Primary Care Assessment Tools

Efforts to improve the accountability of health services organizations are likely to increase over time.  Since the ultimate goal of health services systems is to optimize health, both in the present through curative and rehabilitative care and in the future through preventive care, services that do not contribute to this end will be increasingly difficult to justify.  Therefore, measures of both the structures and processes of care continue to be important.  Given mounting evidence that primary care contributes in a major way to improving at least some outcomes (1), efforts to assess and assure the quality of primary care services delivery are important.

The Primary Care Assessment Tools have been developed for this purpose.  This set of tools consists of:

• Consumer-client surveys
• Facility surveys
• Provider surveys
• Health system survey (in preparation)

The manual contains information that will help researchers administer it in a research context. For other uses (evaluation of the quality of primary care delivery), some of the sections may be irrelevant, but are included for informational purposes.

The Concept of Primary Care

Characteristics of health services delivery that are unique to primary care have been specified in such a way that it is now possible to assess health services delivery systems according to the adequacy of their approach to providing primary care.  Since primary care services are person-focused, rather than illness- or problem-focused, their provision is equally appropriate to individuals and populations regardless of their levels of health. 

Moreover, since primary care is optimally the gateway to appropriate secondary and tertiary care, experiences with primary care will reflect, in part through its coordinating role, experiences with the rest of the health care system encountered by populations.  Baseline and periodically obtained data will allow states and insurers to hold health services organizations accountable for the services they provide to their enrollees.

Primary care is now well understood as the basis for rational health systems.  Its components are well known (2, 3).  A major challenge has been to translate the broad concepts into characteristics that can be measured.  These concepts include first contact care, person-focused care over time, comprehensiveness, and coordination, as well as the three related aspects of community orientation, family-centeredness and cultural competence.

Using this theoretical framework of primary care attributes and characteristics, tools have been developed to collect and analyze information needed to describe primary care services provided to and experienced by child and adult populations.  These assessments reflect the organizational resources and processes that can be changed in ways that have been demonstrated to positively influence outcomes of health care delivery (4).

The PCAT instruments are organized around the principles of primary care.  An understanding of these concepts will help clarify the purpose and importance of the questions included in the questionnaires.  The following is a brief review of the concept of primary care as it applies to the assessment of the quality of delivery of primary care services.

Primary care serves as an ongoing source of person-oriented care over time.  Primary care is planned and implemented using knowledge about families, communities and cultures of the population served.

The provision of primary care incorporates a set of attributes and characteristics (5).  The following briefly describes each of the four main attributes, as well as three related ones:

• “First-contact” care means that care is first sought from the primary care provider when a new health or medical need arises. The primary care provider serves as the usual entry point into the health care system for each new need for health services, except in the case of serious emergencies.  The primary care provider either provides care directly or serves as a facilitator, directing patients to more appropriate sources of care at the appropriate time. In order to be considered as providing first-contact care, the services must be accessible (a structural characteristic) and used by the population each time a new need or problem arises (a behavioral characteristic).
  
• Continuous (ongoing) care refers to the longitudinal use of a regular source of care over time, regardless of the presence or absence of disease or injury.  The focus here is on the creation of a “medical-” or “health care-" home” recognized by both the patient and the provider. Continuous care over time is intended to help the provider and the patient build a long-term relationship in order to foster mutual understanding between provider and patient and knowledge of both as to the other’s expectations and needs. Thus, it requires identification of a population for whom the service or provider is responsible, (a population registry), and it requires an ongoing person-focused (not disease-focused) relationship over time between providers and patient.
  
• Coordinated care is the linking of health care visits and services so that patients receive appropriate care forall  of their health problems, physical as well as mental. The essence of coordination is “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).
  
• Comprehensive care refers to the availability of a wide range of services in primary care and their appropriate provision across the entire spectrum of types of needs for all but the most uncommon problems in the population by a primary care provider.  This includes services that promote and preserve health: prevent disease, injury, and dysfunction; and care of illness, disability, and discomfort as long as these needs are not too uncommon for the primary care practitioner to maintain competence in dealing with them (generally occurring in at least one to two thousand people per year.). For example, this range of services includes (but is not limited to) prevention, coaching, counseling when appropriate, care for acute and chronic illnesses and injuries, minor surgery, injections, aspiration of joints, simple dislocations, common skin problems, behavioral health and common mental health problems, and community health resources information.

Each of the above four core domains of primary care has two subdomains: a structure-related subdomain (which indicates the capacity to provide needed services) and a behavior-related subdomain (which indicates that the service is provided when needed). Thus, there are a total of eight core subdomains.  All eight core subdomains of primary care apply to both adult and child consumer-client surveys and to the provider/facilities versions.

Three aspects of care follow from the achievement of the four main ones, and are sometimes also included in assessments of primary care.

• Family-centered care recognizes that the family is a major participant in the assessment and treatment of a patient.  Families have the right and responsibility to participate individually and collectively in determining and satisfying the health care needs of family members. Family-centered care reflects an understanding of the nature, role, and impact of family members’ health, illness, disability, or injury on the entire family and the impact of family structure, function, and dynamics, as well as family history of illnesses on both the risks of ill health and promotion of health of family members.
  
