire for more of each, also relate to interest in more information; it rises
among those who have a regular personal doctor, or dont have but want
one; as well as among those who would like to see the same provider more
consistently than they do now. Additionally, more educated low-income
Californians are more interested in greater information about treatments
cnc prcvicer:, |ike|y refecIing Iheir ccnfcence u:ing infcrmcIicn effecIive|y.
Women are more likely than men to say theyre interested in information on
the pros and cons of treatments, training and experience of providers, and
pcIienI :cIi:fccIicn rcIing:, Ly :mc|| LuI :IcIi:Iicc||y :ignifccnI mcrgin:. {Ihe
difference is smaller on the fourth item, quality ratings of care providers in
the area.)
Interest in more information is high across patients of different facility types
for the most part, albeit generally lower among hospital emergency room
patients. And CCHC patients are particularly interested in information
about patient satisfaction ratings of healthcare facilities 91 percent.
Poor and near-
poor Californians
who feel more
ccnfcenI,
comfortable,
and involved are
more likely to
be interested in
obtaining further
information.
the cycle of patient engagement
i
n
f
o
r
m
atio
n
e
n
g
a
g
e
m
e
n
t
e
m
p
o
w
e
r
m
e
n
t
In this survey, information about ones health leads to greater
patient empowerment and engagement; these, in turn,
p|ec|ct c ce:||e |c| nc|e nec|tn-|e|ctec |n|c|nct|cn.
enhancing patient-centered care 37
lI: 85 percenI cmcng ncn-CCHC c|inic pcIienI:, 82 percenI cf Kci:er
FermcnenIe cr privcIe cccIcr: cffce pcIienI:, cnc 7 percenI cf hc:piIc|
emergency room users.
seal of approval
Given interest in information on satisfaction and quality ratings, a substantial
number of low-income Californians though not a majority say their
chcice cf fcci|iIy ccu|c Le pc:iIive|y infuencec Ly iI: hcving receivec
c :ec| cf cpprcvc|" frcm c ncIicnc| hec|Ihccre c::ccicIicn.
Forty-seven percent say theyd be more likely to go to a particular facility
in Iheir crec if iI hcc c rcIing cf Ihi: Iype: 43 percenI :cy iI wcu|c mcke nc
difference and 9 percent actually say theyd be less likely to use such a
facility. Other factors price, location, and personal recommendations may
simply be more important, and the result also may indicate some reluctance
to accept ratings that are produced by a national group rather than locally.
While further research on this question could be useful, its clear that a
general desire for more information is related to patients saying theyd
consider a seal of approval. Among those who are interested in more
information on health treatments and healthcare providers and facilities
in their area, roughly half indicate theyd be positively persuaded by a
seal of approval, compared with just over a quarter of those who are not
interested in more health information.
Fifty-three percent of CCHC users say a seal of approval would increase
their likelihood of using a particular facility, compared with a low of
40 percenI cmcng Kci:er FermcnenIe u:er:. FcIienI: cf cIher fcci|iIy
types fall in between these two.
section ix: cultural competence and
community understanding
Beyond information, low-income Californians also express interest in other
elements of patient-centered care cultural competence and community
awareness. Two-thirds say its important for their healthcare providers to
effect of seal of approval on choice of healthcare facility
more likely to go there
no difference
no opinion
less likely to go there
2%
47%
43%
9%
A substantial
number of low-
income Californians
albeit not a
majority say their
choice of a facility
could be positively
infuencec Ly c
ncIicnc| :ec| cf
cpprcvc|."
38 enhancing patient-centered care
understand their ethnic or cultural background. More, three-quarters, prefer
that their providers know whats going on in their community. And among
Ihc:e whc mcin|y :peck c |cngucge cIher Ihcn Eng|i:h cI hcme {44 percenI
overall), a vast 92 percent want a provider who can speak with them in the
language of their choice.
Kncwing Ihe ccmmuniIy cnc Ihe pcIienI: eIhnic cnc cu|Iurc| Lcckgrcunc
matters far more to people who say its important that someone at
their facility knows them well (80 vs. 59 percent and 70 vs. 52 percent,
respectively). In this way, knowledge of the community and understanding
of patients ethnic and cultural backgrounds and linguistic needs, can
Le viewec c: :pecifc excmp|e: cf wcy: prcvicer: ccn geI Ic kncw Iheir
patients better, and with that increased connectedness improve patient
empowerment and engagement.
Low-income Californians who already have a close relationship with
their caregiver or facility are more apt to view these competencies as
important. Those who have a health coach, team-based care, or who
see the same care provider at least some of the time are all more likely
than their counterparts to think its important for providers to know whats
gcing cn in Ihe ccmmuniIy {Ly 15-, 14-, cnc 11-pcinI mcrgin:, re:pecIive|y)
and to understand their cultural or ethnic background (by 12-, 15-, and
13-point margins). Non-English speaking respondents who have a personal
connection at their care facility or who have team-based care are 12 and
11 points more apt to view a providers ability to speak with them in the
language they prefer as very important, vs. non-English speakers who do not.
Clinic patients are especially interested in community and cultural
competence. Eighty-one percent of clinic-goers overall, including 86
percent of CCHC patients, say a providers knowledge of the community
i: impcrIcnI Ic Ihem. Ihi: fc||: Ic 74 percenI cf pecp|e whc gc Ic privcIe
cccIcr: cffce:, 71 percenI cf Kci:er FermcnenIe pcIienI:, cnc percenI
of those who use hospital emergency rooms for their care. Understanding
of their cultural and ethnic background, similarly, is more important for
puL|ic c|inic pcIienI: {7 percenI) Ihcn iI i: fcr Kci:er FermcnenIe cnc
privcIe cccIcr: pcIienI: { cnc 4 percenI, re:pecIive|y). /nc CCHC
patients (71 percent) and non-CCHC clinic patients (72 percent) alike show
more interest in cultural understanding than do hospital emergency room
patients (55 percent).
% who see cultural, community and linguistic competence as important
knowledge of
community
understanding cultural/
ethnic background
speaking language of
choice (non-english)
75%
67%
92%
enhancing patient-centered care 39
The broad interest expressed in cultural competence differs from a result
in the 2011 Blue Shield of California survey, in which just 20 percent of
respondents indicated that they would rather go to a facility that has a
fccu: cn :erving pecp|e cf :imi|cr Lcckgrcunc: c: ycur cwn." Ihi: yecr:
measurement instead focuses more on the personal whether the facility
understands the patients own ethnic and personal background, rather
than catering to others with similar backgrounds.
Attention to cultural and community details is more important to Latinos,
other racial or ethnic minorities, and noncitizens than it is to whites and
citizens. Nearly three-quarters of Latinos and nonwhites alike say cultural
understanding is important, compared with half of whites. Eighty-two
percent of Latinos say knowledge of the community is important, falling
to 65 percent of whites (other racial or ethnic groups fall in between, at
72 percent). In addition, 78 percent of noncitizens say its important that a
prcvicer uncer:Icnc: Iheir eIhnic cnc cu|Iurc| Lcckgrcunc, cnc 84 percenI
want their provider to know about their community, exceeding citizens on
Ihe:e mec:ure: Ly 18 cnc 14 pcinI:, re:pecIive|y.
These results underscore the important relationship aspect of patient-
centered care, in which community and cultural awareness are of value
to majorities of individuals across population groups, and particularly
appealing to some.
endnotes
24 See /ppencix /, Mcce| fcr ceIci|: cf Ihe mcce| precicIing Ihe incex cf
interest in more health information.
community knowledge cultural understanding
importance of cultural competence and understanding of the community by facility type
public clinics CCHCs private doctors
cffce:
Kci:er
Permanente
hospital
emergency rooms
86%
79%
86%
71%
74%
64%
71%
66% 66%
55%
40 enhancing patient-centered care
part d: conclusions
Fe:u|I: cf Ihi: :urvey |enc Ihem:e|ve: Ic :pecifc ccIicn: Ly hec|Ihccre
providers and facilities in California to engage and involve their low-
income patients. First, as laid out in the separate report on continuity
and connectedness, is to recognize the critical value of ongoing,
personal relationships, and to implement new models to achieve those
aims for example, through the use of team-based care, as well as via
healthcare navigators, group care programs and the enhanced use of
communication technology.
This report adds details on the equally critical role of clear health
infcrmcIicn in empcwering pcIienI: Ic hcve ccnfcence in Iheir ceci:icn-
making abilities, to feel comfortable asking questions and to be better
equipped to understand providers answers.
Cne impcrIcnI fncing i: IhcI infcrmcIicn empcwer: pcIienI: regcrc|e:: cf
:cciceccncmic Lcckgrcunc: iI he|p: |eve| Ihe p|cying fe|c. /ncIher i: IhcI
while information can be enhanced by continuity and connectedness,
it also independently predicts empowerment even in the absence of
such connections. Current information that patients understand, then, is a
uniquely powerful tool in achieving the goals of patient-centered care.
As described above, information needs can vary across groups. Patients
with chronic conditions or lower health status are more likely to have failed
to follow providers instructions because they didnt understand what to do
pointing to a particular need for concerted information delivery to these
groups. Clear instructions also need to be devised to cross language and
education barriers, marking the value of cultural, community and linguistic
competence, an area in which many CCHCs have particular expertise.
More broadly, the survey shows that fostering an environment in which
patients feel comfortable asking questions decreases the chance of
misunderstanding. And it shows that appeals to self-responsibility already
widely valued by patients may be effective in encouraging patients to
take a greater role in their own care.
ln :um, ccnIinuiIy cnc ccnnecIecne:: imprcve Ihe fcw cf infcrmcIicn.
Information enhances empowerment. Empowerment in turn leads to
engaged patients who are more active in their care decisions, more
likely to desire an even greater role, and more likely as well to step up to
the ultimate aim of shared decision making. Its a promising pathway to
patient-centered care.
Information is a
uniquely powerful
tool in achieving
the goals of
patient-centered
care.
enhcncing pcIienI-cenIerec ccre 41
methodology
This Blue Shield of California Foundation survey was conducted March 12
to April 8, 2012, via telephone interviews with a representative statewide
:cmp|e cf 1,024 Cc|ifcrnicn: LeIween Ihe cge: cf 1 Ic 4 wiIh fcmi|y
incomes below 200 percent of the federal poverty level (FPL).
25
The sample
wc: ccmpri:ec cf 18 |cnc|ine cnc 40 ce|| phcne inIerview:, wiIh 71
interviews conducted all or mostly in English and 305 in Spanish. The survey
was produced, managed and analyzed by Langer Research Associates of
New Ycrk, N.Y., wiIh :cmp|ing, fe|cwcrk cnc ccIc IcLu|cIicn Ly SSFS/Sccic|
Science Research Solutions of Media, Pa.
sample design
Samples from landline and cell phone telephone exchanges were
generated by Marketing Systems Group (MSG). The landline sample
wc: ce:ignec Ic recch Ihe IcrgeI pcpu|cIicn c: effcienI|y c: pc::iL|e,
accounting for the high-incidence of Latino families within the low-
income California population and addressing the regional distribution of
|cw-inccme hcu:ehc|c: in Ihe :IcIe. Ihree mcin :IrcIc were icenIifec:
(1) the High Latino stratum, comprised of landline telephone exchanges
associated with Census-block groups in which Latinos were at least
57.5 percent of the population; (2) a High Low-Income stratum, which
consisted of all remaining landline phone numbers whose exchanges were
c::ccicIec wiIh Cen:u:-L|cck grcup: in which mcre Ihcn 40 percenI cf Ihe
population had annual household incomes less than $35,000; and (3) a
Residual :IrcIum, which inc|ucec c|| exchcnge: cIher Ihcn Ihc:e in Ihe fr:I
two strata. In addition, a separate phone stratum was constructed of all
phone numbers associated with households whose records in the infoUSA
database indicated there was at least one household resident between
Ihe cge: cf 1 cnc 4 wiIh hcu:ehc|c cnnuc| inccme |e:: Ihcn $23,000.
These numbers were removed from their respective telephone strata and
considered a fourth, Listed Low-Income, stratum. Thus the four landline
strata were mutually exclusive.
Within each of these strata, the sample was broken down by geographical
designations: (1) Los Angeles area: phone numbers whose 6-digit NPA-NXX
exchange was associated with numbers in the Los Angeles metropolitan
statistical area (MSA); (2) San Francisco/San Diego/Sacramento areas:
phone numbers whose exchanges were associated with these MSAs; and
(3) Other areas: All remaining California landline exchanges.
Fcpu|cIicn fgure: fcr ecch cf Ihe 12 :IrcIum-Ly-crec :cmp|ing ce||: were
estimated through MSGs GENESYS system, and a sampling design was
implemented oversampling those cells with an estimated higher incidence
of respondents matching the survey criteria for eligibility (that is, family
income below 200 percent of the federal poverty level). An initial estimate
42 enhancing patient-centered care
of the eligible population was created based on the percentage in each
one of these cells who, according to the GENESYS data, had an annual
household income of less than $35,000.
26
In estimating the size of the eligible
population in each cell, two adjustments were made: (1) Correction for the
proportion of non-working numbers in the listed sample. Because the size of
the unlisted sample in each stratum was calculated as the total population
minus the number of listed records, the size of the listed sample in each
stratum was decreased by the percentage of non-working numbers found
among the listed numbers; and (2) Correction for the cell phone only (CPO)
population. The initial total estimated number of unlisted households in each
stratum included any household that did not have a listed landline number.
Hcwever, :ince cLcuI 40 percenI cf Ihe uc|ifying pcpu|cIicn wc: e:IimcIec
to be CPO, the estimated number of people in each of the unlisted cells was
recucec Ly 40 percenI.
Ce|| phcne numLer: were ncI :IrcIifec, LuI genercIec frcm c|| numLer:
corresponding with California cell phone exchanges. Each record was labeled
Lc:ec cn Ihe exchcnge: gecgrcphic cff|icIicn wiIh Ihe Ihree :cmp|ing crec:
used for the landline (LA; SF/SD/Sac; Other). CPO California residents with
non-California phone numbers could not be included.
In Table 1 we compare the (adjusted) estimated population in each of
the landline sampling cells and their share among the landline interviews.
