The Improving Primary Care Assessment is intended to help sites measure how well a their primary care teams are functioning and to point toward improvements covered by the topics on this website. The Improving Primary Care Assessment can also help sites track progress toward practice transformation when it is completed at regular intervals.

This assessment was developed by the MacColl Center for Health Care Innovation at Group Health Research Institute.  It is based on the PCMH-A measures created by MacColl in collaboration with Qualis Health for the Safety Net Medical Home Initiative and supplemented by measures developed by Dr. Tom Bodenheimer related to his “10 Building Blocks of High-Performing Primary Care.”

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What Do Your Choices Mean?

  • If you score in Level D in any area, your practice is just getting started and may want to review the tools and resources in that section of the Guide to help you prepare for the key changes described there.
  • If you score in Level C in any area, your practice is in the early stages of change and can benefit from the action steps and resources in that section of the guide.
  • If you score in Level B in any area, your practice has implemented basic changes and can build upon your success with the action steps and resources in that section of the guide.
  • If you scored in Level A in any area, your practice has achieved most or all of the important changes required. Congratulations! You can still use the actions steps and resources in that section of the guide to find new ways to improve.

Build the Team

Assessments for The Practice Team

View topic

Clinical leaders...

Level D

intermittently focus on improving quality.
123

Level C

have developed a vision for quality improvement, but no consistent process for getting there.
456

Level B

are committed to a quality improvement process, and sometimes engage teams in implementation and problem solving.
789

Level A

consistently champion and engage clinical teams in improving patient experience of care and clinical outcomes, and provide time, training, and resources to accomplish the work.
101112

Quality improvement activities are conducted by...

Level D

a centralized committee or department.
123

Level C

topic specific QI committees.
456

Level B

all practice teams supported by a QI infrastructure.
789

Level A

practice teams supported by a QI infrastructure with meaningful involvement of patients and families.
101112

Staff other than PCPs...

Level D

play a limited role in providing clinical care.
123

Level C

are primarily tasked with managing patient flow and triage.
456

Level B

provide some clinical services such as assessment or self-management support.
789

Level A

perform key clinical service roles that match their abilities and credentials.
101112

Clinical support staff...

Level D

work with different providers every day.
123

Level C

are linked to providers in teams but are frequently reassigned.
456

Level B

consistently work with a small group of providers and staff in a team.
789

Level A

consistently work with the same provider(s) almost every day.
101112

Workflows for clinical teams...

Level D

have not been documented and/or are different for each person or team.
123

Level C

have been documented, but are not used to standardize workflows across the practice.
456

Level B

have been documented and are utilized to standardize practice.
789

Level A

have been documented, are utilized to standardize workflows, and are evaluated and modified on a regular basis.
101112

The practice...

Level D

does not have an organized approach to identify or meet the training needs for providers and other staff.
123

Level C

routinely assesses training needs and encurages on-the-job training for staff needing it.
456

Level B

routinely assesses training needs, and ensures that staff are appropriately trained for their roles and responsibilities.
789

Level A

routinely assesses training needs, ensures that staff are appropriately trained for their roles and responsibilities, and provides cross training to assure that patient needs are consistently met.
101112

Standing orders that can be acted on by non-independent providers under protocol...

Level D

do not exist for the practice.
123

Level C

have been developed for some conditions but are not regularly used.
456

Level B

have been developed for some conditions and are regularly used.
789

Level A

have been developed for many conditions and are used extensively.
101112

Assessment for The Medical Assistant (MA)

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MAs in our practice...

Level D

mostly take vital signs and room patients.
123

Level C

perform a few clinical tasks beyond rooming patients such as reviewing medication lists or administering a PHQ-2.
456

Level B

perform a few clinical tasks and collaborate with the provider in managing the panel (reviewing exception reports, making outreach calls).
789

Level A

collaborate with the provider in managing the panel, and play a major role providing preventive services, and services to chronically ill patients such as self-management coaching, or follow-up phone calls.
101112

Assessment for The Registered Nurse (RN)

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RNs in our practice...

Level D

are not part of the core practice team.
123

Level C

mostly triage phone calls and do injections or other procedures.
456

Level B

manage transitions within and across levels of care (home care, hospital, specialists). Provide specific intensive care coordination and management to highest risk patients.
789

Level A

provide care management for high risk patients and collaborate with providers in teaching and managing patients with chronic illness, monitoring response to treatment, and titrating treatment according to delegated order sets in independent nurse visits.
101112

Assessment for The Lay Person

View topic

Laypersons in our practice...

Level D

are not involved in clinical care.
123

Level C

mostly provide non-clinical patient-facing roles such as reception or referral management.
456

Level B

include individuals who do one or more of the following: provide self-management coaching, coordinate care, help patients navigate the health care system, or access community services.
789

Level A

perform the functions in Level B and are key members of core practice teams.
101112

Assessment for The Clinical Pharmacist

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A pharmacist(s)...

Level D

is not involved in our practice.
123

Level C

oversees our dispensary but is not much involved in clinical care.
456

Level B

is available to answer medication-related questions from providers and staff both directly and electronically.
789

Level A

works closely with the core practice team to review prescribing practices and proactively assist patients with medication related problems such as non-adherence, side effects and medication management challenges.
101112

Assessment for The Behavioral Health Specialist

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Behavioral health services...

Level D

are difficult to obtain reliably.
123

Level C

are available from mental health specialists but are neither timely nor convenient.
456

Level B

are available from community specialists and are generally timely and convenient.
789

Level A

are readily available from behavior health specialists who are on-site members of the care team or who work in a community organization with which the practice has a referral protocol or agreement.
101112

Do the Work

Assessment for Enhancing Access

View topic

Patients are encouraged to see their paneled provider and practice team...

