The escalating demand for accountability within health services organizations is an undeniable trend. As health systems worldwide strive to optimize health outcomes – both through immediate curative and rehabilitative interventions and long-term preventive strategies – services that do not demonstrably contribute to this core objective will face increasing scrutiny. Consequently, the rigorous evaluation of both the structures and processes of care remains paramount. With a growing body of evidence underscoring the pivotal role of primary care in enhancing various health outcomes (1), the imperative to assess and ensure the quality of primary care service delivery becomes ever more critical.
It is in this context that the Primary Care Assessment Tools (PCATs) have been meticulously developed. This suite of instruments comprises several key components:
- Consumer-client surveys
- Facility surveys
- Provider surveys
- Health system survey (under development)
While the accompanying manual is primarily designed to guide researchers in administering these tools within research settings, much of its content remains valuable for broader applications, such as the evaluation of primary care delivery quality. Certain sections, though perhaps less relevant to specific evaluation purposes, are included to provide comprehensive background information and context.
Understanding Primary Care: A Foundational Concept
Primary care possesses distinct characteristics that differentiate it within the broader spectrum of health services delivery. These unique attributes now enable the systematic assessment of health service delivery systems based on the adequacy of their primary care approach. Crucially, primary care is person-focused, not solely illness- or problem-focused. This patient-centered approach makes it universally applicable to individuals and populations, irrespective of their current health status.
Furthermore, primary care acts as the optimal gateway to specialized secondary and tertiary care. Experiences within primary care, particularly its coordinating function, serve as a reflection of a population’s broader interactions with the entire health care system. The collection of baseline and periodic data through assessment tools allows governmental bodies and insurance providers to hold health service organizations accountable for the quality and effectiveness of the services provided to their constituents.
Primary care is now widely recognized as the cornerstone of effective and rational health systems. Its core components are well-established (2, 3). The principal challenge lies in translating these broad, conceptual elements into measurable characteristics. Key concepts include first contact care, person-focused care over time, comprehensiveness, and coordination, alongside related dimensions such as community orientation, family-centeredness, and cultural competence.
Leveraging this robust theoretical framework of primary care attributes and characteristics, assessment tools have been designed to gather and analyze essential data. This data aims to comprehensively describe the primary care services both delivered to and experienced by child and adult populations. These assessments shed light on the organizational resources and processes that can be strategically modified to yield demonstrable improvements in health care delivery outcomes (4).
The PCAT instruments are fundamentally structured around the core principles of primary care. A thorough grasp of these principles is crucial for understanding the purpose and significance of each question incorporated within the questionnaires. The following section offers a concise overview of the primary care concept as it pertains to evaluating the quality of primary care service delivery.
Primary care functions as a continuous and person-centric source of health management over time. Its planning and implementation are informed by a deep understanding of the families, communities, and cultures of the populations it serves.
The provision of primary care is characterized by a defined set of attributes and characteristics (5). The subsequent sections briefly elaborate on the four primary attributes and three related aspects:
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“First-contact” Care: This principle dictates that primary care providers are the initial point of contact for individuals seeking healthcare for any new health concern or medical need. Except in cases of severe emergencies, the primary care provider serves as the standard entry point into the health care system. They directly provide care or act as a facilitator, guiding patients to the most appropriate sources of specialized care when necessary. For services to qualify as first-contact care, they must be readily accessible (a structural feature) and consistently utilized by the population whenever a new health need arises (a behavioral characteristic).
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Continuous (Ongoing) Care: This aspect emphasizes the longitudinal utilization of a consistent source of care over an extended period. This continuity is crucial irrespective of the presence or absence of illness or injury. The central idea is establishing a medical or health care “home,” mutually recognized by both patient and provider. Continuous care aims to cultivate a lasting relationship between provider and patient, fostering mutual understanding of expectations and needs. This necessitates a defined population for whom the service or provider is responsible (often managed through a population registry), and a sustained, person-focused (rather than disease-focused) relationship over time.
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Coordinated Care: Coordination involves seamlessly linking health care visits and services to ensure patients receive appropriate and holistic care for all health issues, encompassing both physical and mental health needs. The essence of coordination lies in “the availability of information about prior and existing problems and services, and the recognition of that information as it bears on needs for current care” (3). Effective coordination ensures that all aspects of a patient’s health are considered in their care plan.
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Comprehensive Care: Comprehensive care refers to the breadth of services available within primary care settings and their appropriate delivery across the full spectrum of common health needs within a population. This excludes only the most uncommon or highly specialized problems. A primary care provider should be equipped to address a wide range of needs, including health promotion, disease prevention, injury prevention, dysfunction prevention, and the management of illness, disability, and discomfort. The range of services typically includes (but is not limited to) preventative care, health coaching, counseling, management of acute and chronic illnesses and injuries, minor surgical procedures, injections, joint aspirations, simple dislocation management, common skin conditions, behavioral health support, common mental health problem management, and information on community health resources.
Each of these four core domains of primary care is further divided into two subdomains: a structure-related subdomain (indicating the capacity to provide necessary services) and a behavior-related subdomain (verifying that services are provided when needed). This results in a total of eight core subdomains. All eight subdomains are applicable to both adult and child consumer-client surveys, as well as provider and facility versions of the PCAT.
Beyond these four core domains, three additional aspects of care are closely linked to the successful implementation of primary care and are often incorporated into primary care assessments:
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Family-centered Care: This approach acknowledges the crucial role of the family unit in a patient’s health assessment and treatment. Families possess both the right and the responsibility to actively participate in determining and addressing the health care needs of their members, both individually and collectively. Family-centered care is rooted in an understanding of the nature, role, and impact of family members’ health, illness, disability, or injury on the entire family system. It also considers the influence of family structure, function, dynamics, and family health history on health risks and health promotion within the family.