SF/S/C/SD" {:eccnc rcw) refer: Ic Ihe :cmp|e in Ihe Scn Frcnci:cc, SccrcmenIc
and San Diego metropolitan statistical areas. Data in the third and fourth columns
represent original estimates of the number and percentage of low-income
hcu:ehc|c: in Ihe ce||. Ihe ffIh cc|umn repre:enI: ecch ce||: :hcre cmcng
landline households based on the observed incidence of those meeting
survey eligibility.
table 1. estimated and observed share of low-income households compared
with number of landline interviews, by stratum and area
Low-Income Households Interviews
Stratum Area Estimated # Estimated % Observed % % #
Residual Los Angeles 74,35 20% 22% 10% 62
Residual SF/SAC/SD 777,174 20 21 10 60
Residual Other 27,040 7 7 7 44
High Latino Los Angeles 471,844 12 13 18 109
High Latino SF/SAC/SD 41,028 1 1 4 24
High Latino Other 76,052 2 2 3 21
High Low Income Los Angeles 387,198 10 11 15 95
High Low Income SF/SAC/SD 7,447 2 3 4 27
High Low Income Other 260,109 7 8 8 50
Low Income Listed Los Angeles 297,607 8 5 7 4
Low Income Listed SF/SAC/SD 161,027 4 5 5 29
Low Income Listed Other 217,477 6 3 8 51
Total 3,794,367 100% 100% 100% 618
enhcncing pcIienI-cenIerec ccre 43
Sample numbers were generated within each sampling cell using an
epsem (equal probability of selection method) from active blocks (area
code + exchange + two-digit block number) that contained three or
more residential directory listings (3+ listed RDD sample). The cell phone
sample was not list-assisted, but was drawn through a systematic sampling
from dedicated wireless 100-blocks and shared service 100-blocks with no
directory-listed landline numbers. Following generation, the landline RDD
sample (excluding the Listed-Low Income sample) was prepared using
MSGs GENESYS IDplus procedure, which not only limits sample to non-zero
Lcnk:, LuI c|:c icenIife: cnc e|imincIe: cpprcximcIe|y 0 percenI cf c||
non-working and business numbers. (At present, there is no capability to
scrub such a sample or to run it through listed databases.)
fe|c prepcrcIicn:, fe|cing cnc ccIc prcce::ing
8efcre Ihe fe|c pericc SSFS prcgrcmmec Ihe :Iucy inIc CfMC CcmpuIer
Assisted Telephone Interviewing (CATI) software. Extensive checking of
the program was conducted to assure that skip patterns followed the
questionnaire design. The questionnaire was translated into Spanish so
respondents could choose to be interviewed in English or Spanish, or to
switch between the languages according to their comfort level.
In advance of interviewing, CATI interviewers received both formal training
on the survey and written materials including an annotated questionnaire
containing information about the goals of the study as well as the meaning
and pronunciation of key terms. Additional written materials detailed
potential obstacles to overcome in obtaining meaningful responses,
pcIenIic| re:pcncenI ciffcu|Iie: cnc :IrcIegie: fcr cccre::ing Ihem.
Interviewer training was conducted both prior to the study pretests
cnc immecicIe|y Lefcre Ihe :urvey wc: cffcic||y |cunchec. Cc||-cenIer
supervisors and interviewers were walked through each question in the
questionnaire. Interviewers were given instructions to help maximize
response rates and ensure accurate data collection. Interviewers were
monitored throughout the study and project staff provided feedback to
interviewers throughout the survey period.
A live pretest of the survey instrument was conducted on March 5, 2012.
In all, 18 pretest interviews were completed throughout the afternoon and
evening. Pretest interviews were scheduled prior to the live pretest and
respondents were offered a $20 incentive to participate. Langer Research
Associates and BSCF representatives monitored the interviewing live,
along with SSRS project managers, for approximately two hours. Additional
interviews were digitally recorded and placed on a secure FTP site for
review. Several questions were reworded or removed altogether based on
the pretest results.
The questionnaire screened for eligible households by establishing the
respondents family size and annual family income,
27
then selecting only
re:pcncenI: LeIween Ihe cge: cf 1 Ic 4 wiIh fcmi|y inccme: |cwer Ihcn
44 enhancing patient-centered care
200 percent of the FPL.
28
In households that were reached by landline,
respondents were randomly selected from the age-qualifying household
residents by asking for the male or female with the most recent birthday.
Interviews in the High Latino and Listed Low-Income strata were initiated by
bilingual interviewers. All interviews were conducted using the CATI system,
ensuring that questions followed logical skip patterns and that complete
dispositions of all call attempts were recorded.
In order to maximize survey response, SSRS enacted the following
prccecure: curing Ihe fe|c pericc:
- Each non-responsive number not already set up with a callback
(answering machines, no answers and busies) was called approximately
eight times, varying the times of day and days of the week that callbacks
were placed using a programmed differential call rule.
- Interviewers explained the purpose of the study and offered to give the
respondent the name of the sponsor at the completion of the interview.
- Respondents were permitted to set the schedule for a return call.
- The study offered reimbursement of $5 for any cell phone respondent
who mentioned concerns with the costs of cell phone usage.
- Respondents who initially refused to participate in the survey but were
considered soft refusals (respondents who simply hung up the phone,
stated the timing was bad or expressed disinterest in participating) were
contacted at least once more and offered a $10 participation incentive.
procedures for identifying healthcare facility usage
The survey included a highly detailed effort to identify usage of various types
of healthcare facilities. Respondents were asked if they usually go for health
ccre Ic c Kci:er FermcnenIe fcci|iIy, c privcIe cccIcr: cffce, c ccmmuniIy
clinic or health center, a hospital or someplace else. (These options were
cfferec in rcnccmizec crcer, wiIh :cmep|cce e|:e" c|wcy: |c:I.)
Those who said they have no usual place of care (5 percent) were asked
where they last went for care (using the same options listed above), and
whether it was in California. Those who said they went for care to a non-
professional location (e.g., a relative or friend) were asked where they go
for professional care.
Respondents who said they see a doctor were asked if that was a
privcIe cccIcr: cffce cr c cccIcr cI cne cf Ihe cIher |i:Iec fcci|iIy Iype:.
Respondents who said they use a hospital for care were asked if that was a
hospital clinic or a hospital emergency room. If a hospital clinic, they were
asked the type of hospital, county or private/religious.
enhcncing pcIienI-cenIerec ccre 45
The CATI program included codes for more than 800 CCHCs or hospital-
based clinics. Those who said they use a clinic were asked the clinics name
and location. These were compared with a list of California community
clinics and health centers compiled by the California Primary Care
Association (CPCA) and a list of California public hospital clinics compiled
by the California Association of Public Hospitals and Health Systems (CAPH).
For clinics not initially matched to the lists, respondents were asked if the
clinic was operated by a hospital. If yes, they were asked the type of
hospital, county or private/religious. If the clinic was not operated by a
hospital, they were asked if it was run by a county/city, or privately.
All clinics that did not match to the CPCA and CAPH lists during the
interview were later back-checked to ensure the lack of match wasnt due
to a misspelling or the respondents use of a shortened version of a clinic
ncme. C|inic Iype wc: furIher ccnfrmec fcr cmLigucu: cccing Ly inIerneI
searches or by directly calling the clinics named.
Some facilities were not subcategorized, either because the respondent
prcvicec in:uffcienI infcrmcIicn cr Leccu:e Iheir fcci|iIy Iype cic ncI
fall into any of the other categories. These were coded, using available
infcrmcIicn, c: c|inic, cIher/unkncwn Iype," hc:piIc| c|inic, cIher/
unkncwn Iype," hc:piIc|, un:pecifec" cr :cmep|cce e|:e."
This procedure produced the following breakdown of facility usage:
C|inic:, 43 percenI: privcIe cccIcr: cffce:, 27 percenI: Kci:er FermcnenIe,
13 percent; and hospital emergency rooms, 10 percent. Remaining
ccIegcrie: were hc:piIc|, un:pecifec, 1 percenI: :cmep|cce e|:e, 4 percenI:
never have received health care, 1 percent; and no opinion, 1 percent.
Clinics were subcategorized as follows: CCHCs, 17 percent; public hospital
clinics, 9 percent; clinic, other/unknown type, 7 percent; private clinics,
4 percenI: privcIe/re|igicu: hc:piIc| c|inic:, 4 percenI: ccunIy cr ciIy c|inic:,
2 percent; and hospital clinic, other/unknown type, 1 percent.
CCHC estimates
The 2011 BSCF survey estimated that 11 percent of the population used CCHCs,
vs. the 2012 estimate of 17 percent. Given this difference, SSRS and Langer
Research undertook a highly detailed review of all procedures related to this
mec:uremenI - :cmp|ing, ue:Iicnncire, fe|c wcrk, cccing prcIccc|: cnc
weighting in comparison to the 2011 survey. SSRS took the additional step of
re-ccnIccIing 4 c|inic pcIienI:, c|| cf whcm ccnfrmec Iheir c|inic Iype.
Ihere wc: e::enIic||y nc chcnge in cverc|| prcvicer-Iype c|c::ifccIicn:.
C|inic u:er: cverc|| were 43 percenI cf Ihe :cmp|e in 2012, 44 percenI in
2011: privcIe cccIcr: cffce pcIienI:, 27 v:. 28 percenI: Kci:er FermcnenIe
patients, 13 vs. 12 percent; hospital ER, 10 percent both times. The only
change of any size was in the clinic subgroup of CCHC users, with slight
numerical declines in use of other clinic types.
4 enhancing patient-centered care
3/3c/4/4c. Where cc ycu u:uc||y gc when ycu cre :ick cr neec hec|Ih ccre
fcr cny rec:cn - {Kci:er), {c privcIe cccIcr: cffce), {c ccmmuniIy c|inic
or health center), (a hospital) or someplace else? (IF NO USUAL PLACE)
Wheres the last place you went?
4/08/12 4/25/11 Difference
Kci:er FermcnenIe 13% 12% +1
DccIcr: cffce 27 28 -1
Clinic NET 43 44 -1
Community clinic/health center 17 11 +6
Public hospital clinic 9 10 -1
Private hospital clinic 4 5 -1
Hospital clinic other/unknown type 1 1 =
County/city clinic 2 5 -3
Private/other clinic 4 5 -1
Clinic other/unknown type 7 8 -1
Hospital emergency room 10 10 =
Hc:piIc| un:pecifec 1 2 -1
Someplace else 4 2 +2
Never have gone for health care 1 2 -1
No opinion 1 1 =
Numerical increases in CCHC use was found across almost all groups
in 2012 vs. 2011; they were largest in three related populations: Spanish
speakers, noncitizens and the lowest-income respondents.
Differences did appear in other estimates in 2012 vs. 2011, e.g., -7 points
in non-employment, +5 in full-time employment, -6 in ratings of personal
hec|Ih c: gccc" cnc +5 in :Ircng" preference ncI Ic hcve cn euc|
:cy. CIher fgure: mcIchec c|c:e|y: neI prcvicer Iype, rcIing: cf currenI
care provider, overall interest in an equal say, prevalence of a disability or
chronic condition, insurance type, marital status and education all were
within 2 points year-to-year.
NcIhing wc: icenIifec in Ihe :urvey ce:ign cr execuIicn IhcI crecIec Ihe
chcnge in Ihe CCHC e:IimcIe. Scme cf iI mcy refecI cn ccIuc| increc:e in
CCHC usage, albeit presumably not at this level; the rest seems attributable
to sampling variation.
personal doctor estimate
There was a deliberate change in approach to measurement of the
prevc|ence cf hcving c per:cnc| cccIcr, re:u|Iing in c 47 percenI e:IimcIe
in the 2012 survey vs. 57 percent in 2011.
enhcncing pcIienI-cenIerec ccre 47
ln 2011, curing fe|c wcrk preIe:I:, :cme re:pcncenI: whc :cic Ihey wenI
Ic c privcIe cccIcr: cffce were ccnfu:ec cr cnncyec when c:kec if Ihey
had a regular personal doctor. We elected to automatically code those
who said they went to a private doctor as having a personal doctor.
Upon reconsideration in 2012, the autocode was dropped. There were no
IrcuL|e repcrI: frcm Ihe fe|c, inciccIing Ihe 2011 ccju:ImenI hcc Leen
unnece::cry. Mcrecver, 32 percenI cf privcIe cccIcr: cffce pcIienI: in
2012 said they did not have a regular personal doctor.
Had the autocode been retained, the 2012 estimate of individuals with a
regular private doctor would have been 55 percent overall, essentially the
:cme c: 2011: 57 percenI. We ccnc|uce, hcwever, IhcI 47 percenI i: Ihe
better estimate.
weighting procedures
A multi-stage weighting design was applied to ensure an accurate
representation of the target population. Weighting involved the
following stages:
1. Sample design correction. In order to correct for over- or undersampling
of each of the 12 stratum-by-area landline cells, each landline case was
assigned a weight equal to the estimated percentage of the cell among
landline-qualifying households divided by the percentage of the cell
among completed landline interviews. For example, cases in the Residual-
LA cell received a weight equal to their estimated share among low-
income households (22 percent) divided by their share among the landline
interviews (10 percent). Using more exact values, the calculation for the
weight for this cell (W
resid-LA
), is:
W
resid-LA
=.21783/.10032=2.17131.
Cell phone design weights were based on the three sampling areas. The
estimated share of target cell phone completes was based on the percent
of CPO households in each area. The percent of qualifying low-income
hcu:ehc|c: wc: Ihen e:IimcIec Lc:ec cn Ihe ccIuc| ccIc {uc|ifec
hcu:ehc|c: civicec Ly uc|ifec+unuc|ifec). WeighI: were Ihen c::ignec Ic
each cell phone case equal to the estimated percent of qualifying households
in the area divided by the areas percentage of cell phone interviews.
