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Chapter 2
PRIMARY HEALTH CARE DEFINED
The idea of primary care in health is well-known and widely
supported, but there is considerable disagreement about the precise mean-
ing of the term. In formulating a definition of primary care useful to
practitioners and patients, and to educators and policy-makers, the
committee examined dozens of definitions put forward by organizations
and individuals. Several views on the meaning of primary care were
presented at an open meeting held by the committee in January 1976 at
the National Academy of Sciences in Washington, D.C. Thirty-eight
definitions used by various individuals and groups were analyzed and
compared. 1/ The committee found these views helpful to its own efforts
to construct a definition of primary care and to develop criteria for
determining whether primary care is being delivered.
One conclusion drawn from the definitional analysis and discussion
was that primary care is distinguished from other levels of personal
health services by the scope, character, and integration of the services
provided. Personal health services exclude public, environmental, and
occupational health programs. Primary care cannot sufficiently be
defined by the location of care, by the provider's disciplinary training,
or by the provision of a particular set of services. The scope, character,
and integration of services therefore are the basis of the definition of
primary care presented in this chapter.
Because services define primary care, good practitioners can be
trained in any of a variety of disciplines. Many more primary care
practitioners graduate from family medicine programs than from surgery
programs. Nonetheless, it is possible for a graduate from either program
to practice exemplary primary care. It is also possible for a family
physician to provide care other than primary care.
Primary care may be furnished by a solo practitioner, a group
practice clinic, or a health maintenance organization. Excellent primary
care services can be delivered by a nonphysician, such as a family nurse
practitioner with suitable backup. In most cases, the complete array of
services cannot be offered by a single individual and should be provided
by a team that might include physicians, nurses, physician assistants,
social workers, technicians, administrators, secretaries, and others.
In addition, important health services are provided by dentists, podi-
atrists, optometrists, pharmacists, and other health professionals. 2/
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Primary care responsibility is exercised by physicians, nurse
practitioners, and physician assistants. This report uses the term
'primary care practitioner' to refer to physicians, nurse practitioners,
and physician assistants providing primary care as defined in this
chapter. Similarly, the term 'primary care physician' refers in this
report to a licensed doctor of medicine or osteopathy who provides
primary care as defined, irrespective of the physician's specialty
designation or training.
The attributes discussed below describe primary care as it should
and could be practiced in the United States today. Primary care units
that meet all criteria specified in this paper are not often found, but
all primary care providers should attempt to achieve these standards.
Professionals who train men and women for primary care should accustom
their students to a practice environment that meets or exceeds these
standards.
THE DEFINITION
The five attributes essential to the practice of good
primary care are accessibility, comprehensiveness, co-
ordination, continuity, and accountability.
ACCESSIBILITY OF SERVICES
Accessibility is especially important at the primary
care level because primary care practitioners are the
initial and most constant providers of health services.
Patients must be able to reach the practitioner or a
member of the team at all times. In addition, the
physical location and the internal facilities of the
primary care unit should be such that the patient can
reach and use the provided services. The provider
should be concerned that the cost of services and the
way in which they are provided are acceptable to
patients so that those who need care are not deterred
from seeking it.
Accessibility refers to the responsibility of the
provider team to assist the patient or the potential
patient to overcome temporal, spatial, economic, and
psychologic barriers to health care. Secondary to
accessibility are availability, attainability, and
acceptability. Availability refers to the temporal
aspects of access--for example, the maintenance of
around-the-clock coverage and reasonably fast
response to requests for service. Attainability
covers physical and economic aspects of access.
Acceptability refers to psychologic and social
aspects of access.
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Services should be available 24 hours a day, seven
day a week, although it is recognized that isolated
practitioners, who may practice excellent primary
care, cannot keep such a schedule. These practi-
tioners usually have a coverage arrangement with a
doctor in a neighboring town or a nearby emergency
room. The arrangement is known to the patients and
to the covering provider who routinely transmits
patient information back to the practitioners. How-
ever, a practitioner who leaves town without ensuring
that patients are informed of coverage arrangements,
or even without arranging for coverage, is not
practicing adequate primary care.