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Community-oriented Care: Community-oriented care emphasizes the delivery of health services within the broader context of the community it serves. The defining characteristic of community-oriented primary care (COPC) is its focus on the health care needs of a defined population group. COPC extends beyond individual patients and families to encompass the unmet health care needs within the community and the community characteristics that influence the health of all its members.
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Culturally Competent Care: Culturally competent care is characterized by respect for and consideration of the beliefs, interpersonal styles, attitudes, and behaviors of individuals as they relate to health and healthcare. It involves the application of skills to effectively translate these cultural factors into actionable strategies that preserve and promote health within diverse populations.
Evolution and Development of Primary Care Assessment Tools
Evolving trends in health services organization and delivery have spurred significant research and programmatic initiatives in primary health care. The conceptual framework and subsequent development of the Primary Care Assessment Tools represent a direct outcome of ongoing efforts to measure the extent to which primary care principles are effectively implemented for populations enrolled in various types of health care organizations and plans. This collaborative endeavor originated through the financial and administrative support of the U.S. Maternal and Child Health Bureau (MCHB), numerous state and local MCH programs (1990-1996), the Henry J. Kaiser Family Foundation, the Child and Adolescent Health Policy Center (CAHPC), and the Primary Care Policy Center for the Underserved (funded by the Bureau of Primary Health Care) at the Johns Hopkins Bloomberg School of Public Health.
Historically, prior to the 1990s, definitions of primary care often lacked the specificity needed for practical measurement of the degree to which primary care components were being realized (3, 5). However, the attainment of primary care can be effectively assessed by examining the structural and process elements of a health services system. Structural elements include critical factors such as accessibility, range of services, definition of a patient population, and continuity of care mechanisms. Process elements encompass the utilization of health services and the effectiveness of health problem recognition. All four primary domains of primary care – first contact care, continuity (often referred to as longitudinality to underscore care over time), comprehensiveness, and coordination of care – can be evaluated by analyzing these structural (“capacity”) and process (“actions” or “behavior”) elements within a health services system.
The Primary Care Assessment Tools are specifically designed to measure the degree to which primary care attributes are achieved. They provide valuable insights into the structure and process elements associated with the four core domains of primary care. This includes detailed information on the focus of health care facilities, patient demographics, available on-site services, and perspectives from patients, providers, and facilities regarding care experiences. Subdomain (structure and process), domain, and overall primary care scores can be derived from the individual item scores within the PCAT instruments.
Between 1995 and 1996, as part of the rigorous development and validation process for the Primary Care Assessment Tools, child and adolescent versions of the Consumer-Client and Provider surveys were administered via telephone to parents of 1,017 children enrolled in Florida’s Healthy Kids subsidized insurance program (6).
Further validation testing of the instruments was conducted and detailed in a study published in 1998. This research assessed the quality of primary care provided to children across diverse health care settings in Washington, D.C. The Consumer-Client and Provider survey tools were administered via telephone to a random sample of 450 consumers and by mail to 101 of their respective providers. The study findings indicated that the tools demonstrated “reliability and a consistency that [suggested] validity” in measuring key primary care domains. Furthermore, the PCAT tools were able to effectively detect variations in primary care delivery across different types of provider organizations and facilities (4).
To adapt and test the tools for adult populations, a survey was conducted in South Carolina in 1999. This involved in-person and mail surveys of 890 individuals randomly selected from an HMO group and a low-income group (7). The data collected from these surveys were utilized for further statistical testing to evaluate the validity, reliability, and refine the instruments for use with adult populations.
Since these initial studies, the PCAT tools have been utilized and evaluated in diverse international settings, including Canada (particularly Quebec), Brazil, Spain (Catalonia), South Korea, and China (both Taiwan and the People’s Republic of China-PRC). Versions of the PCAT tools are now available in Spanish, Catalan, Portuguese, Mandarin Chinese (both PRC and Taiwan), and Korean, reflecting the growing global recognition of the need for robust primary care assessment. Several evaluations of the PCAT tools have been published (see PCAT references below), consistently demonstrating the cross-cultural reliability of the instrument in assessing primary care quality across different populations and health systems.
For more detailed information regarding the PCAT, its administration, and its diverse applications, please contact Dr. Leiyu Shi ([email protected]).
PCAT Research Publications
[van Stralen CJ, Belisario SA, van Stralen TB, Lima AM, Massote AW, Oliveira CL. Perceptions of primary health care among users and health professionals: a comparison of units with and without family health care in Central-West Brazil]. Cad Saude Publica 2008;24 Suppl 1:S148-58.](/sites/default/files/2023-04/van-stralen-2008.pdf “van-stralen-2008”)
References
- Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.
- Institute of Medicine. A Manpower Policy for Primary Health Care. IOM Publication 78-02. Washington, DC: National Academy of Sciences, 1978.
- Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.
- Starfield B, Cassady C, Nanda J, Forrest CB, Berk R. Consumer experiences and provider perceptions of the quality of primary care: implications for managed care. J Fam Pract 1998;46:216-26.
- Starfield B. Measuring the attainment of primary care. J Med Educ 1979;54:361-9.
- Hurtado MP. Factors associated with primary care quality for low-income children in HMOs: Florida’s Healthy Kids Program. Baltimore, MD: Johns Hopkins School of Public Health, 1999.
- Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Pract 2001;50:161W,175W.