48 enhancing patient-centered care
2. Within-household selection correction. This stage corrected for the
uneuc| prcLcLi|iIie: ccu:ec Ly :cme hcu:ehc|c: hcving mcre uc|ifec
ccu|I: Ihcn cIher:. Hcu:ehc|c: wiIh c :ing|e ccu|I cge 1 Ic 4 receivec
a weight of 1, whereas households with two or more qualifying adults
received a weight of 2. Cases were adjusted so that the sum of this weight
totaled the unweighted sample size. Cell phone respondents were given
the mean landline weight (1).
The product of these two corrections (design weight, within-household
correction) was then calculated as the sampling weight, or baseweight.
3. Fost-strot|0cot|on we|ght|ng. With the baseweight applied, the sample was
puI Ihrcugh iIercIive prcpcrIicnc| fIIing {lFF, cr 'rcking), in which Ihe :cmp|e
wc: Lc|cncec Ic refecI Ihe kncwn ci:IriLuIicn cf Ihe IcrgeI pcpu|cIicn
c|cng :pecifc cemcgrcphic pcrcmeIer:. Ihe:e pcrcmeIer: were Lc:ec cn
the 2011 American Community Survey (ACS) for the state of California, based
cn re:icenI: cge 1 Ic 4 cnc memLer: cf fcmi|ie: wiIh inccme: |e:: Ihcn 200
percent FPL. In addition, a balancing target was set for the CPO population,
based on an estimate provided by Dr. Stephen Blumberg of the Centers for
Disease Control and Prevention, a leading CPO researcher.
Ihe weighIing pcrcmeIer: u:ec were cge {1-2, 30-3, 40-4 cnc 50-4):
education (less than high school, high school, some college and college or
more); race (white non-Latino, African-American non-Latino, other non-
Latino and Latino); sex by Latino status (i.e., Latino-male, Latino-female,
non-Latino-male, non-Latino-female); region (Northern and Sierra counties,
Greater Bay Area, Sacramento area, San Joaquin Valley, Central Coast
area, Los Angeles County and other Southern CA);
29
and percent CPO.
4. Weight truncation (trimming). ln crcer Ic minimize Ihe infuence cf cuI|ier
cases on the data and to contain variance, the weights were truncated so
IhcI nc cne cc:e receivec c weighI grecIer Ihcn 4.0 cr :mc||er Ihcn .25.
Ihe ce:ign effecI i: 1.4.
enhcncing pcIienI-cenIerec ccre 4
ACS estimates and unweighted and weighted sample percentages
are listed below. (Percentages for several parameters do not add
Ic 100 percenI Leccu:e cf ccnI kncw" re:pcn:e:.)
table 2. acs estimates and unweighted and weighted sample percentages
ACS Unweighted Sample Weighted Sample
Race
White non-Latino 28.0% 29.0% 27.3%
Black non-Latino 7.1 8.8 7.0
Latino 52.8 51.3 53.9
Other non-Latino 12.1 .4 11.6
Sex/race
Male, non-Latino 21.1 24.5 21.6
Female, non-Latino 25.3 23.1 24.8
Male, Latino 25.1 23.2 25.4
Female, Latino 27.3 29.3 28.1
Education
Less than high school 33.3 33.0 33.1
High-school education 26.0 25.6 26.1
Some college 29.9 25.2 29.9
College graduate + 10.9 12.0 10.9
Age
19-29 33.5 23.6 33.3
30-39 23.4 18.3 23.2
40-4 21.0 21.1 21.0
50-4 21.2 37.0 22.6
Region
Sierra/Northern Counties 4.4 7.1 4.5
Greater Bay Area 14.4 10.6 13.7
Sacramento Area 5.4 5.9 5.4
San Joaquin Valley 12.9 13.4 12.4
Central Coast 5.6 6.2 5.5
LA County 30.4 27.9 29.2
Other Southern CA 27.0 27.1 25.7
Phone status
Cell phone only 43.2 31.8 43.1
Some landline use 5.4 68.1 56.7
response rate
The response rate for this study was calculated at 27.6 percent for
the landline sample and 22.1 percent for the cell phone sample
u:ing Ihe Fe:pcn:e FcIe 3" fcrmu|c cf Ihe /mericcn /::ccicIicn
for Public Opinion Research.
50 enhancing patient-centered care
Following is a full disposition of the sample selected for this survey:
Landline Cell Total
Eligible, Interview (Category 1)
Complete 704 301 1005
Eligible, non-interview (Category 2)
Refusal (Eligible) 303 57 360
Answering machine household 32 20 52
Physically or mentally unable/incompetent 6 1 7
Language problem 13 86 99
No interviewer available for needed language 0 3 3
Unknown eligibility, non-interview (Category 3)
Always busy 532 1632 2164
No answer 8696 3866 12562
Technical phone problems 144 20 164
Call blocking 8 0 8
No screener completed 234 2126 4760
Housing unit, unknown if eligible 2623 4085 6708
Not eligible (Category 4)
Fax/data line 1814 40 2223
Non-working number 28517 6865 35382
8u:ine::, gcvernmenI cffce, cIher crgcnizcIicn: 47 609 1556
No eligible respondent 1930 1311 3144
Total phone numbers used 4803 21304 70294
endnotes
25 The federal poverty level is calculated on the basis of family size and the
combined income of family members.
26 These numbers were then adjusted based on the actual share of qualifying
households found in each stratum during the course of the survey.
27 If respondents were uncertain about their annual income, they were
asked about the corresponding monthly income.
28 Fcmi|ie: were cefnec in ccccrccnce wiIh Ihe cefniIicn cpp|iec Ly Ihe U.S.
Census bureau and FPL was based on the 2012 HHS Poverty Guidelines.
2 Fegicn: were cefnec fc||cwing Ihe Cc|ifcrnic Hec|Ih lnIerview
Survey (CHIS) operationalization of regions. Each California county
was assigned to one of the seven regions. County was derived from
respondents self-reported ZIP code. When respondents refused to
identify their ZIP codes, region was derived from the ZIP code associated
with their landline exchange. Cell phone respondents who declined to
provide their zip code were considered region-unknown.
enhancing patient-centered care 51
appendix a
statistical modeling
Several sections of this study refer to regression analyses used to measure
the relationships among various attitudes, demographic variables, and
precicIec cuIccme:, :uch c: pcIienI engcgemenI, ccnfcence in
healthcare decision making abilities, and feeling informed about ones
health. This appendix provides details of these statistical analyses.
A regression is a form of statistical modeling that measures the independent
strength of the relationship between each predictor with the posited
outcome, known as the dependent or outcome variable. While it does
not establish causality, a regression reveals the strength of the relationship
between a predictor (e.g., feeling informed about ones health) and the
dependent variable (e.g., patient engagement), with other predictors in the
model held constant.
Mcny vcricL|e: mcy Le re|cIec Ic c given cuIccme. / regre::icn icenIife:
which of them explain the most unique variance in the dependent variable,
after adjusting for these other relationships. Below we describe the variables
used in the regression analyses reported in this study, followed by details of
the regression results.
key variables
Overall health (W1): / ccnIinucu: vcricL|e refecIing re:pcncenI: :e|f-
reported health status, with 1 = poor health and 5 = excellent health (Mean
= 3.1, Standard Deviation = 1.2).
Prioritize health (Q1): A binary variable indicating whether or not
respondents say that taking care of their health is their top priority (0 = not
health, 1 = health).
Number of medical appointments in the past year (Q2): A continuous
variable indicating the number of times respondents have had a medical
cppcinImenI in Ihe pc:I yecr {M = 4.3, SD = 7.).
28
Facility type (Q3-4): The type of facility used by each respondent was
coded using a series of binary variables indicating, separately, whether he
or she received care at a community clinic and health center (CCHC), or
ncI: c Kci:er FermcnenIe fcci|iIy, cr ncI: c privcIe cccIcr: cffce, cr ncI:
a public clinic, or not; some other type of clinic (not CCHC or public) or
not; and a hospital emergency room (ER), or not. For each facility type,
respondents were coded 1 if a patient, 0 if not.
Has a personal connection (Q7): A binary variable indicating whether or
not respondents say there is someone at their healthcare facility who knows
them well (0 = no, 1 = yes).
52 enhancing patient-centered care
Has a personal doctor (Q10): A binary variable indicating whether or not
the respondents have a regular personal doctor (0 = no personal doctor,
1 = personal doctor).
Want a personal doctor (Q10-11): A binary variable indicating whether
or not respondents desire a personal doctor (0 = have a personal doctor
already or lacks one, but say having one is not important to them, 1 = does
not have a personal doctor but wants one).
Continuity in a care provider (Q13): A continuous variable reflecting
how frequently respondents see the same healthcare provider when
they have an appointment on a scale from 1 = never to 5 = every time
(M = 3.66, SD = 1.28).
Desire for continuity in a care provider (Q14): A binary variable indicating
whether or not respondents would like to be able to see the same
healthcare provider more often (0 = do not think seeing the same provider
more often is important or already see the same provider every visit, 1 =
would like to see the same provider more often.
Usually see a doctor for care (Q15): A binary variable indicating whether
respondents normally see a doctor or usually see a non-physician provider
(e.g., a nurse or physicians assistant) for routine care (0 = usually see a
non-physician provider for routine care, 1 = usually see a doctor, or both a
doctor and a non-physician provider for routine care).
Has a health navigator (Q20): A binary variable indicating whether or not
respondents currently have a health navigator or health coach (0 = do not
have a health navigator, 1 = have a health navigator).
Has team care (Q23): A binary variable indicating whether or not
respondents currently have team-based care (0 = do not have team-based
care, 1 = have team-based care).
Impact of national seal (Q31): / ccnIinucu: vcricL|e refecIing Ihe impccI
a seal of approval from a national healthcare association would have on
respondents with 1 = less likely to go there, 2 = make no difference and 3 =
mcre |ike|y Ic gc Ihere {M = 2.3, SD = .4).
Patient engagement in care decisions (Q35): A continuous variable
refecIing hcw much :cy Ihe re:pcncenI fee|: Ihey currenI|y hcve in
decisions about their health care on a scale from 1 = no say to 5 = a great
cec| cf :cy {M = 3.8, SD = 1.04).
Desire for greater say (Q36): A binary variable indicating whether or not
respondents want more of a say in their healthcare decisions (0 = current
say is about right, or would like less of a say, 1 = want more of a say in
healthcare decisions).
enhancing patient-centered care 53
Informed about health (Q37): / ccnIinucu: vcricL|e refecIing hcw
informed the respondents feel about their health and any health problems
Ihey mcy hcve cn c :cc|e in which 1 = ncI infcrmec cI c|| cnc 4 = very
informed (M = 3.28, SD = .83).
Frequency use the internet for health information (Q38-39): A continuous
vcricL|e refecIing hcw freuenI|y Ihe re:pcncenI: u:e Ihe inIerneI Ic
access health information on a scale in which 0 = never have used the
internet to access health information and 5 = use the internet very often to
ccce:: hec|Ih infcrmcIicn {M = 2.0, SD = 1.41).
Index of interest in more health information (Q40a-d): A composite measure
of interest in having more information about the pros and cons of different
tests or treatments, the training and experience of local health professionals,
patient satisfaction ratings for local healthcare facilities, and quality ratings
for local healthcare providers. These four items were recoded so that 1 =
ncI inIere:Iec cI c|| cnc 4 = very inIere:Iec cnc Ihen cvercgec Ic fcrm
the index (_ = .83), which ranges from 1 (indicating no interest in more
infcrmcIicn cn cny cf Ihe fcur Icpic:) Ic 4 {inciccIing :Ircng inIere:I in mcre
infcrmcIicn cn c|| fcur Icpic:). Ihe cvercge incex vc|ue i: M = 3.28, SD = .74.
Con0dence con moke heo|thcore dec|s|ons [Q41}: A continuous variable
refecIing hcw ccnfcenI re:pcncenI: cre in Iheir cLi|iIy Ic mcke ceci:icn:
cLcuI Iheir hec|Ih ccre cn c :cc|e where in which 1 = ncI cI c|| ccnfcenI
cnc 4 = very ccnfcenI {M = 3.45, SD = .70).
Responsible for health: Me (Q42): A binary variable indicating whether or
not respondents think they are ultimately responsible for managing their
health, rather than the care provider (0 = provider or both provider and me
responsible for health, 1 = me responsible for health).
Frequency provider explains things in a way you can understand (Q43): A
ccnIinucu: vcricL|e refecIing hcw cfIen re:pcncenI: fee| Iheir hec|Ihccre
provider explains things in a way they can understand on a scale ranging
frcm 1 = never Ic 5 = every Iime {M = 4.10, SD = 1.02).
Comfort asking provider questions (Q44): / ccnIinucu: vcricL|e refecIing
how comfortable respondents feel asking the healthcare provider questions
about their health or treatment on a scale in which 1 = very uncomfortable
cnc 4 = very ccmfcrIcL|e {M = 3.4, SD = .75).
Has misunderstood care provider (Q45): A binary variable indicating
whether or not there has been a time when the respondents didnt follow
a healthcare providers advice or treatment plan because they didnt
understand what they were supposed to do (0 = have not misunderstood
care provider, 1 = have misunderstood care provider).
54 enhancing patient-centered care
Has a disability (Q48): A binary variable indicating whether or not
respondents have a disability or chronic medical condition (0 = do not have
a disability or chronic condition, 1 = have a disability or chronic condition).