Similarly, a hospital that closes the doors to its
general clinic at 5:00 p.m. and routes all later
patients to the emergency room without additional
instructions or arrangements is not practicing
acceptable primary care. Such a clinic should have
an off-hours call schedule so that a patient can
contact his or her own practitioner or one who has
immediate access to the patient's records. Less
acceptable would be a system in which a member of
the primary care practice unit is "on call" to the
emergency room, responding when one of his or her
patients arrives, and incorporating a report of all
such visits into the office record. Some feel that
primary care practitioners should care for their
patients regardless of their ability to pay* Others
feel that a primary care practitioner should always
accept assignment under Medicare, and should always
accept Medicaid patients. Under the current system
of payment, the provider unit must maintain some
control over the payment structure or face economic
disaster. For this reason, these qualifications are
not considered essential to this definition; however,
the primary care provider should be concerned about
the economic status of the patients, and should
assist them whenever and however possible to over-
come financial barriers.
COMPREHENSIVENESS OF SERVICES
Comprehensiveness refers to the willingness and
ability of the primary care team to handle the
great majority of the health problems arising in
the population it serves.
A primary care practitioner may limit practice to an
age group (pediatrics, internal medicine) or to one
sex (obstetrics and gynecology). However, he or she
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should handle most of the problems arising in the
served population For example, an obstetrician and
gynecologist who refers patients elsewhere for general
physical examinations, headaches, febrile illnesses,
and other similar needs and problems is not practicing
primary care. Primary care includes provision of
such preventive services as blood pressure and weight
measurement, in addition to pap smears and breast
examinations. Most obstetricians and gynecologists
neither practice nor desire to practice primary care
as defined in this paper, although they could do so
if they wished. Similarly, the internist or pedia-
trician who has a subspecialty interest should provide
total care for the majority of patients' complaints
and be willing to care for patients in the appropriate
setting--whether the hospital, chronic care unit, or
the home.
Comprehensiveness of services is an attribute that
distinguishes the primary care practitioner from the
secondary care practitioner or referral specialist.
The latter chooses not to provide common medical
services in order to concentrate on more specialized
services. The primary care practitioner may have an
area of special medical interest, such as heart
disease or diabetes mellitus, but does not limit
services to concentrate on this interest.
Many professional groups provide services that are
an important part of the spectrum of primary care
services. Pharmacists provide valuable advice and
services to patients. Optometrists, podiatrists,
dentists, and many other health professionals
provide services that are a part of good health and
medical care. However, these professionals generally
do not provide the range of services characteristic
of primary care.
Nurse practitioners, physician assistants, and other
nonphysicians working as part of a primary care unit
can provide most, but not all, primary care services.
In most states, they would be violating medical
practice acts if they practiced independently. They
are valuable members of the primary care team, not
only because of their ability to increase the number
of patients seen but also because they can add to
the physician's usual range of services. Social
workers also expand the scope of services.
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COORDINATION OF SERVICES
The primary care practitioner coordinates the patient's
care, including that care provided by other specialists.
The practitioner is the ombudsman for patient contacts
with other providers, referring patients to appropriate
specialists, providing pertinent information to and
seeking opinions from these specialists, and explain-
ing diagnosis and treatment to patients.
In addition, the primary care practitioner coordinates
the patient's plan of care with his or her financial
capabilities and personal desires. This implies an
understanding of the patient's family and occupational
environment, financial circumstances, preferences,
and way of life.
CONTINUITY OF SERVICES
Continuity is the fourth essential attribute of primary
care, and it cannot exist without the first three.
Inaccessibility of a practitioner encourages patients
to use emergency rooms or other providers of services,
destroying continuity. Referral of patients to others
for services that should be within the scope of the
primary care unit promotes discontinuous and fragmented
care. Failure of the primary care practitioner to seek
results from referral sources and to incorporate this
information into the patient's record or failure to
accommodate and adapt to the patient's preferences also
destroy continuity.
