PURPOSE Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process. METHODSWe conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics). RESULTSThe interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff.CONCLUSIONS Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff. INTRODUCTIONH igh-quality primary care is important for prevention and treatment of chronic diseases such as diabetes and hypertension, 1 which disproportionately affect minorities and those of low socioeconomic status.2 Inadequate access to high-quality, patient-centered care 3 can have detrimental effects including poor outcomes, 4 use of emergency services for nonurgent conditions, 5,6 or forgoing care altogether. 7,8 Patient experience, the measure of patient-centeredness, has become increasingly important in assessments of primary care quality. 9Patient experience surveys, however, have been used primarily with Medicare and privately insured populations, leaving the voices of patients in the lowest socioeconomic status underrepresented. 10 Qualitative studies suggest that vulnerable patients place a high value on access to care, care coordination, and continuity, 11,12 but may perceive primary care to be less accessible and of lower technical quality than hospital care. 6Patient experience is rarely compared with clinician experience, despite the fact that job satisfaction of both primary care clinicians and support staff has been correlated with patient satisfaction.13 Studies directly comparing patient and physician experience of insomnia and depression treatment in primary care have shown that disease understanding and expectations for treatment can affect the experience for both parties.14,15 A qualitative study of patients, physicians, nurses, and administrative staff showed widespread agreement that communication and tailored "whole-person" care was essential to patient-centered care, Elizabeth...

To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room.