Demographic variables: In addition to the variables listed above, the
following demographic variables were included in all models unless otherwise
indicated: insurance status, employment status, gender, age, household size,
relationship status, education, race/ethnicity, language mainly spoken at
home (English vs. not English), income, and citizenship status. All models also
controlled for regional differences. All demographic variables were coded
as binary variables by category except for age, household size, income, and
education, which were coded as continuous variables.
modeling details and results
model 1: patient engagement in care decisions
To determine what factors independently predict patients involvement in
their medical care, we performed a regression with patient engagement in
care decisions entered as the outcome variable and the following variables
inc|ucec c: precicIcr vcricL|e: {:ee cLcve fcr cefniIicn:): cverc|| hec|Ih,
prioritize health, number of medical appointments in the past year, facility
type, has a personal connection, has a personal doctor, continuity in a care
provider, usually see a doctor for care, has a health navigator, has team care,
informed about health, frequency use the internet for health information,
ccnfcence ccn mcke hec|Ihccre ceci:icn:, re:pcn:iL|e fcr hec|Ih: me,
frequency provider explains things in a way you can understand, comfort
asking provider questions, and has a disability. All demographic variables listed
above also were included. Table 1 shows the results of this model (Model 1).
table 1. key predictors of patient engagement
in care decisions
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
frequency provider explains things in a way
you can understand
.16 4.1***
ccnfcence ccn mcke hec|Ihccre ceci:icn: .13 3.75***
informed about health .12 3.24**
comfort asking provider questions .10 2.4**
age .08 1.80+
has a personal connection .06 1.80+
Model R
2
= .19, p < .001
Here cnc Le|cw: ***p < .001, **p < .01, *p < .05, +p < .10
model 2: informed about health
To determine what factors independently predict feeling informed about
ones health, we performed a regression with informed about health as the
outcome variable. Model 2 used the same predictors as Model 1, with the
excepIicn IhcI ccnfcence ccn mcke hec|Ihccre ceci:icn: cnc infcrmec
about health were both omitted as predictors. See Table 2 for the results.
enhancing patient-centered care 55
table 2. key predictors of informed about health
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
frequency provider explains things in a way
you can understand
.23 .1***
comfort asking provider questions .20 5.87***
income .12 3.23**
has a personal connection .10 2.**
continuity in a care provider .09 2.47*
race/ethnicity: white .08 1.87+
prioritize health .06 2.00*
Model R
2
= .32, p < .001
mcce| 3: ccnfcence ccn mcke hec|Ihccre ceci:icn:
A similar model was performed to determine what factors independently
precicI re:pcncenI: ccnfcence IhcI Ihey ccn mcke hec|Ihccre ceci:icn:.
Model 3 was identical to Model 2, with the exception that comfort asking
provider questions was removed as a predictor variable while informed
about health and has misunderstood care provider were both added as
predictors. Table 3 shows the results of this regression.
29
IcL|e 3. key precicIcr: cf ccnfcence ccn mcke
healthcare decisions
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
informed about health .22 5.5***
frequency provider explains things in a way
you can understand
.16 4.40***
responsible for health: me .12 3.***
health status .11 2.**
Model R
2
= .19, p < .001
mcce| 4: freuency prcvicer exp|cin: Ihing: in c wcy
you can understand
To determine what factors independently predict the frequency
respondents feel the provider explains things in a way they can understand,
we performed a model similar to Model 3. Frequency provider explains
things in a way you can understand was entered as the outcome variable,
cnc c|| precicIcr: u:ec in Mcce| 3 were u:ec in Mcce| 4 {excepI, cLvicu:|y,
frequency the provider explains things in a way you can understand).
CcmfcrI c:king ue:Iicn: wc: c|:c enIerec c: c precicIcr in Mcce| 4. Fe:u|I:
cre :hcwn in IcL|e 4.
56 enhancing patient-centered care
IcL|e 4. key precicIcr: cf freuency prcvicer exp|cin: Ihing:
in a way you can understand
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
comfort asking provider questions .35 10.3***
informed about health .22 .2***
continuity in a care providerr .14 4.22***
facility: hospital ER -.11 3.43**
gender: male .06 2.11*
has team-based care .06 1.85+
Model R
2
= .35, p < .001
model 5: comfort asking provider questions
The model predicting respondents comfort asking their healthcare provider
ue:Iicn: wc: :imi|cr Ic Mcce| 4, LuI cccec infcrmec cLcuI hec|Ih,
ccnfcence ccn mcke hec|Ihccre ceci:icn:, cnc freuency prcvicer
explains things in a way you can understand as predictors. Results of this
model are shown in Table 5.
30
table 5. key predictors of comfort asking provider questions
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
frequency provider explains things in a way
you can understand
.34 10.34***
ccnfcence ccn mcke hec|Ihccre ceci:icn: .10 .21***
informed about health .16 4.0***
race/ethnicity: white .11 2.4*
has a personal connection .06 1.87+
Model R
2
= .35, p < .001
model 6: index of interest in more health information
To determine what factors independently predict interest in more health-
related information, we entered the index of interest in more health
information as the outcome variable and all the variables entered in Model
1 as predictors. In addition, the following variables were also included as
predictors: impact of national seal, patient engagement in care decisions,
desire for greater say, and have misunderstood care provider. Table 6 shows
the results of this model.
enhancing patient-centered care 57
table 6. key predictors of the index of interest in more
health information
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
ccnfcence ccn mcke hec|Ihccre ceci:icn: .17 4.***
desire for greater say .16 4.5***
want a personal doctor .16 3.81***
impact of national seal .14 4.48***
has a personal doctor .14 2.**
household size .12 3.25**
patient engagement in care decisions .11 3.20**
frequency use the internet for health information .11 3.20**
education .10 2.7**
comfort asking provider questions .10 2.55*
desire for continuity in a care provider .09 2.58*
gender: male -.08 2.5*
Model R
2
= .28, p < .001
model 7: frequency use the internet for health information
To determine the independent predictors of the frequency respondents use
the internet to access health information, we repeated Model 6, only with
frequency use the internet for health information as the outcome variable.
Key precicIcr: cre :hcwn in IcL|e 7.
table 7. key predictors of frequency use the internet
for health information
Standardized
coe|0c|ent [`)
Signi0conce
test (t)
education .28 7.28***
has a disability .13 3.5***
fcci|iIy: Kci:er FermcnenIe .12 3.00**
have misunderstood care provider .11 3.28**
race/ethnicity: latino -.10 2.10*
age -.09 2.13*
speak english .08 1.75+
impact of national seal -.07 2.11*
health status .07 2.00*
Model R
2
= .26, p < .001
mediation models
A mediation model is a series of regressions that can clarify the relationship
between an independent or predictor variable and a dependent variable
by examining potential underlying processes. Essentially, mediation analyses
he|p Ic cn:wer Ihe ue:Iicn cf hcw vcricL|e x infuence: vcricL|e y.
Simple linear regression reveals the direct relationship between an
independent variable and an outcome variable (e.g., that having a
58 enhancing patient-centered care
personal connection is related to increased patient engagement in
care decisions). But there may also be an indirect relationship between
the independent variable and the outcome variable through a third
variable. For example, having a personal connection might be related
to respondents feeling more informed about their health which, in turn,
predicts increased patient engagement in care decisions. Mediation
analyses allow us to explore these potential indirect relationships.
31
Specifcc||y, we hypcIhe:izec IhcI even Ihcugh hcving c per:cnc|
connection has only a weak positive relationship with patient engagement
in care decisions in Model 1, it might have an indirect relationship with
engagement by increasing how informed respondents feel about their
hec|Ih, Iheir ccnfcence Ihey ccn mcke hec|Ihccre ceci:icn:, Iheir ccmfcrI
asking providers questions, and their understanding of the providers
explanations and advice (i.e., the four indicators of patient empowerment).
Since these variables, in turn, predict increased engagement (see Model
1) this would show the importance of connectedness in increasing patient
engagement, albeit by indirect means. We further hypothesized that
continuity might operate in the same way that is, even though it has no
direct effect on engagement in Model 1, it might be indirectly associated
with engagement by increasing the four indicators of empowerment.
Ic Ie:I Ihe mecicIicn mcce|:, we fc||cwec 8crcn cnc Kenny: {18) :Iep:
for mediation, which include the following:
1. Regressing the outcome variable on the independent variable (x A y) to
ccnfrm IhcI Ihe incepencenI vcricL|e {lV) cce: in fccI precicI Ihe cuIccme
of interest when no other variables are included (e.g., that connectedness
predicts engagement when no other variables are entered).
2. Regressing the mediator on the independent variable (x A m) Ic ccnfrm
IhcI Ihere i: c :ignifccnI re|cIicn:hip LeIween Ihe Iwc vcricL|e: {e.g.,
that connectedness predicts feeling informed about ones health).
3. Regressing the outcome variable on both the mediator and the
independent variable (x and m A y) Ic ccnfrm IhcI Ihe mecicIcr i: c
:ignifccnI precicIcr cf Ihe cuIccme, cnc IhcI Ihe re|cIicn:hip LeIween
the IV and the outcome variable assessed in Step 1 is reduced once the
mecicIcr i: inc|ucec {e.g., Ic :hcw IhcI fee|ing infcrmec i: c :ignifccnI
predictor of engagement, and that the effect of connectedness on
engagement is less than it was in Step 1).
We then computed a Sobel t-test, which tests whether the indirect effect
cf Ihe lV cn Ihe cuIccme Ihrcugh Ihe mecicIcr i: :IcIi:Iicc||y :ignifccnI. lf c
:IcIi:Iicc||y :ignifccnI mecicIicn i: ccnfrmec, iI mecn: IhcI Ihe effecI cf Ihe
IV on the outcome variable (shown in Step 1) is at least partially (or entirely)
cue Ic Ihe fccI IhcI Ihe lV infuence: Ihe mecicIcr, which in Iurn infuence:
the outcome variable. In other words, the mediator or mediators explain
Ihe prcce:: Ihrcugh which Ihe lV infuence: Ihe cuIccme.
enhancing patient-centered care 59
The table below shows the results for each step of the mediation separately
for each of the two independent variables (continuity and connectedness)
cnc Ihe fcur pcIenIic| mecicIcr: {infcrmec cLcuI hec|Ih, ccnfcence
can make healthcare decisions, comfort asking provider questions, and
frequency provider explains things in a way you can understand), a total of
eight mediation models. As can be seen, in each case the indirect effect of
ccnnecIecne:: cnc ccnIinuiIy Ihrcugh Ihe mecicIcr i: :IcIi:Iicc||y :ignifccnI.
Ihe fnc| mcce|, :hcwn cI Ihe enc cf Ihe IcL|e, ccmLine: ecch cf Ihe
incivicuc| mecicIicn: Ic :hcw Ihe cc||ecIive effecI. Specifcc||y, Ihe fr:I :Iep
shows that when connectedness and continuity alone are regressed on
pcIienI engcgemenI, ecch i: c :IcIi:Iicc||y :ignifccnI precicIcr. Hcwever
when the four empowerment variables are also included in the model, the
effect of continuity is eliminated and the effect of connectedness is cut
in hc|f. Ihi: :hcw: IhcI ccnnecIecne:: cnc ccnIinuiIy hcve c :ignifccnI
impact on patient engagement in large part because they increase
patients feelings of empowerment.
table 8. mediation models
standardized
coe|0c|ent [`)
signi0conce
test (t)
mediation model 1: connectedness A information A engagement
step 1: connectedness A engagement .18 5.75***
step 2: connectedness A information .26 8.53***
step 3: connectedness + information A engagement
connectedness .11 3.50***
information .27 8.***
Sobel test of indirect effect .08***
mediation model 2: Continuity A Information A Engagement
step 1: continuity A engagement .15 4.7***
step 2: continuity A information .27 8.***
step 3: continuity + information A engagement
continuity .07 2.34*
information .28 8.8***
Sobel test of indirect effect .30***
mediation model 3: connectedness A con0dence A engagement
step 1: connectedness A engagement .18 5.75***
step 2: connectedness A ccnfcence .12 3.0***
:Iep 3: ccnnecIecne:: + ccnfcence A engagement
connectedness .15 4.2***
ccnfcence .24 7.***
Sobel test of indirect effect 3.51**
60 enhancing patient-centered care
mediation model 4: continuity A con0dence A engagement
step 1: continuity A Engagement .15 4.7***
step 2: continuity A Ccnfcence .10 3.1**
:Iep 3: ccnIinuiIy + Ccnfcence A Engagement
continuity .12 4.08***
ccnfcence .25 8.14***
Sobel test of indirect effect 3.01**
mediation model 5: connectedness A understanding A engagement
step 1: connectedness A Engagement .18 5.75***
step 2: connectedness A Understanding .18 5.88***
step 3: connectedness + Understanding A Engagement
connectedness .13 4.12***
understanding .30 .75***
Sobel test of indirect effect 5.04***
mediation model 6: continuity A understanding A engagement
step 1: continuity A Engagement .15 4.7***
step 2: continuity A Understanding .27 8.71***
step 3: continuity + Understanding A Engagement
continuity .07 2.21*
understanding .30 .2***
Sobel test of indirect effect .51***
mediation model 7: connectedness A comfort A engagement
step 1: connectedness A engagement .18 5.75***
step 2: connectedness A comfort .19 5.8***
step 3: connectedness + comfort A engagement
connectedness .13 4.24***
comfort .26 8.55***
Sobel test of indirect effect 4.2***
mediation model 8: continuity A comfort A engagement
step 1: continuity A engagement .15 4.7***
step 2: continuity A comfort .15 4.74***
step 3: continuity + comfort A engagement
continuity .11 3.54***
comfort .27 8.82***
Sobel test of indirect effect 4.11***
enhancing patient-centered care 61
combined models predicting patient engagement
step 1: connectedness and continuity alone
connectedness .15 4.44***
continuity .10 3.11**
step 2: connectedness and continuity with the four
empowerment variables
connectedness .07 2.3*
continuity .02 .54
informed .13 3.7***
ccnfcence .13 4.27***
understanding .16 4.***
comfort .10 2.83**
Ncte. 8eccu:e c| :pcce ccn:t|c|nt: we u:e :nc|tenec vc||cc|e ncne:. Ccnnectecne:: = nc: c pe|:cnc| ccnnect|cn. |n|c|nct|cn
= informed about health, engagement = patient engagement in care decisions, continuity = continuity in a care provider,
ccn|cence = ccn|cence ccn ncke nec|tncc|e cec|:|cn:. unce|:tcnc|ng = ||equency p|cv|ce| exp|c|n: tn|ng: |n c wcy ycu ccn
unce|:tcnc. cnc ccn|c|t = ccn|c|t c:k|ng p|cv|ce| que:t|cn:.
endnotes
28 The mean was skewed by one respondent who indicated he/she had
had more than 300 medical appointments in the past year. This response
was removed.
2 Ccnfcence ccn mcke hec|Ihccre ceci:icn:" hcc c :ignifccnI
negative skew. We transformed the variable to eliminate this skew,
reran the regression and found nearly identical results. Since the same
precicIcr: were :IcIi:Iicc||y :ignifccnI, we pre:enI Ihe re:u|I: cf Ihe ncn-
transformed regression for ease of interpretation.
