Efforts to strengthen the accountability of health service organizations are continuously gaining momentum. As healthcare systems strive to optimize health outcomes—both through immediate curative and rehabilitative interventions and long-term preventative strategies—services that do not demonstrably contribute to these goals are facing increasing scrutiny. Consequently, the evaluation of healthcare structures and processes remains critically important. With growing evidence highlighting 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 crucial.
In response to this need, Primary Health Care Assessment Tools (PCAT) have been meticulously developed. This comprehensive suite of tools includes:
- Consumer-client surveys
- Facility surveys
- Provider surveys
- Health system survey (currently in development)
This article will delve into the concept of primary care and the evolution of these essential assessment tools, drawing upon information initially compiled for researchers administering the PCAT in research settings. While some aspects of the original documentation may cater specifically to research contexts, the core principles and tools are broadly applicable to evaluating and improving the quality of primary care delivery in diverse settings.
Understanding the Essence of Primary Care
Primary care possesses unique characteristics in health service delivery, allowing for the assessment of healthcare systems based on their effectiveness in providing primary care. Unlike approaches focused on specific illnesses or problems, primary care is person-centered. This patient-focused approach is equally relevant and beneficial to individuals and populations irrespective of their current health status.
Moreover, primary care ideally acts as the gateway to specialized secondary and tertiary care. Experiences within primary care, particularly its coordinating function, reflect broader interactions with the entire healthcare system. Baseline and regularly collected data from primary care assessments empower states and insurers to hold health service organizations accountable for the care provided to their enrolled populations.
The foundational role of primary care in rational healthcare systems is now widely recognized. Its key components are well-defined (2, 3) and include first contact care, person-focused care over time, comprehensiveness, and coordination. Furthermore, it encompasses the interconnected dimensions of community orientation, family-centeredness, and cultural competence.
Utilizing this robust theoretical framework of primary care attributes, assessment tools have been created to gather and analyze data. This data describes the primary care services delivered to and experienced by both children and adults. These assessments are designed to reflect organizational resources and processes that can be strategically modified to positively impact health care delivery outcomes (4).
The PCAT instruments are structured around these core principles of primary care. A thorough understanding of these concepts is vital for grasping the purpose and significance of the questions within the questionnaires. The following section offers a concise overview of primary care as it relates to evaluating the quality of primary care service delivery.
Primary care functions as a consistent and ongoing source of person-oriented healthcare over time. It is thoughtfully planned and delivered using insights into the families, communities, and cultures of the populations served.
The delivery of primary care is defined by a set of key attributes and characteristics (5). Below is a brief description of the four primary attributes, along with three related aspects:
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“First-contact” Care: This principle signifies that individuals initially seek care from their primary care provider when a new health concern or medical need arises. The primary care provider serves as the standard point of entry into the healthcare system for all new health needs, except in cases of severe emergencies. The provider may deliver care directly or act as a facilitator, guiding patients toward the most appropriate sources of care in a timely manner. For services to be considered as providing first-contact care, they must be readily accessible (a structural element) and consistently utilized by the population whenever a new health need or problem occurs (a behavioral element).
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Continuous (Ongoing) Care: This refers to the sustained use of a regular source of care over time, regardless of whether an individual is currently experiencing illness or injury. The central idea is establishing a medical or healthcare “home” recognized by both the patient and the provider. Continuous care aims to cultivate a lasting relationship between provider and patient, fostering mutual understanding and awareness of each other’s expectations and needs. This necessitates identifying a defined population for whom the service or provider is responsible (through a population registry) and maintaining an ongoing, person-focused (rather than disease-focused) relationship between providers and patients over time.
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Coordinated Care: This involves effectively linking health care visits and services to ensure patients receive appropriate care for all their health concerns, encompassing both physical and mental health. 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 seamless transitions and prevents fragmented care.