• Community-oriented care refers to care that is delivered in the context of the community. The distinguishing feature of community-oriented primary care (COPC) is that it takes into account the health care needs of a defined population.  COPC, therefore, is concerned with the health care needs not only of patients and families being seen by the provider, but also of people in the community whose health care needs are not being met, and the characteristics of communities that influence the health care needs of everyone in the community.
  
• Culturally competent care refers to care that honors and respects the beliefs, interpersonal styles, attitudes, and behaviors of people as they influence health. It implies skills that help to translate beliefs, attitudes, and orientation into action and behavior to preserve and promote health.

Evolution of the Primary Care Assessment Tools

Trends in the evolution of health services organization and delivery have promoted new research and programmatic efforts in the area of primary health care.  The framework for and development of the Primary Care Assessment Tools represents an outgrowth of ongoing efforts to determine the extent to which primary care is achieved for populations enrolled in different types of health care organizations and plans. These efforts represent a partnership that originated with the financial and administrative commitment of the U.S. federal Maternal and Child Health Bureau (MCHB), several 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 (before the 1990s), primary care definitions were problematic because they did not lend themselves to actual measurement of the degree of attainment of components related to primary care (3, 5). This degree of attainment, however, can be assessed by examining the structural and process elements of a health services system.  Structural elements include accessibility, range of services, definition of a patient population, and continuity of care.  Process elements include utilization of health services and health problem recognition.  All four major domains of primary care – first contact care, continuity (sometimes called longitudinality to convey the idea of care over time), comprehensiveness, and coordination of care – can be assessed by examining these structural (“capacity”) and process (“actions” or “behavior”) elements of a health services system.

The Primary Care Assessment Tools are appropriate for measuring the attainment of primary care attributes because they provide information on the structure and process elements related to the four key domains of primary care. This also includes information on the focus of the health care facility, patient characteristics, services available onsite, and patient-, provider-, and facility-related perspectives on the experiences of care received and care provided. Subdomain (structure and process), domain, and total primary care scores can be derived from the item scores.

Between 1995 and 1996, as part of the effort to develop and validate 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 enrolled in Florida’s Healthy Kids subsidized insurance program (6).

Further testing of the instruments was conducted and described in a 1998-published study, which ascertained the quality of primary care delivered by various health care settings to children in Washington, D.C. The Consumer-Client and Provider survey tools were administered by telephone to a random sample of 450 consumers and by mail to 101 of their providers.  Results indicated that the tools measured key primary care domains with a “reliability and a consistency that [suggested] validity” and that they had the ability to detect differences across various types of provider organizations and facilities with regard to primary care delivery (4).

In order to test an adaptation of the tools for adult populations, a 1999 in-person and mail survey of 890 individuals randomly selected from an HMO group and a low-income group was conducted in South Carolina (7). The data collected in these surveys were used to conduct additional statistical testing for validity, reliability, and instrument refinement of adult populations.

Further experience with the PCAT tools has taken place in Canada (especially Quebec), Brazil, Spain (Catalonia), South Korea, and China (both Taiwan and People’s Republic of China-PRC).  Versions exist in Spanish, Catalan, Portuguese, Mandarin Chinese (both PRC and Taiwan), and Korean and, as the need for assessment of the adequacy of primary care arises throughout the world. Some of the evaluations have been published (see PCAT references below); they indicate cross-cultural reliability of the instrument for assessing primary care.

For further information about the PCAT, its administration, and its use, please contact Dr. Leiyu Shi (lshi@jhsph.edu) or Dr. Barbara Starfield (bstarfie@jhsph.edu).

PCAT Research Publications

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.

Cassady CE, Starfield B, Hurtado MP, Berk RA, Nanda JP, Friedenberg LA. Measuring consumer experiences with primary care. Pediatrics (J Ambul Pediatr Assoc) 2000;105:998-1003.

Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Pract 2001;50:161W,175W (http://jfponline.com/content/2001/02/jfp_0201_01610.asp).

Villalbi JR, Pasarin M, Montaner I, Cabezas C, Starfield B. [Evaluation of primary health care]. Aten Primaria 2003;31:382-5.

Harzheim E, Starfield B, Rajmil L, Alvarez-Dardet C, Stein AT. [Internal consistency and reliability of Primary Care Assessment Tool (PCATool-Brasil) for child health services]. Cad Saude Publica 2006;22:1649-59.

Pasarin MI, Berra S, Rajmil L, Solans M, Borrell C, Starfield B. [An instrument to evaluate primary health care from the population perspective]. Aten Primaria 2007;39:395-401.

Haggerty JL, Pineault R, Beaulieu MD, et al. Practice features associated with patient-reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008;6:116-23.

Lee JH, Choi YJ, Sung NJ, et al. Development of the Korean primary care assessment tool--measuring user experience: tests of data quality and measurement performance. Int J Qual Health Care 2009;21:103-11.

References

1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.
   
2. Institute of Medicine. A Manpower Policy for Primary Health Care. IOM Publication 78-02. Washington, DC: National Academy of Sciences, 1978.
3. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.
4. 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.
5. Starfield B. Measuring the attainment of primary care. J Med Educ 1979;54:361-9.
6. 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.
7. Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Pract 2001;50:161W,175W (http://jfponline.com/content/2001/02/jfp_0201_01610.asp).

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