30 CcmfcrI c:king prcvicer" ue:Iicn: hcc c :ignifccnI negcIive :kew.
We transformed the variable to eliminate the skew and reran the
regression using the transformed variable. The results were essentially
Ihe :cme: c|| :ignifccnI precicIcr: :hcwn in IcL|e 5 remcinec :c u:ing
the transformed variable. We present the results of the non-transformed
regression for ease of interpretation.
31 As with regression analyses more broadly, mediation analyses cannot
conclusively establish causality.
62 enhancing patient-centered care
appendix b
topline data report
This appendix provides complete question wording and topline results for
data included in this report on the 2012 Blue Shield of California Foundation
survey of low-income Californians. Some material was previously released
in Ihe fr:I repcrI frcm Ihi: :urvey, enIiI|ec Connectedness and Continuity:
Patient-Provider Relationships Among Low-Income Californians.
*= |e:: Ihcn 0.5 percenI
1-28, 4-47 previcu:|y re|ec:ec cr he|c fcr re|ec:e.
29. How much does it matter to you that the healthcare provider and staff
at your healthcare facility [ITEM] is that very important to you, somewhat
important, not so important or not important at all?
Important NET Not Important NET
Very Somewhat Not so At all No opinion
a. know whats going on in
your community
417 34 75 13 11 24 *
b. understand your cultural or
ethnic background
39 28 67 15 18 33 1
c. (asked if not primarily an english
speaker) are able to speak with
you in the language you prefer
76 16 92 2 6 8 *
30 previously released.
31. If a healthcare facility in your area had a seal of approval from a
national healthcare association would that make you (more likely) to go
there, (less likely) to go there, or wouldnt it make a difference?
More likely No difference Less likely No opinion
477 43 9 2
32. Thinking about healthcare decisions, is it your preference to (leave
decisions about your health care mostly up to the doctor or nurse), or would
you prefer to (have an equal say with the doctor or nurse in decisions about
your health care)? Do you feel that way strongly, or somewhat?
Leave to the doctor NET Have an equal say NET
Strongly Somewhat Somewhat Strongly No opinion
29% 10 39 10 48 59 1
enhancing patient-centered care 63
33. (IF LEAVE TO THE DOCTOR, Q32) Is that more because (you feel you
dont have enough information to make the right decision) or more
because (you feel that making care decisions is the doctors responsibility,
not yours)?
Not enough
information
Doctors
responsibility
Both
(vol.)
Other
(vol.)
No
opinion
51% 40 4 1 3
32/33 NET:
Prefer to leave decisions to the doctor NET
Not enough
information
Doctors
responsibility
Both
(vol.)
Other
(vol.)
Prefer equal
say
No
opinion
20% 16 2 1 39 59 1
34. {lF DCESNI W/NI ECU/L S/Y, C32) Ncw imcgine Ihe cccIcr hc:
selected treatment options for you a choice of things you might do, any
of which is medically appropriate and youve been given information that
you understand about these options. In this situation, would you prefer to
(leave the decisions mostly up to the doctor or nurse) or would you prefer to
(have an equal say with the doctor or nurse in the decisions)?
Leave to
the doctor
Have an
equal say
Have most of
the say (vol.)
No
opinion
427 54 1 3
32/34 NEI:
Prefers equal say or more NET
Always If given options Prefer to leave to the doctor No opinion
59% 22 81 17 3
35. How much of a say do you feel you currently have in decisions about
your health care a great deal of say, a good amount, just some or only
a little?
Has more say NET Has less say NET
Great deal Good amount Some Little None (vol.) No opinion
38% 34 72 14 12 1 27 1
36. Regardless of whether or not you want an equal say, would you like
more of a say in decisions about your health care than you have now, less
of a say, or is it about right?
More say About right Less say No opinion
33% 58 7 2
4 enhancing patient-centered care
37. In general, how informed do you feel about your health and any health
problems you may have very informed, somewhat informed, not so
informed or not informed at all?
Informed NET Not informed NET
Very Somewhat Not so At all No opinion
487 36 84 11 4 16 *
38. Have you ever used the internet to access health information, or not?
Yes No No opinion
437 56 *
Ccmpcre Ic Kci:er Fcmi|y FcunccIicn/Wc:hingIcn Fc:I ncIicnc| :cmp|e:
Yes No No opinion
02/09/11 60% 39 *
39. (IF HAS USED THE INTERNET TO ACCESS HEALTH INFORMATION, Q38)
Do you do that very often, somewhat often, just occasionally or rarely?
Often NET Not often NET
Very Somewhat Occasionally Rarely No opinion
23% 21 44 40 16 56 *
38/39 NET:
Have used internet to access health information
Often NET Not often NET NET
Very Somewhat Occasionally Rarely Have not No opinion
10% 9 19 17 7 24 43 56 *
40. Hcw inIere:Iec, if cI c||, wcu|c ycu Le in hcving mcre infcrmcIicn cLcuI
[ITEM] very interested, somewhat interested, not so interested or not
interested at all?
Interested NET Not interested NET
Very Somewhat Not so At all No opinion
a. the pros and cons of different tests
or treatments you might need
58% 30 88 4 8 11 *
b. the training and experience of the
health professionals in your area
52 32 84 8 7 15 1
c. patient satisfaction ratings for the
healthcare facilities in your area
45 38 83 7 9 16 1
d. quality ratings for providers in your area
like with more stars for the better ones
48 35 83 8 8 16 1
enhancing patient-centered care 65
41. Hcw ccnfcenI cre ycu in ycur cLi|iIy Ic mcke ceci:icn: cLcuI ycur hec|Ih
ccre - very ccnfcenI, :cmewhcI ccnfcenI, ncI :c ccnfcenI cr ncI ccnfcenI
at all?
Con0dent NET Not con0dent NET
Very Somewhat Not so At all No opinion
56% 36 92 6 2 8 *
42. Cverc||, whc cc ycu fee| i: mc:I re:pcn:iL|e fcr mcncging ycur hec|Ih - {ycu
yourself) or (your healthcare provider)?
Me My provider Both (vol.) No opinion
73% 21 5 1
43. When ycu gc fcr mecicc| ccre, hcw cfIen cce: Ihe hec|Ihccre prcvicer
explain things in a way you understand every time, most of the time, some of
the time, rarely or never?
Often explains NET Rarely explains NET
Every time Most of the time Some of the time Rarely Never No opinion
447 31 76 17 4 3 7 *
44. Hcw ccmfcrIcL|e cr unccmfcrIcL|e cc ycu fee| c:king Ihe hec|Ihccre
provider questions about your health or treatment very comfortable,
somewhat comfortable, somewhat uncomfortable or very uncomfortable?
Comfortable NET Uncomfortable NET
Very Somewhat Somewhat Very No opinion
62% 28 89 7 3 10 1
45. Hc: Ihere ever Leen c Iime when ycu cicnI fc||cw c hec|Ihccre prcvicer:
advice or treatment plan because you didnt understand what you were
supposed to do, or has that not happened?
Yes No No opinion
19% 80 *
48. Dc ycu hcve cny ci:cLi|iIy cr chrcnic mecicc| ccnciIicn IhcI reuire:
ongoing health care, or not?
Yes No No opinion
29% 71 *
66 enhancing patient-centered care
4. WhcI i: ycur mcin :curce cf hec|Ih in:urcnce ccvercge, if cny
Private health insurance through an employer 22%
Private health insurance that you buy on your own 11
Medi-Cal, also known as Medicaid 25
Any other state health insurance program 5
The V.A., Tri-Care, military, federal insurance 2
Indian Health Service *
Medicare 2
Medicare and Medi-Cal 2
None, you are uninsured 29
No opinion 3
selected demographics:
Sex
Male 477
Female 53
Age
19-29 33%
30-39 23
40-4 21
50-4 23
Relationship status
Married 39%
Living with a partner 15
Widowed 3
Divorced 6
Separated 4
Single 33
Employment status
Employed, full-time 36%
Employed, part-time 21
Not employed NET 41
Retired 4
Homemaker 8
Student 9
Unemployed 14
Disabled 6
Other *
No opinion 2
Education
Less than high school NET 33%
8th grade or less 12
Some high school 21
High school graduate 26
Some college/associates degree 30
College graduate NET 11
Graduated college 10
Post graduate 1
Race/Ethnicity
White, non-Latino 27%
Black, non-Latino 7
Latino NET 54
White Latino 36
Black Latino 13
LcIinc un:pecifec 5
Asian 8
Multiracial 1
Other 2
Income
< $16,000 30%
$16,000-$30,999 47
$31,000-$51,999 15
$52,000+ 2
No opinion 6
enhancing patient-centered care 67
appendix c
full questionnaire
This appendix reproduces the full, formatted questionnaire for Blue Shield of
California Foundations 2012 survey of low-income Californians.
[CONFIRM LANGUAGE AT THE BEGINNING OF THE INTERVIEW]
INTRO [ALL SAMPLE]: Hello. My name is ______________. Im calling from SSRS
and were conducting research on important issues concerning healthcare
in California. Were not selling anything just getting opinions on how to
make health care better for more people. Our questions are for research
cn|y cnc ycur cn:wer: cre :IricI|y ccnfcenIic|.
(IF CELL SAMPLE)
CELL1. May I please ask if Ive reached you on a cell phone, or on a regular
landline phone?
lNIEFVlEWEF NCIE: lF FESFCNDENI /SKS, WHY DC YCU NEED IC KNCW
CELL VS. L/NDLlNE FHCNE S/Y, Sc we ccn mcke :ure c|| pecp|e cre
inc|ucec whcIever phcne Ihey u:e."
1 Cell phone
2 Lcnc|ine phcne IH/NK /ND IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK /ND IEFM.
(IF CELL SAMPLE)
CELL2. Before we continue, are you driving or doing anything that requires
your full attention right now?
1 Ye:, re:pcncenI i: criving/ccing :cmeIhing SEI UF C/LL8/CK
2 No, respondent is not driving/doing something CONTINUE TO CELL3
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
{lF CELL S/MFLE /ND lF FESFCNDENI /SKS /8CUI CF C8JECIS IC CCSI CF
C/LL CF LCSS CF MlNUIES DUFlNG /NY F/FI CF IHE lNIEFVlEW, IYFE CELL"
AT PROMPT TO REACH THE FOLLOWING SCEEEN): We are able to offer you
fve cc||cr: c: reimLur:emenI fcr Ihe u:e cf ycur ce|| phcne minuIe: fcr Ihi:
call. If you complete the full survey, I will ask for your mailing address at the
enc cf Ihe :urvey :c we ccn :enc ycu c check. l: Ihi: CK {CCNIlNUE IC
CELL3 OR TO NEXT QUESTION)
68 enhancing patient-centered care
(IF CELL SAMPLE)
CELL3. So we can ask you the right questions, could you please tell me if you
are 18 or younger, older than 18 but younger than 65 or are you 65 or older?
1 18 cr ycunger IH/NK & IEFM.
2 1 Ic 4
3 5 cr c|cer IH/NK & IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
(IF Q.CELL3 =2)
CELL4. ln whcI :IcIe cc ycu currenI|y |ive
1 California
2 NcI Cc|ifcrnic IH/NK & IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
W1. Id like to ask about your overall health. In general, would you say your
health is excellent, very good, good, fair, or poor?
1 Excellent
2 Very good
3 Good
4 Fcir
5 Poor
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
lNSEFI Ihi: hcu:ehc|c" lF LL S/MFLE
lNSEFI Ihe :cme hcu:e c: ycu" lF CELL S/MFLE
S1. To ask the right questions we need to know how many people in your
family usually live in (this household/the same house as you). By family we
mean any blood relatives or people related to you by birth, marriage or
adoption. Including yourself, how many people in your family live there?
(INTERVIEWER NOTES:
THIS INCLUDES ANY FAMILY MEMBER THAT LIVES IN THE SAME HOME. FAMILY
MEMBERS WHO NORMALLY LIVE IN THE HOUSEHOLD BUT ARE TEMPORARILY
LIVING SOMEPLACE ELSE (e.g. hospital or school) SHOULD BE COUNTED
UNMARRIED COUPLES DO NOT COUNT AS FAMILY MEMBERS. IF THERE
ARE ANY CHILDREN FROM THIS RELATIONSHIP, THEY DO COUNT AS
FAMILY MEMBERS
INTERVIEWER NOTE: IF HH SIZE MORE THAN 15, PLEASE CONFIRM BEFORE
ENTERING RESPONSE.)
___________ (valid: 1-100)
FFF {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
enhancing patient-centered care 69
{/SK C.S2c lF C.S1=1 /ND LL S/MFLE)
S2a. And are you 18 or younger, older than 18 but younger than 65 or are
you 65 or older?
1 18 cr ycunger IH/NK & IEFM.
2 1 Ic 4
3 5 cr c|cer IH/NK & IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
{/SK C.S2 lF C.S1=2+ /ND LL S/MFLE)
S2. And how many of these family members, including you are older than
18 but younger than 65?
________ (RANGE = 1- RESPONSE IN Q.S1)
NN Ncne IH/NK & IEFM.
FF {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
{/SK EVEFYCNE: FE/D lIEM lN F/FENS lF S1=2+)
S3. To ask the right questions, we need to know whether in 2011, your
(familys) total annual income from all sources, before taxes, was more or
|e:: Ihcn {lNSEFI Y*)
(IF NEEDED: Family income includes income from you and any family
members living with you. Income can be pay for work or any other money
coming in.)
(IF NEEDED: Your income makes it easy or hard to take care of healthcare
costs. We need to know that to ask the right questions.)
[INTERVIEWER: IF RESPONDENT REFUSES: Your responses are strictly
ccnfcenIic| cnc cre ncI cIIcchec Ic cny icenIifying infcrmcIicn. lI i:
important for us to know this information to ask you about your healthcare.]
[INTERVIEWER: IF RESPONDENT IS UNSURE, PROBE: Can you estimate?]
1 Mcre Ihcn {/MCUNI) IH/NK & IEFM.
2 Less than (AMOUNT)
3 {DC NCI FE/D) ExccI|y {/MCUNI) IH/NK & IEFM.