The primary care provider should be more aggressive
in seeking continuity than is commonly the case today.
An instruction to return in one year for an examination
should be followed by a reminder card or telephone
call before the scheduled visit, and a missed ap-
pointment should evoke some effort to determine the
reason and to reschedule for a later time.
In today's practice environment, the patient's
record is of increasing importance in achieving
continuity of services. The solo practitioner of the
past may have been able to recall the most relevant
facts about his or her patients. However, in a
modern practice, quantitative data from tests and
coverage shared among partners place more importance
on a readily accessible record in which significant
problems are highlighted and the treatment plan is
outlined clearly.
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ACCOUNTABILITY
Accountability is an attribute not unique to primary
care, but essential to it. The primary care unit
should review regularly both the process and the out-
comes of its care. Reviews should lead to education
activities to correct deficiencies and expand skills
and services. All members of the staff should be
included.
In addition, the professional staff of the primary
care unit should establish a policy of providing
appropriate information to the patient about risks
and possible undesirable effects of treatment, and
about unexpected or undesirable outcomes, so that
the patient can make informed decisions about
proposed care.
Also, the physician has an obligation to maintain
appropriate financial accountability, including
adequate professional liability coverage.
A PRIMARY CARE CHECKLIST
To introduce as much specificity as possible into this definition of
primary care, a list of activities or indicators has been prepared.
They would be useful evidence of the achievement or presence of these
attributes in a given practice unit.
These indicators are not of equal importance or value. They have
been placed in order by separating those considered "essential" from
those considered "important." An essential indicator must be present
for the unit to be considered as having achieved the attribute under
which the indicator is listed.
This checklist could have many uses. Among the most important is its
use as a self-evaluative instrument for a clinic or practice unit. The
checklist could also be used by an outside agency as one measure In
determining whether or not a teaching clinic provides a true primary
care experience for its trainees. There are other indicators that
might have equal or greater value, and others may wish to validate these
indicators with more precision or to use another format.
In the list below, those items considered essential are designated by
the enclosed box in the right hand column, while those that are important,
but not essential, are designated by a dash.
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A. ARE SERVICES ACCESSIBLE ?
1. Are Services Available to Patients?
Is access to primary care
services provided 24 hours
a day, seven days a week?
b. Is there an opportunity for
a patient to schedule an
appointment?
c. Are scheduled office hours
compatible with the work
and way of life of most of
the patients?
d.
Can most (90 percent)
medically urgent cases be
seen within one hour?
Can most patients (90
percent) with acute but not
urgent problems be
seen within one day?
Can most (90 percent)
appropriate requests for
routine appointments, such
as preventive exams, be
met within one week?
2. Are Services Convenient to
Patients?
a. Is the practice unit
conveniently located, so
that most patients can
reach it by public or
private transportation?
b. Is the practice unit so
designed that handicapped
or elderly patients are not
inconvenienced?
Does the practice unit
accept patients who have
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l
a means of payment,
regardless of source
(Medicare, Medicaid)?
3. Are Services Acceptable to
Patients?
a. Is the waiting time for
most (90 percent) of the
scheduled appointments
less than one half hour?
b If a substantial minority
(25 percent) of patients
have a special language or
other communication bar-
rier, does the office staff
include people who can deal
with this problem?
c. Are waiting accommodations
comfortable and uncrowded?
d. Does the practice staff
consistently demonstrate an
interest in and appreciation
of the culture, background,
socioeconomic status. work
environment, and living
circumstances of patients?
Is simple, understandable
information provided to
patients about fees, billing
procedures, scheduling of
appointments, contacting the
unit after hours, and grievance
procedures?
Are patients encouraged to
ask questions about their
illness and their care, to
discuss their health problems
freely, and to review their
records, if desired?
Does the practice unit
accept patients without
regard to race, religion,
or ethnic origin?
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_/
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B. ARE SERVICES COMPREHENSIVE?
