Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities

Abstract

Background: The four primary care (PC) core functions (the ‘4Cs’, ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health. However, their broad definitions have led to variations in their assessment, in the innovations implemented to improve these functions and ultimately in their performance. Objectives: To update and operationalise the 4Cs’ definitions by using a literature review and analysis of enhancement strategies, and to identify innovations that may lead to their enhancement. Methods: Narrative, descriptive analysis of the 4Cs definitions, coming from PC international reports and organisations, to identify measurable features for each of these functions. Additionally, we performed an electronic search and analysis of enhancement strategies to improve these four Cs, to explore how the 4Cs inter-relate. Results: Specific operational elements for first contact include modality of contact, and conditions for which PC should be approached; for comprehensiveness, scope of services and spectrum of population needs; for coordination, links between PC and higher levels of care and social/community-based services, and workforce managing transitions and for continuity, type, level and context of continuity. Several innovations like enrolment, digital health technologies and new or enhanced PC provider’s roles, simultaneously influenced two or more of the 4Cs. Conclusion: Providing clear, well-defined operational elements for these 4Cs to measure their achievement and improve the way they function, and identifying the complex network of interactions among them, should contribute to the field in a way that supports efforts at practice innovation to optimise the processes and outcomes in PC.

Diagnostic excellence in primary care

“…The 4Cs of primary care essential for quality healthcare include first contact, comprehensiveness, coordination, and continuity. Its achievement not only improves health outcomes for patients but also improves inequalities and cost‐effectiveness 4 . This definition is consistent with the foundation of diagnostic excellence 2 .…”

The impact of remote care approaches on continuity in primary care: a mixed-studies systematic review

“…Primary care, the "provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (1, 2) has four key attributes: first contact access; a long-term person focus (i.e. continuity); comprehensiveness; and coordination, with a secondary focus on family centeredness, cultural competency and community orientation (3,4). Healthcare systems with strong primary care sectors are associated with improved and more equitable health outcomes and greater cost efficiencies than those more reliant on specialist services (5,6).…”

“…These are first-contact access; a long-term person focus (continuity); comprehensiveness; and coordination; with a secondary focus on family-centredness, cultural competency, and community orientation. 3 , 4 Healthcare systems with strong primary care sectors are associated with improved and more equitable health outcomes and greater cost efficiencies than those more reliant on specialist services. 5 , 6 …”

Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes

“…In several countries primary care and secondary care play an important role in health care organisation. The aim of primary care is providing access and use of health services whenever necessary, comprehensiveness, coordination and continuity of care [ 1 ]. Secondary care mostly takes place in hospitals, is more specialised and is only accessible through referral.…”