D (DO NOT READ) Dont know GO TO Q.S3b
R (DO NOT READ) Refused GO TO Q.S3b
V/LUES FCF Y*
IF S1=1 $23,000 IF S1=6 $62,000
IF S1=2 $29,000 IF S1=7 $70,000
IF S1=3 $36,000 IF S1=8 $78,000
lF S1=4 $4,000 lF S1=+ $3,000
IF S1=5 $55,000
70 enhancing patient-centered care
{/SK C.S3L lF C.S3 = D CF F)
(READ ITEM IN PARENS IF S1=2+)
S3b. How about average monthly income? Can you estimate whether your
(familys) average monthly income from all sources was more or less than
{lNSEFI M*)
(IF NEEDED: Family income includes income from you and any family
members living with you. Income can be pay for work or any other money
coming in.)
(IF NEEDED: Your income makes it easy or hard to take care of healthcare
costs. We need to know that to ask the right questions.)
[INTERVIEWER: IF RESPONDENT REFUSES: Your responses are strictly
ccnfcenIic| cnc cre ncI cIIcchec Ic cny icenIifying infcrmcIicn. lI i:
important for us to know this information to ask you about your healthcare.]
[INTERVIEWER: IF RESPONDENT IS UNSURE, PROBE: Can you estimate?]
1 Mcre Ihcn {/MCUNI) IH/NK & IEFM.
2 Less than (AMOUNT)
3 {DC NCI FE/D) ExccI|y {/MCUNI) IH/NK & IEFM.
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
V/LUES FCF M*
IF S1=1 $2,000 IF S1=6 $5,100
lF S1=2 $2,400 lF S1=7 $5,800
IF S1=3 $3,000 IF S1=8 $6,500
lF S1=4 $3,800 lF S1=+ $7,800
lF S1=5 $4,500
{/SK C.S3c lF LL S/MFLE /ND C.S3L = D CF F /ND C.S1>1)
S3c. Is there someone else there you can ask?
1 Ye:, ccming Ic phcne FE-FE/D lNIFC & GC IC C.S3
2 Ye:, LuI pre:enI|y uncvci|cL|e GEI N/ME & SCHEDULE C/LL8/CK
3 Nc IH/NK & IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
(IF CELL SAMPLE OR Q.S2a = 2 GO TO Q.S5)
{/SK C.S4 lF LL S/MFLE /ND C.S1 = 2+)
(IF Q.S2 = 1, DO NOT INSERT ANY OF THE VERBIAGE IN PARENS)
S4. Ic ccmp|eIe cur :urvey we neec Ic :peck wiIh Ihe {mc|e/femc|e) fcmi|y
memLer |iving in ycur hcu:ehc|c, whc i: LeIween Ihe cge: cf 1 cnc 4
and had the last birthday. Is that person at home right now?
enhancing patient-centered care 71
{lNIEFVlEWEF NCIE: lF FESFCNDENI /SKS WHY DC YCU NEED IC I/LK IC
IHE M/LE/FEM/LE WHC H/D IHE L/SI 8lFIHD/Y S/Y, Cur re:ecrch experI:
:eI iI up IhcI wcy :c IhcI c|| Iype: cf pecp|e wi|| Le repre:enIec.")
1 Yes, respondent on the phone
2 Ye:, re:pcncenI ccming Ic Ihe phcne FEFE/I lNIFC & GC IC C.S5
3 Person is unavailable GEI N/ME & SCHEDULE C/LL8/CK
4 Nc cne in Ihe HH cf IhcI gencer
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
{/SK C.S4c lF C.S4 = 4)
S4c. Ihen mcy l p|ec:e :peck wiIh Ihe {femc|e/mc|e) {lNSEFI CFFCSlIE
GENDEF FFCM C.S4) fcmi|y memLer |iving in ycur hcu:ehc|c, whc i:
LeIween Ihe cge: cf 1 cnc 4 cnc hcc Ihe |c:I LirIhccy
1 Yes, respondent on the phone
2 Yes, respondent coming to the phone REPEAT INTRO AND GO TO Q.S5
3 Person is unavailable GEI N/ME & SCHEDULE C/LL8/CK
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
S5. What language do you mainly speak at home? (DO NOT READ.)
1 English
2 Spanish
3 Chinese/Mandarin/Cantonese
4 Kcrecn
5 Filipino/Tagalog
7 Other
R (DO NOT READ) Refused
S6. RECORD GENDER OF RESPONDENT
1 Male
2 Female
main questionnaire
S7. /nc ju:I Ic ccnfrm, whcI i: ycur cge
_________ {1-4)
LL 18 cr |e:: IH/NK /ND IEFM.
5 5 CF MCFE IH/NK /ND IEFM.
RR (DO NOT READ) Refused
{/SK C.S7c lF C.S7 = FF)
S7a. Could you please tell me if you are? (READ LIST.)
72 enhancing patient-centered care
{lNIEFVlEWEF NCIE: lF FESFCNDENI S/YS YCUNGEF IH/N 1" CF CLDEF
IH/N 5" - FLE/SE CCNFlFM 8EFCFE ENIEFlNG FESFCNSE)
1 Ycunger Ihcn 1 IH/NK /ND IEFM.
2 19 to 29
3 30 to 39
4 40 Ic 4
5 50 Ic 4, cr
5 CF CLDEF IH/NK /ND IEFM.
R (DO NOT READ) Refused
{/SK C.S7L lF C.S7c = F)
S7L. Ccn ycu ju:I ccnfrm IhcI ycu cre c|cer Ihcn 18 cnc ycunger Ihcn 5
1 Yes
2 Nc IH/NK /ND IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK /ND IEFM.
(SCRAMBLE LIST)
1. Of the items I name please tell me which one is the single biggest
concern for you right now is it ?
(READ LIST.)
1 Housing issues
2 Being able to pay for basics like food
3 Getting or holding a job
4 lmmigrcIicn cr |egc| i::ue:
5 Or, taking care of your health
7 (DO NOT READ) Other
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
2. About how many times in the past year have you seen a doctor, nurse or
other healthcare provider? (IF NEEDED: Just your best guess)
_________ NUMBER OF TIMES
NN None
DD (DO NOT READ) Dont know
RR (DO NOT READ) Refused
(ROTATE VERBIAGE IN PARENS)
3. Where do you usually go when you are sick or need health care for any
rec:cn - {Kci:er), {c privcIe cccIcr: cffce), {c ccmmuniIy c|inic cr hec|Ih
center), (a hospital) or someplace else?
enhancing patient-centered care 73
(INTERVIEWER NOTES:
- lF MULIlFLE FL/CES, /SK Which cne u:uc||y"
- lF FESFCNDENI S/YS DCCICF" /SK: lS IH/I / FFlV/IE DCCICFS CFFlCE
OR A DOCTOR AT [REPEAT OTHER CHOICES]?
- lF FESFCNDENI S/YS NCN-FFCFESSlCN/L, l.E., F/FENI, F/MlLY, HCME",
S/Y l mecn fcr prcfe::icnc| hec|Ihccre." /ND FE-/SK CUESIlCN.)
1 Kci:er
2 / privcIe cccIcr: cffce
3 A community clinic or health center
4 / hc:piIc|
5 Someplace else
6 (DO NOT READ) No place I usually go
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.3c lF C.3 = , D, CF F)
3c. CK, where: Ihe |c:I p|cce ycu wenI when ycu neecec hec|Ih ccre
(ENTER ONE ONLY)
(INTERVIEWER NOTES:
- lF FESFCNDENI S/YS DCCICF" /SK: lS IH/I / FFlV/IE DCCICFS CFFlCE
OR A DOCTOR AT [REPEAT OTHER CHOICES]?
- lF FESFCNDENI S/YS NCN-FFCFESSlCN/L, l.E., F/FENI, F/MlLY, HCME",
S/Y l mecn fcr prcfe::icnc| hec|Ihccre." /ND FE-/SK CUESIlCN.)
1 Kci:er
2 / privcIe cccIcr: cffce
3 A community clinic or health center
4 / hc:piIc|
5 Or, someplace else
6 (DO NOT READ) Never have gone to doctor/nurse/healthcare provider
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{lF C.3c = 1, 2, 4, 5)
3b. Was this in California, or not?
1 Yes
2 Nc IH/NK & IEFM.
D {DC NCI FE/D) DcnI kncw IH/NK & IEFM.
F {DC NCI FE/D) Fefu:ec IH/NK & IEFM.
74 enhancing patient-centered care
{/SK C.4 lF C.3 = 3 CF C.3c = 3)
4. WhcI: Ihe ciIy cr Icwn where ycur c|inic i: |cccIec
(ENTER 1ST LETTER OF CITY/TOWN FOR LIST OF AVAILABLE CITIES/TOWNS)
096 Fresno 259 San Francisco
158 Los Angeles 263 San Jose
201 Oakland 330 Ventura
213 Oxnard 997 Other answer given (SPECIFY) _______
254 SccrcmenIc DDD {DC NCI FE/D) DcnI kncw
255 Salinas RRR (DO NOT READ) Refused
258 San Diego
{/SK C.4cc lF C4 = 0, 158, 201, 213, 254, 255, 258, 25, 23, CF 330 CF 7)
4cc. WhcI: Ihe ncme cf Ihe :IreeI where ycur c|inic i: |cccIec
(ENTER 1ST LETTER OF STREET FOR LIST OF AVAILABLE CLINICS)
001 Answer given (SPECIFY) _______
DDD (DO NOT READ) Dont know
RRR (DO NOT READ) Refused
{/SK C.4c lF C.3 = 3 CF C.3c = 3)
4c. WhcI: Ihe ncme cf IhcI c|inic
(ENTER 1ST LETTER OF CLINIC FOR LIST OF AVAILABLE CLINICS)
(INTERVIEWER NOTE: IF 2+ CLINICS WITH SAME NAME, VERIFY STREET NAME IF
AVAILABLE)
997 Answer given (SPECIFY) _______
DDD (DO NOT READ) Dont know
RRR (DO NOT READ) Refused
{/SK C.4L lF C.4c = 7, DDD, CF FFF)
4L. /: fcr c: ycu kncw, i: IhcI c c|inic IhcI: cpercIec Ly c hc:piIc|, cr ncI
(ENTER ONE ONLY)
1 Yes, operated by a hospital
2 No, not operated by a hospital
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.4c lF C.4L = 1: FCI/IE VEF8l/GE lN F/FENS)
4c. l: Ihi: c|inic run Ly c {ccunIy hc:piIc|) cr c {privcIe cr re|igicu: hc:piIc|)
(ENTER ONE ONLY)
1 County hospital
2 Private or religious hospital
3 (DO NOT READ) Other
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
enhancing patient-centered care 75
{/SK C.4c lF C.4L = 2)
(ROTATE VERBIAGE IN PARENS)
4c. l: Ihi: c|inic run Ly c {ccunIy cr ciIy), cr Ly c {privcIe ccmpcny)
{lNIEFVlEWEF NCIE: lF CCLLEGE CF UNlVEFSlIY-FUN SIUDENI CLlNlC"
CCDE /S 3 CIHEF")
1 County or city
2 Private company
3 (DO NOT READ) Other
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.4e lF C.3 = 4 CF C.3c = 4)
(ROTATE VERBIAGE IN PARENS)
4e. l: IhcI c {hc:piIc| c|inic), cr i: iI c {hc:piIc| emergency rccm)
1 Hospital clinic
2 Hospital emergency room
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.4f lF C.4e = 1)
(ROTATE VERBIAGE IN PARENS)
4f. l: Ihi: c|inic run Ly c {ccunIy hc:piIc|) cr c {privcIe cr re|igicu: hc:piIc|)
1 County hospital
2 Private or religious hospital
3 (DO NOT READ) Other
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.5 lF C.3 = 1-5)
5. Thinking about the place where you usually go for health care, how
would you rate the health care you receive excellent, very good, good,
not so good or poor?
1 Excellent
2 Very good
3 Good
4 NcI :c gccc
5 Poor
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
76 enhancing patient-centered care
{/SK C.5c lF C.3c = 1-5, D CF F)
5a.Thinking about the last time you received health care was the health
care you received
excellent, very good, good, not so good or poor?
1 Excellent
2 Very good
3 Good
4 NcI :c gccc
5 Poor
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C. lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
6. Apart from the health care they provide, what about the kind of
assistance they offer to help you get the support services you may need,
such as information, referrals, transportation and other assistance would
you rate this as excellent, very good, good, not so good or poor?
1 Excellent
2 Very good
3 Good
4 NcI :c gccc
5 Poor
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.7 lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
INSERT 1ST VERBIAGE IN PARENS IF Q.3 = 1-5; INSERT 2ND VERBIAGE IN PARENS
IF Q.3a = 1-5, D, OR R)
7. Thinking about the people working at the place where you (usually go/
last went) for care, do you feel theres a person there who knows you pretty
well, or not really?
(IF NEEDED: I mean someone who has a pretty good idea of whats going
on in your life that may affect your health. This can be anyone you see
there, not necessarily the doctor.)
1 Yes, there is someone that knows you pretty well
2 No, there is no one that knows you pretty well
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.8 lF C.7 = 1)
{SCF/M8LE 01-04)
8. Who is that person I mean their job?
{lF NEEDED: Ccu|c Le c {lNSEFI CCDES 01-04), cr :c fcrIh)
(READ LIST.)
enhancing patient-centered care 77
lNIEFVlEWEF NCIE: hec|Ihccre ncvigcIcr c|:c ccn Le hec|Ihccre cccch"
or similar
01 Doctor
02 Nurse
03 Healthcare navigator (Spanish: Promotores de salud)
04 Scmecne cI recepIicn
05 (DO NOT READ) Nurses aide
06 (DO NOT READ) Physicians assistant (PA)
07 (DO NOT READ) Pharmacist
08 (DO NOT READ) Nutritionist
09 (DO NOT READ) Case worker/social worker
10 (DO NOT READ) Billing clerk
97 (DO NOT READ) Other (SPECIFY) _____________
DD (DO NOT READ) Dont know
RR (DO NOT READ) Refused
{/SK C. lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
lNSEFI l: IhcI" lF C.7 = 1
lNSEFI Wcu|c IhcI Le" lF C.7 = 2, D, CF F
9. How much does this matter to you having someone there who knows
you well? (Is that/Would that be) very important to you, somewhat
important, not so important or not important at all?