Within the patient population
served, and realizing that
this might be restricted to a
certain age (pediatrics) or
sex (obstetrics
and gynecology),
unit willing to
is the practice -v
handle, without referral, the
great majority (over 90 percent)
of the problems arising in this
population (for example, general
complaints such as fever or
fatigue, minor trauma, sore
throat, cough, and chest pain)?
-
2- Are appropriate primary and
secondary preventive measures
used for those people at risk
(for example:
for tetanus, polio; early
detection of hypertension;
control of risk factors for
coronary disease)?
. . .
Immunizations
Are the practiti Inure '
. . .
In the
Unit W1 lung, if appropriate,
to admit and care for patients
in hospitals?
4. Are the practitioners in the
unit willing to admit and care
for patients in nursing homes
or convalescent homes?
Are the practitioners in the
unit willing, if appropriate,
to visit the patient at home?
6. Are patients encouraged and
assisted in providing for their
own care and participating
allies in their own health
plan (for example, through
instruction in a_ :_ _ , ~ ,
exercise, accident prevention,
family planning, and adolescent
problems)?
as
care
mltr, ti on rli at
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/ /
/
/
/ /
/ /
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7. Do the practitioners in the unit
provide support to those agencies
and organizations promoting com-
munity health (for example: health
education programs for the public;
disease detection programs; school
health and sports medicine pro-
grams; emergency care training)?
C. ARE SERVICES COORDINATED?
1. Do the practitioners in the unit
furnish pertinent information to
other providers serving the
patient, actively seek relevant
feedback from consultants and
other providers, and serve as the
patient's ombudsmen in contacts
with other providers?
Is a summary or abstract of
the patient's record provided
to other physicians when needed?
3. Do the practitioners in the unit
develop a treatment plan with the
patient that reflects consideration
of the patient's understanding?
Do the practitioners use a variety
of tactics to ensure that the
patient will cooperate in the
treatment? Does the plan of treat-
ment reflect the patient's physical,
emotional, and financial ability to
carry it out?
4. Is another source of care recom-
mended when a patient moves to
another geographic area?
D. ARE SERVICES CONTINUOUS?
1. Can a patient who desires to do
so make subsequent appointments
with the same provider?
2. Are complete records maintained
in a form that is easily retriev-
able and accessible?
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3. Are relevant items or problems
in the patient's record high-
lighted, regularly reviewed,
and used in planning care?
4. Is each patient reminded of
his or her next appointment?
E. IS THE UNIT ACCOUNTABLE?
1. Do the practitioners in the unit
assume responsibility for alert-
ing proper authorities if a
patient's problem reveals a health
hazard that may affect others in
the community (for example:
discovery of exposure to toxic
chemicals in an industrial plant;
discovery of a communicable
disease)?
2. Is there a patient-disease and
age-sex registry maintained
that can provide the basis of :
practice audit?
Is there a system for regular
review of the quality of the
process of medical care (for
example, reviews for complete-
ness of therapeutic programs and
follow-up of acute illnesses)?
Is there a system for regular
assessment of the outcomes of
the care offered (for example:
review of outcome of treatment
of specific illnesses; review of
level of satisfaction of patients
with the services provided; review
of compliance with recommendations)?
5. Is there evidence that the unit
regularly assesses the capability
of the staff and provides oppor-
tunity for continuing education?
6. Are patients appropriately informed
about the nature of their condition,
the benefits and risks of available
treatments, and the expected outcome?
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Are they provided the opportunity to
ask questions and discuss their
medical record?
7. If unexpected or undesired outcomes
occur, are they made known and
adequately explained to patients,
and is a method established for
responding to any expressed dis-
satisfaction (such as conferences,
counseling, arbitration, adjustment
of billing, or referral)?
8. Does the provider maintain financial
accountability by keeping accurate
records and having adequate profes-
sional liability coverage?
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REFERENCE S
Chapter 2
1. See staff paper, "Definitions of Primary Care. "
2. See staff paper, "Roles of Other Professions in Primary Care. "
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Representative terms from entire chapter:
care unit