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Comprehensive Care: This attribute refers to the availability of a broad spectrum of services within primary care. These services should be appropriately delivered to address the vast majority of health needs within a population, excluding only the most uncommon or highly specialized problems. A primary care provider should be equipped to offer services that promote and maintain health (preventing disease, injury, and dysfunction) and manage illness, disability, and discomfort, provided these conditions are within the provider’s competence (generally conditions occurring at a frequency of at least one to two thousand people per year in the population). This range of services 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 treatments, common skin condition management, behavioral health and common mental health issue support, 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 (indicating that the service is actually provided when needed). This results in a total of eight core subdomains. Crucially, all eight core subdomains are applicable to both adult and child consumer-client surveys, as well as provider and facility versions of the PCAT.
Building upon these four primary attributes, three additional aspects of care are often considered in primary care assessments:
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Family-centered Care: This approach acknowledges the family as a vital participant in a patient’s health assessment and treatment. Families have the inherent right and responsibility to actively engage, both individually and collectively, in decisions regarding the health care needs of their members. Family-centered care demonstrates an understanding of the interconnectedness of family health, recognizing the impact of a family member’s health, illness, disability, or injury on the entire family unit. It also considers how family structure, function, dynamics, and family health history influence both health risks and health promotion for all family members.
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Community-oriented Care: This refers to care delivery that is deeply rooted in the context of the community it serves. The defining feature of community-oriented primary care (COPC) is its focus on the health care needs of a defined population. COPC extends its concern beyond individual patients and families seen by providers to include the unmet health care needs of individuals within the community and the broader community characteristics that influence the health of all its members.
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Culturally Competent Care: This denotes care that respects and values the beliefs, interpersonal styles, attitudes, and behaviors of individuals as they relate to health. It encompasses the skills necessary to translate these beliefs, attitudes, and orientations into practical actions and behaviors that effectively preserve and promote health within diverse cultural contexts.
The Evolution and Impact of Primary Care Assessment Tools
Evolving trends in health services organization and delivery have spurred significant research and programmatic endeavors in primary health care. The development of Primary Health Care Assessment Tools is a direct result of ongoing initiatives to evaluate the extent to which primary care principles are implemented for populations enrolled in various types of health care organizations and plans. This collaborative effort originated from 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 at the Johns Hopkins Bloomberg School of Public Health.
Historically, prior to the 1990s, defining primary care in measurable terms proved challenging (3, 5). However, the degree to which primary care components are achieved can be effectively assessed by examining the structural and process elements of a health service system. Structural elements include accessibility, service range, patient population definition, and continuity of care. Process elements encompass health service utilization and health problem recognition. All four core domains of primary care—first contact care, continuity (or longitudinality), comprehensiveness, and coordination—can be evaluated by analyzing these structural (“capacity”) and process (“actions” or “behavior”) elements.
Alt text: Doctor explaining primary health care assessment results to a patient in a clinic, emphasizing clear communication and patient understanding.
The Primary Care Assessment Tools are specifically designed to measure the realization of primary care attributes. They provide valuable data on the structural and process elements linked to the four key domains of primary care. This includes information on the healthcare facility’s focus, patient demographics, available onsite services, and perspectives from patients, providers, and facilities regarding care experiences. Scores at the subdomain (structure and process), domain, and overall primary care levels can be derived from 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 and health plans participating in Florida’s Healthy Kids subsidized insurance program (6).
Further validation of the PCAT instruments was conducted and detailed in a study published in 1998. This research assessed the quality of primary care provided to children in diverse healthcare settings within 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 providers. The study findings indicated that the tools effectively measured key primary care domains with “reliability and a consistency that [suggested] validity.” Furthermore, they demonstrated the ability to detect variations in primary care delivery across different types of provider organizations and facilities (4).
To adapt and validate the tools for adult populations, a study 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 instrumental in conducting further statistical analyses to assess the validity, reliability, and refine the instruments for use with adult populations.
The PCAT tools have since been extensively utilized in various countries, 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 are available in Spanish, Catalan, Portuguese, Mandarin Chinese (for both PRC and Taiwan), and Korean, reflecting the global recognition of the need to assess primary care adequacy. Several evaluations using PCAT tools have been published (refer to the PCAT references below), demonstrating the cross-cultural reliability of the instrument in assessing primary care across diverse settings.
For those seeking more detailed information about the PCAT, its administration, and its 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.