1 Very important
2 Somewhat important
3 Not so important
4 NcI impcrIcnI cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
10. Do you have a regular personal doctor, or not?
[IF NEEDED: I mean one you would regularly see if you need a checkup,
want advice about a health problem, or get sick or hurt. ]
1 Yes, do
2 No, do not
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.11 lF C.10 = 2)
11. Would you like to have your own personal doctor, or is it not that
important to you?
1 Yes, would like to
2 No, not that important
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
78 enhancing patient-centered care
{/SK C.12 lF C.10 = 1)
12. Do you like having your own personal doctor, or is it not that important
to you?
1 Yes, like it
2 No, not that important
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
13. Regardless of whether or not you have a personal doctor, how often
do you see the same healthcare provider when you have a healthcare
appointment every time, most of the time, some of the time, rarely or never?
1 Every time
2 Most of the time
3 Some of the time
4 Fcre|y
5 Never
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.14 lF C.13 = 2, 3, 4, 5, D, CF F)
14. Wcu|c ycu |ike Ic Le cL|e Ic :ee Ihe :cme hec|Ihccre prcvicer mcre
often than you do now, or is that not that important to you?
1 Yes, would
2 Not that important
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.15 lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
(ROTATE VERBIAGE IN PARENS)
15. Thinking about when you go in for routine care or a checkup, not for a
special problem (do you usually see a doctor), or (do you usually see a
care provider who is not a doctor, like a nurse or a physicians assistant)?
1 Usually see a doctor
2 Usually see a care provider who is not a doctor, like a nurse or
physicians assistant
3 (DO NOT READ) Usually see both
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(ROTATE VERBIAGE IN PARENS)
16. For routine visits or checkups, would you prefer to see (a doctor), would
you prefer to see (a nurse or physicians assistant) or does it not matter
much to you either way?
enhancing patient-centered care 79
{lNIEFVlEWEF NCIE: lf re:pcncenI :cy: LcIh", :cy, We||, if ycu hcc Ic chcc:e.")
1 Prefer to see a doctor
2 Prefer to see a nurse or physicians assistant
3 Doesnt matter either way
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.1c lF C.1 = 1 CF 2)
lNSEFI cccIcr" lF C.1 = 1
lNSEFI nur:e cr phy:icicn: c::i:IcnI" lF C.1 = 2
16a. Do you feel that way strongly or somewhat?
(IF NECESSARY: That you prefer to see a (doctor/nurse or physicians assistant)
1 Strongly
2 Somewhat
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK lF C.1 = 1)
(ROTATE VERBIAGE IN PARENS)
(SCRAMBLE ITEMS)
17. What if (INSERT ITEM) in that case would you (still prefer to see a doctor)
for routine care, or would you (prefer to see a nurse or physicians assistant)?
1 Still prefer to see a doctor
2 Prefer to see a nurse or physicians assistant
3 (DO NOT READ) Either/Doesnt matter
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
a. Its harder to get an appointment with a doctor
b. The appointment with the doctor is shorter than it would be with a nurse
or physicians assistant
c. The doctor doesnt know you as well as the nurse or physicians assistant
{/SK C.17c lMMEDl/IELY FCLLCWlNG C.17 FCF E/CH = 1 CF 2)
lNSEFI :Ii|| prefer Ic :ee c cccIcr" lF C.17 = 1
lNSEFI wcu|c prefer Ic :ee c nur:e cr phy:icicn: c::i:IcnI" lF C.17 = 2
17a. Do you feel that way strongly or somewhat?
(IF NECESSARY: That you (still prefer to see a doctor/would prefer to see a
nurse or physicians assistant)
1 Strongly
2 Somewhat
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
80 enhancing patient-centered care
a. Its harder to get an appointment with a doctor
b. The appointment with the doctor is shorter than it would be with a nurse
or physicians assistant
c. The doctor doesnt know you as well as the nurse or physicians assistant
18. For routine health questions, how would you feel about talking with a
healthcare provider over the telephone instead of having an in-person
appointment would you be very willing to do this, somewhat willing,
somewhat unwilling or very unwilling?
1 Very willing
2 Somewhat willing
3 Somewhat unwilling
4 Very unwi||ing
5 (DO NOT READ) Depends
6 (DO NOT READ) Already do this
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
19. How about using e-mail? For routine health questions, how would you
feel about using e-mail instead of having an in-person appointment to
communicate with a healthcare provider would you be very willing to do
this, somewhat willing, somewhat unwilling or very unwilling?
1 Very willing
2 Somewhat willing
3 Somewhat unwilling
4 Very unwi||ing
5 (DO NOT READ) Depends
6 (DO NOT READ) Already do this
7 (DO NOT READ) Do not use internet/e-mail and/or computer
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.20 lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
lNSEFI ycu gc" lF C.3 = 1-5
lNSEFI |c:I wenI" lF C.3c = 1-5, D, CF F
20. On another subject, some places have a person whose job it is to help
people get the appointments, information and services they need, make
sure their questions have been addressed, or may even call to check in
on them between visits. There are different names for this kind of role, for
example a healthcare navigator or healthcare coach [Spanish: promotores
de salud]. Do you personally have a health navigator or health coach at the
place (you go/last went) for care, or not?
1 Yes
2 No
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
enhancing patient-centered care 81
{/SK C.21 lF C.20 = 1)
21. How do you like having this healthcare navigator do you like it a great
deal, somewhat, not so much or not at all?
1 A great deal
2 Somewhat
3 Not so much
4 NcI cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.22 lF C.20 = 2, D, CF F)
22. How interested would you be in having a healthcare navigator
providing these services very interested, somewhat interested, not so
interested or not interested at all?
1 Very interested
2 Somewhat interested
3 Not so interested
4 NcI inIere:Iec cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.23 lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
lNSEFI ycu gc" lF C.3 = 1-5
lNSEFI |c:I wenI" lF C.3c = 1-5, D, CF F
23. Some places have whats called team-based care. Each patient gets
a healthcare team that includes a doctor, a healthcare navigator, a nurse
or physicians assistant and a health educator. The same team always
works with that patient. As far as youre aware do you personally have a
healthcare team at the place (you go/last went) for care, or not?
1 Yes
2 No
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.24 lF C.23 = 1)
24. Hcw cc ycu |ike Ihi: Iecm-Lc:ec cpprccch - cc ycu |ike iI c grecI cec|,
somewhat, not so much or not at all?
1 A great deal
2 Somewhat
3 Not so much
4 NcI cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
82 enhancing patient-centered care
{/SK C.25 lF C.23 = 2, D, CF F)
25. If it was available where you go for care, would you be very willing to have
team-based care, somewhat willing, somewhat unwilling or very unwilling?
1 Very willing
2 Somewhat willing
3 Somewhat unwilling
4 Very unwi||ing
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.2 lF C.23 = 2, D, CF F)
26. The idea of team-based care is that while you may see a doctor less
often, its easier to see more types of healthcare providers who know you
cnc ccn he|p in cifferenI wcy:. Kncwing Ihi:, wcu|c ycu Le very wi||ing Ic
participate in team-based care somewhat willing, somewhat unwilling or
very unwilling?
1 Very willing
2 Somewhat willing
3 Somewhat unwilling
4 Very unwi||ing
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(SCRAMBLE a-e)
(IF CODE 6, ENTERED AT ANY TIME, THEN ALL OTHER INTERNET-RELATED ITEMS
SHOULD BE AUTO-GEND A CODE 6 [ITEMS c, d, e]. IF CODE 7 ENTERED AT
ANY TIME, THEN ALL OTHER TEXTING-RELATED ITEMS SHOULD BE AUTO-GEND
A CODE 7 [ITEMS a,b])
27. There can be different ways to communicate with a healthcare
provider. For each item I name, please tell me how interested you are in
ccing IhcI, if cI c||. lf ycure c|reccy ccing Ihi:, p|ec:e ju:I :cy :c. Ihe fr:I i:
(INSERT ITEM) are you very interested in doing that, somewhat interested,
not so interested or not interested at all? How about (INSERT NEXT ITEM)?
1 Very interested
2 Somewhat interested
3 Not so interested
4 NcI inIere:Iec cI c||
5 Already doing this
6 (DO NOT READ) No e-mail/internet/computer access
7 (DO NOT READ) No cell phone/dont text message
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
enhancing patient-centered care 83
a. Receiving text messages reminding you to take medicine or come
in for a test
b. Receiving text messages with information about health issues you
may be having
c. Being able to schedule a medical appointment over the internet
d. Being able to look at your health records over the internet
e. Being able to renew prescription medicines over the internet
28. How concerned are you, if at all, about the privacy of your health
information on the internet and in e-mails very concerned, somewhat
concerned, not so concerned or not concerned at all?
1 Very concerned
2 Somewhat concerned
3 Not so concerned
4 NcI ccncernec cI c||
5 (DO NOT READ) Do not use internet/e-mail
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(SCRAMBLE ITEMS)
{/SK lIEM c lF C.S5 = 2-7 CF F)
29. How much does it matter to you that the healthcare provider and staff
at your healthcare facility (INSERT ITEM) is that very important to you,
somewhat important, not so important or not important at all?
{lNIEFVlEWEF NCIE: lF F S/YS NC F/ClLlIY" S/Y, lF YCU H/D CNE.")
1 Very important
2 Somewhat important
3 Not so important
4 NcI impcrIcnI cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
c. Kncw whcI: gcing cn in ycur ccmmuniIy
b. Understand your cultural or ethnic background
c. Are able to speak with you in the language you prefer
30. Some places offer group programs on healthcare issues. There may be
a program for people with diabetes, or for pregnant women, or for people
trying to quit smoking, for example. These are places for people to share
their experiences as well as get healthcare information. If there was a
group program where you go that addressed a health issue you have, how
willing would you be to participate in that very willing, somewhat willing,
somewhat unwilling or very unwilling?
{lNIEFVlEWEF NCIE: lF F S/YS NC HE/LIH lSSUES" S/Y, WELL, lF YCU DlD
H/VE CNE.")
84 enhancing patient-centered care
1 Very willing
2 Somewhat willing
3 Somewhat unwilling
4 Very unwi||ing
5 (DO NOT READ) Depends
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(ROTATE VERBIAGE IN PARENS)
31. If a healthcare facility in your area had a seal of approval from a
national healthcare association would that make you (more likely) to go
there, (less likely) to go there, or wouldnt it make a difference?
1 More likely
2 Less likely
3 Wouldnt make a difference
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(ROTATE VERBIAGE IN PARENS)
32. Thinking about healthcare decisions, is it your preference to (leave
decisions about your health care mostly up to the doctor or nurse), or would
you prefer to (have an equal say with the doctor or nurse in decisions about
your health care)?
{lNIEFVlEWEF NCIE: lf re:pcncenI :eem: ccnfu:ec Ly Ihe Ierm euc| :cy"
p|ec:e :cy: ECU/L S/Y - LlKE /N ECU/L VClCE.")
1 Prefer to leave decisions mostly up to the doctor or nurse
2 Prefer to have an equal say with the doctor or nurse in decisions
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.32c lF C.32 = 1 CF 2)
32a. Do you feel that way strongly, or somewhat?
(IF NECESSARY: That you would [INSERT RESPONSE FROM Q.32])
1 Strongly
2 Somewhat
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.33 lF C.32 = 1)
(ROTATE VERBIAGE IN PARENS)
33. Is that more because (you feel you dont have enough information
to make the right decision) or more because (you feel that making care
decisions is the doctors responsibility, not yours)?
enhancing patient-centered care 85
1 You feel you dont have enough information to make the right decision
2 You feel that making care decisions is the doctors responsibility, not yours
3 (DO NOT READ) Both
4 {DC NCI FE/D) NeiIher/cIher
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.34 lF C.32 = 1, D, CF F)
(ROTATE VERBIAGE IN PARENS)
34. Ncw imcgine Ihe cccIcr hc: :e|ecIec IrecImenI cpIicn: fcr ycu - c
choice of things you might do, any of which is medically appropriate and
youve been given information that you understand about these options.
In this situation, would you prefer to (leave the decisions mostly up to the
doctor or nurse) or would you prefer to (have an equal say with the doctor
or nurse in the decisions)?
{lNIEFVlEWEF NCIE: lf re:pcncenI :eem: ccnfu:ec Ly Ihe Ierm euc| :cy"
p|ec:e :cy: ECU/L S/Y - LlKE /N ECU/L VClCE.")
1 Prefer to leave the decision mostly up to the doctor or nurse
2 Prefer to have an equal say with the doctor or nurse in the decision
3 (DO NOT READ) Prefer to have most of the say
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
35. How much of a say do you feel you currently have in decisions about your
health care a great deal of say, a good amount, just some or only a little?
{lNIEFVlEWEF NCIE: lf re:pcncenI :eem: ccnfu:ec Ly Ihe Ierm :cy" p|ec:e
:cy: S/Y - /S lN VClCE.")
1 A great deal
2 A good amount
3 Just some
4 Cn|y c |iII|e
5 (DO NOT READ) None
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
36. Regardless of whether or not you want an equal say, would you like
more of a say in decisions about your health care than you have now, less
of a say, or is it about right?
{lNIEFVlEWEF NCIE: lf re:pcncenI :eem: ccnfu:ec Ly Ihe Ierm euc| :cy"
p|ec:e :cy: ECU/L S/Y - LlKE /N ECU/L VClCE.")
1 More say
2 Less say
3 Its about right
86 enhancing patient-centered care
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
37. In general, how informed do you feel about your health and any health
problems you may have very informed, somewhat informed, not so
informed or not informed at all?
