Development of the Primary Care Quality-Homeless (PCQ-H) Instrument: A Practical Survey of Homeless Patients’ Experiences in Primary Care

Kertesz SG, Pollio DE, Jones RN, Steward J, Stringfellow EJ, Gordon AJ, Johnson NK, Kim TA, Daigle SG, Austin EL, Young AS, Chrystal JG, Davis LL, Roth DL, Holt CL
Source: Med Care
Publication Year: 2014
Patient Need Addressed: Homelessness/housing, Patient satisfaction/engagement
Population Focus: Vulnerable/disadvantaged
Intervention Type: Best practices
Study Design: Other Study Design
Type of Literature: White

Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients’ priorities and concerns.

This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients; and (b) the methods utilized in its development.

Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA healthcare for the Homeless Program. Using Item Response Theory, we examined Test Information Function (TIF) curves to eliminate less informative items and devise plausibly distinct subscales.

The resulting 33-item instrument (Primary Care Quality-Homeless) has 4 subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items), and Homeless-specific Needs (4 items). Evidence for divergent and convergent validity is provided. TIF graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation, and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (α=0.75) and patients frequently reported problems in this aspect of care. CONCLUSIONS:
Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.

Insights Results

Overview of article

  • This article describes the development, and resulting content and psychometric properties of the Primary Care Quality-Homelessness Instrument, a survey that assesses patients with homelessness’ experiences with primary care
  • This tool was developed given the limited tools targeted homeless populations’ care, and for those that do exist, they have high literacy. As such, this tools was developed as an instrument sensitive to homeless patients’ concerns and practical for administration resource-constrained clinical settings and research contexts
    Method of article
  • The method of tool development derives from 3 assumptions: 1) General constructs relevant to quality out to derive from the IOM’s definition of primary care and its Rules for Quality; 2) Homeless patients’ needs and concerns are unique, requiring qualitative inquiry to guide item development; and 3) To validate the results from these assumptions, the final instrument had to demonstrate adequate psychometric properties
  • Through interviews and focus groups with patients with homelessness and experts in the field, the developers identified 11 key constructs. For each of the 11 constructs, 15-80 items were drafted based on the move evocative qualitative interview quotes pertinent to the construct. As such, the Primary Care Quality-Homeless survey (PCQ-H, v1) was developed and included 78 items for 11 constructs. A 4-point Likert scale was used to help with simplicity
  • The 11 constructs are: 1) Accountability; 2) Patient as the Source of Control; 3) Cooperation among Clinicians; 4) Continuous Healing Relationships; 5) Integration/Coordination; 6) Evidence-Based Decision-Making; 7) Accessibility; 8) Shared Knowledge and the Free Flow of Information; 9) Homeless-Specific Needs; 10) Trust/Respect; and 11) Substance Abuse/Mental Illness
  • The tool was validated by a racially diverse sample of 563 homeless persons


  • The resulting 33-item instrument has 4 subscales: 1) Patient-clinician relationship; 2) Cooperation among clinicians; 3) Access/coordination; and 4) Homeless-specific needs. Moreover, the Toolkit addresses obesity using the social ecological model, which effectively links complexities of health determinants and environmental influences on health. The tool has a 7th grade reading level and has high convergent and divergent validity
  • For example, questions under accessibility ask about outreach services, walking in for care and payment barriers. Questions related to patient-clinician relationship ask about control, trust, respect, and perceptions of competence
  • Specific prompts, to be answered using the 4 point Likert scale, include: “My PCP never doubts my health needs”, “My primary care and other healthcare providers need to communicate with each other more”, ” This place is open at times of the day that are convenient to me”, and more
  • This instrument may be used to support federal and state credentialing patient-centered medical home models

Key takeaways/implications

  • This tool offers guidance for future population-specific instrument development
  • Limitations to the instrument include small scope/sample size, impact of inclusion of a state with universal Medicaid, and uncertainty of stability of response over time
  • Strengths of the instrument include systematic qualitative assessment and inclusion of experiences from homeless-experienced patients and providers