{lNIEFVlEWEF NCIE: lF F S/YS NC HE/LIH FFC8LEMS", S/Y HCW
lNFCFMED DC YCU FEEL /8CUI YCUF HE/LIH lN GENEF/L")
1 Very informed
2 Somewhat informed
3 Not so informed
4 NcI infcrmec cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
38. Have you ever used the internet to access health information, or not?
1 Yes
2 No
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.3 lF C.38 = 1)
39. Do you do that very often, somewhat often, just occasionally or rarely?
(IF NEEDED: Use the internet to access health information)
1 Very often
2 Somewhat often
3 Just occasionally
4 Fcre|y
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(SCRAMBLE ITEMS)
40. Hcw inIere:Iec, if cI c||, wcu|c ycu Le in hcving mcre infcrmcIicn cLcuI
(INSERT ITEM) very interested, somewhat interested, not so interested or not
interested at all?
1 Very interested
2 Somewhat interested
3 Not so interested
4 NcI inIere:Iec cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
enhancing patient-centered care 87
a. The pros and cons of different tests or treatments you might need
b. The training and experience of the health professionals in your area
c. Patient satisfaction ratings for the healthcare facilities in your area
d. Quality ratings for providers in your area like with more stars for the
better ones
41. Hcw ccnfcenI cre ycu in ycur cLi|iIy Ic mcke ceci:icn: cLcuI ycur
hec|Ih ccre - very ccnfcenI, :cmewhcI ccnfcenI, ncI :c ccnfcenI, cr ncI
ccnfcenI cI c||
1 Very ccnfcenI
2 ScmewhcI ccnfcenI
3 NcI :c ccnfcenI
4 NcI ccnfcenI cI c||
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(ROTATE VERBIAGE IN PARENS)
42. Cverc||, whc cc ycu fee| i: mc:I re:pcn:iL|e fcr mcncging ycur hec|Ih -
(you yourself) or (your healthcare provider)?
1 You yourself
2 Your healthcare provider
3 (DO NOT READ) Both equally
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.43 lF C.3 = 1-5 CF C.3c = 1-5, D CF F)
43. When ycu gc fcr mecicc| ccre, hcw cfIen cce: Ihe hec|Ihccre prcvicer
explain things in a way you can understand every time, most of the time,
some of the time, rarely, or never?
1 Every time
2 Most of the time
3 Some of the time
4 Fcre|y
5 Never
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.44 lF C.3 = 1-5 CF C.3c = 1-5, D, CF F)
44. Hcw ccmfcrIcL|e cr unccmfcrIcL|e cc ycu fee| c:king Ihe hec|Ihccre
provider questions about your health or treatment very comfortable,
somewhat comfortable, somewhat uncomfortable, or very uncomfortable?
1 Very comfortable
2 Somewhat comfortable
3 Somewhat uncomfortable
4 Very unccmfcrIcL|e
88 enhancing patient-centered care
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.45 lF C.3 = 1-5 CF C.3c = 1-5, D, CF F)
45. Hc: Ihere ever Leen c Iime when ycu cicnI fc||cw c hec|Ihccre
providers advice or treatment plan because you didnt understand what
you were supposed to do, or has that nothappened?
1 Yes, there has been a time
2 No, this has not happened
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
4. Chcnging :uLjecI:, c: ycu mcy kncw, c hec|Ih refcrm Li|| wc: :ignec
into law in 2010. Given what you know about the health reform law, do you
have a generally favorable or generally unfavorable opinion of it?
{GEI /NSWEF IHEN /SK: l: IhcI c very fcvcrcL|e/unfcvcrcL|e cr :cmewhcI
favorable/unfavorable opinion?)
1 Very favorable
2 Somewhat favorable
3 Somewhat unfavorable
4 Very unfcvcrcL|e
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
(ROTATE VERBIAGE IN PARENS)
47. Dc ycu Ihink ycu cnc ycur fcmi|y wi|| Le {LeIIer cff) cr {wcr:e cff) uncer
the health reform law, or dont you think it will make much difference?
1 Better off
2 Worse off
3 Dont think it will make much difference
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
48. Cn cncIher Icpic, cc ycu hcve cny ci:cLi|iIy cr chrcnic mecicc|
condition that requires ongoing health care, or not?
1 Yes, do
2 No, do not
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
4. WhcI i: ycur mcin :curce cf hec|Ih in:urcnce ccvercge, if cny
(READ LIST IF RESPONDENT DOES NOT IMMEDIATELY VOLUNTEER AN ANSWER
FROM THE LIST)
enhancing patient-centered care 89
{lNIEFVlEWEF NCIE: lF FESFCNDENI S/YS Kci:er FermcnenIe", /nIhem/
8|ue Crc:: cr cIher in:urcnce ccmpcny" FFC8E FCF WHEIHEF lIS CCDE
01" CF 02."lF FESFCNDENI S/YS CC8F/", CCDE /S 02:" lF FESFCNDENI
S/YS SCHlF", CCDE /S 04.")
01 Private health insurance through an employer
02 Private health insurance that you buy on your own
03 MediCal, also known as Medicaid
04 /ny cIher :IcIe hec|Ih in:urcnce prcgrcm
05 The V.A., military insurance through Tri-Care or any other federal
government program
06 Indian Health Service
07 Medicare, which would only be if you are disabled
08 (DO NOT READ) Both Medicare and MediCAl (Medi-Medi)
00 Or none, you are uninsured
DD (DO NOT READ) Dont know
RR (DO NOT READ) Refused
FE/D: Ncw fcr c|c::ifccIicn purpc:e: cn|y...
{/SK CELL S/MFLE CNLY)
D1a. For personal calls do you only use a cell phone, or do you also have
regular landline telephone service in your home on which I could have
reached you?
1 Only use a cell phone
2 Have regular landline
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK LL S/MFLE)
D1b. For personal calls, do you only use a landline phone like this one, or do
you also have a cell phone on which I could have reached you?
1 Landline phone only
2 Cell phone also
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
D2. Are you currently married, living with a partner, widowed, divorced,
separated, or single, meaning never married and not living with a partner?
1 Married
2 Living with a partner
3 Widowed
4 Divcrcec
5 Separated
6 Single, meaning never married and not living with a partner
R (DO NOT READ) Refused
90 enhancing patient-centered care
D3. Currently, are you yourself employed full time, part time, or not at all?
1 Fu|| Iime {SKlF IC C.D4)
2 FcrI Iime {SKlF IC C.D4)
3 Not employed (GO TO Q.D3a)
F Fefu:ec {SKlF IC C.D4)
{/SK lF C.D3=3)
D3a. Are you: (READ LIST)?
1 Retired
2 A homemaker
3 A student, or
4 Iempcrcri|y unemp|cyec
5 (DO NOT READ) Disabled/handicapped
7 (DO NOT READ) Other
D {DC NCI FE/D) DcnI Kncw
R (DO NOT READ) Refused

D4. Mcy l p|ec:e hcve ycur zip ccce
_____________ ZIP CODE
99997 (DO NOT READ) Other (Specify)
DD (DO NOT READ) Dont know
RR (DO NOT READ) Refused
D5. What is the last grade of school youve completed?
(DO NOT READ LIST)
1 8th grade or less
2 Some high school
3 Graduated high school
4 Scme cc||ege/c::ccicIe: cegree
5 Graduated college
6 Post graduate
R (DO NOT READ) Refused
D6. Are you of Hispanic origin or descent?
1 Yes
2 No
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.Dc lF C.D = 1)
D6a. Are you white Hispanic or black Hispanic?
1 White
2 Black
enhancing patient-centered care 91
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
{/SK C.DL lF C.D = 2, D, CF F)
D6b. Are you white, black, Asian or some other race?
1 White
2 Black
3 Asian
4 {DC NCI FE/D) Mu|Iirccic|
7 Other (SPECIFY) ________________
D (DO NOT READ) Dont know
R (DO NOT READ) Refused

(DISPLAY CODES 01-03 FOR EVERYONE)
{DlSFL/Y CCDE 04 lF S1>1)
{DlSFL/Y CCDE 05 lF S1>2)
{DlSFL/Y CCDES 0 /ND 07 lF S1>3)
{DlSFL/Y CCDES 08 /ND 0 lF S1>4)
{DlSFL/Y CCDE 10 lF S1>)
(READ ITEM IN PARENS IF S1=2+)
D7. To help us describe the people who took part in our study, it would
help to know which category describes your (familys) total annual income
last year before taxes. Thats income from all family members living in your
hcu:ehc|c. l: iI. FFC8E: Ycur Le:I e:IimcIe i: fne. {FE/D LlSI.)
01 Less than $16,000
02 At least $16,000 but less than $20,000
03 /I |ec:I $20,000 LuI |e:: Ihcn $24,000
04 /I |ec:I $24,000 LuI |e:: Ihcn $31,000
05 At least $31,000 but less than $36,000
0 /I |ec:I $3,000 LuI |e:: Ihcn $41,000
07 /I |ec:I $41,000 LuI |e:: Ihcn $47,000
08 /I |ec:I $47,000 LuI |e:: Ihcn $52,000
09 At least $52,000 but less than $62,000
10 Or $62,000 or more
DD (DO NOT READ) Dont know
RR (DO NOT READ) Refused
D8. CcnfcenIic||y cnc fcr :IcIi:Iicc| purpc:e: cn|y, cre ycu c ciIizen cf Ihe
United States, or not?

1 Yes, citizen
2 No, not a citizen
D (DO NOT READ) Dont know
R (DO NOT READ) Refused
92 enhancing patient-centered care
FOR INTERVIEWER
INT0. DO NOT READ. Did respondent ask for sponsor information at intro?
1 Yes, asked for sponsor information
2 No, did not ask for sponsor information
(READ IF INT0 =1)
Ihe :urvey :pcn:cr i: Ihe 8|ue Shie|c cf Cc|ifcrnic FcunccIicn, c ncnprcfI
group that works on healthcare issues in the state. The Foundation is a
:epcrcIe ncn-prcfI crgcnizcIicn frcm Ihe 8|ue Shie|c cf Cc|ifcrnic hec|Ih
plan. It has an independent Board of Trustees, which oversees its grant-
making program. The Foundation is funded entirely by a contribution from
the health plan.

FOR INTERVIEWER (CELL PHONE SAMPLE ONLY):
INT1. DO NOT READ. Did respondent request money for using their cell
phone minutes?
1 Yes, requested money
2 No, did not request money GO TO END OF INTERVIEW
(READ IF SAMPLE = CELL AND INT1=1)
Thats the end of the interview. Wed like to send you $5 for your time. Can I
please have your full name and a mailing address where we can send you
the money?
INTERVIEWER NOTE: If R does not want to give full name, explain we only
need it so we can send the $5 to them personally.
1 [ENTER FULL NAME] INTERVIEWER: PLEASE VERIFY SPELLING
2 [ENTER MAILING ADDRESS]
3 [City]
4 |SIcIe]
5 CONFIRM ZIP from above
R (VOL.) Respondent does not want the money
CLOSING: That completes our interview. Thank you very much for your time.
end of questionnaire
enhancing patient-centered care 93
appendix d
references
Several health care professionals kindly shared their insight and expertise
during the development of this survey for Blue Shield of California Foundation.
We acknowledge here, in alphabetical order by last name, the generosity
of these individuals:
Carol Beasley, director of strategic projects, Institute for Healthcare Improvement
Susan Dentzer, editor, Health Affairs
Rushika Fernandopulle, co-founder and CEO, Iora Health
Ed ONeill, director, Center for the Health Professions at University
of California, San Francisco
Lyn Paget, director of policy and outreach, Informed Medical
Decisions Foundation
Ju|ic Fcrcci:e, c::ccicIe cirecIcr, Kci:er Ccmmi::icn cn Meciccic
and the Uninsured
Jane Stafford, managing director, Community Clinics Initiative
l:cLe||e Vcn Kchcrn, prcgrcm cffcer, ln:IiIuIe cf Mecicine
In addition to these experts, the following references were consulted in
preparation and analysis of Blue Shield of California Foundations 2012
survey of low-income Californians.
Agency for Healthcare Research and Quality. (2010). Engaging Patients
cnc Fcn|||e: |n tne /ec|cc| Hcne. Washington, DC: Agency for
Healthcare Research and Quality, Publication No. 10-0083-EF. [http://
pcmh.chr.gcv/pcrIc|/:erver.pI/ccmmuniIy/pcmh__hcme/1483/FCMH_
HTMLConversion_10-0083-EF_v2]
The Aspen Institute. (2008). Transforming Health Care: American Attitudes
on Shared Stewardship. Washington, D.C.: The Aspen Institute.[http://www.
c:penin:IiIuIe.crg/:iIe:/cefcu|I/ f|e:/ccnIenI/ccc:/ HE/LIH_FCLLFEFCFI.FDF]
4 enhancing patient-centered care
Balik, B., Conway, J., Zipperer, L. Watson, J. (2011). Acn|ev|ng cn Fxcept|cnc|
Fct|ent cnc Fcn||y Fxpe||ence c| |npct|ent Hc:p|tc| Cc|e [IHI Innovation
Series White Paper]. Cambridge, MA: Institute for Healthcare Improvement.
[http://www.ihi.org/knowledge/Pages/ IHIWhitePapers/chievingException-
alPatientFamilyExperienceInpatientHospitalCareWhitePaper.aspx]
8crcn, F. M. & Kenny, D. /. {18). Ihe mccercIcr-mecicIcr vcricL|e
distinction in social psychological research: Conceptual, strategic and
statistical considerations. Journal of Personality and Social Psychology,
51, 1173-1182.
8eren:cn, F./., Hcmmcn:, F., Gcn:, D.N., Zuckernmcn, S., Merre||, K.,
Uncerwccc, W.S., & Wi||icm:, /.F. {2008). / hcu:e i: ncI c hcme: Keeping
patients at the center of practice redesign. Health Affairs, 27, 1219-1230.
[http://content.healthaffairs.org/content/27/5/ 1219.full.html]
8erwick, D.M., Nc|cn, I.W., & WhiIIingIcn, J. {2008). Ihe Irip|e cim: Ccre,
health, and cost. Health Affairs, 27, 759-769. [http://content.healthaffairs.
org/content/27/3/759.full.html]
Boutwell, S.J. (2011). Dartmouth to offer new primary care medical practice.
Dartmouth Now. [http:// now.dartmouth.edu/2011/11/dartmouth-to-open-
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