Level D

only at the patient’s request.
123

Level C

by the practice team, but is not a priority in appointment scheduling.
456

Level B

by the practice team and is a priority in appointment scheduling, but patients commonly see other providers because of limited availability or other issues
789

Level A

by the practice team, is a priority in appointment scheduling, and patients usually see their own provider or practice team.
101112

Assessment for Self-Management Support

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Self-management support...

Level D

is limited to the distribution of information (pamphlets, booklets).
123

Level C

is accomplished by referral to self-management classes or educators.
456

Level B

is provided by goal setting and action planning with members of the practice team.
789

Level A

is provided by members of the practice team trained in patient empowerment and problem-solving methodologies.
101112

Assessment for Population Management

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Registry information on individual patients...

Level D

is not available to practice teams for pre-visit planning or patient outreach.
123

Level C

is available to practice teams but is not routinely used for pre-visit planning or patient outreach.
456

Level B

is available to practice teams and routinely used for pre-visit planning or patient outreach, but only for a limited number of diseases and risk states.
789

Level A

is available to practice teams and routinely used for pre-visit planning and patient outreach, across a comprehensive set of diseases and risk states.
101112

Assessments for Planned Care

View topic

Visits...

Level D

largely focus on acute problems of patient.
123

Level C

are organized around acute problems but with attention to ongoing illness and prevention needs if time permits.
456

Level B

are organized around acute problems but with attention to ongoing illness and prevention needs if time permits. The practice also uses subpopulation reports to proactively call groups of patients in for planned care visits.
789

Level A

are organized to address both acute and planned care needs. Tailored guideline-based information is used in team huddles to ensure all outstanding patient needs are met at each encounter.
101112

A patient who comes in for an appointment and is overdue for preventive care (e.g., cancer screenings)...

Level D

will only get that care if they request it or their provider notices it.
123

Level C

might be identified as being overdue for needed care through a health maintenance screen or system of alerts, but these tools are inconsistently used.
456

Level B

will be identified as being overdue for care through a health maintenance screen or system of alerts that is used consistently, but clinical assistants may not act on these overdue care items without patient-specific orders from the provider.
789

Level A

will be identified as being overdue for care through a health maintenance screen or system of alerts that is used consistently, and clinical assistants may act on these overdue care items (e.g., administer immunizations or distribute colorectal cancer screening kits) based on standing orders.
101112

Assessments for Care Management

View topic

Follow-up by the primary care practice with patients seen in the emergency room (ER) or hospital...

Level D

generally does not occur because the information is not available to the primary care team.
123

Level C

occurs only if the ER or hospital alerts the primary care practice.
456

Level B

occurs because the primary care practice makes proactive efforts to identify patients.
789

Level A

is done routinely because the primary care practice has arrangements in place with the ER and hospital to both track these patients and ensure that follow-up is completed within a few days.
101112

Clinical care management services for high-risk patients...

Level D

are not available.
123

Level C

are provided by external care managers with limited connection to the practice.
456

Level B

are provided by external care managers who regularly communicate with the care team.
789

Level A

are systematically provided by the care manager functioning as a member of the practice team, regardless of location.
101112

Assessment for Medication Management

View topic

In our practice medication management consists of...

Level D

prescribers who order prescriptions and refills as necessary.
123

Level C

a MA or another clinical staff member who reviews the EHR drug list at the beginning of a patient's appointment.
456

Level B

a pharmacist, nurse, or coach/educator who works directly with patients having challenges understanding or taking their medications, individually or in groups.
789

Level A

in addition to C and B, the practice has a pharmacist and/or nurse who can titrate medications for select groups of patients under standing orders.
101112

Assessment for Referral Management

View topic

Patients in need of specialty care, hospital care, or supportive community-based resources...

Level D

cannot reliably obtain needed referrals to partners with whom the practice has a relationship.
123

Level C

obtain needed referrals to partners with whom the practice has a relationship.
456

Level B

obtain needed referrals to partners with whom the practice has a relationship, and relevant information is communicated in advance.
789

Level A

obtain needed referrals to partners with whom the practice has a relationship, relevant information is communicated in advance, and timely follow-up after the visit occurs.
101112

Assessment for Behavioral Health Integration

View topic

Behavioral health services...

Level D

are difficult to obtain reliably.
123

Level C

are available from mental health specialists but are neither timely nor convenient.
456

Level B

are available from community specialists and are generally timely and convenient.
789

Level A

are readily available from behavior health specialists who are on-site members of the care team or who work in a community organization with which the practice has a referral protocol or agreement.
101112

Assessments for Communication Management

View topic

Contacting the practice team during regular business hours...

Level D

is difficult.
123

Level C

depends on the practice's ability to respond to telephone messages.
456

Level B

is accomplished by staff responding by telephone within the same day.
789

Level A

is accomplished by providing a patient a choice between email and phone interaction, utilizing systems that are monitored for timeliness.
101112

Test results and care plans...

Level D

are not communicated to patients.
123

Level C

are communicated to patients based on an ad hoc approach.
456

Level B

are systematically communicated to patients in a way that is convenient to the practice.
789

Level A

are systematically communicated to patients in a variety of ways that are convenient to patients.
101112

Assessment for Clinic-Community Connections

View topic

Linking patients to supportive community-based resources...

Level D

is not done systematically.
123

Level C

is limited to providing patients a list of identified community resources in an accessible format.
456

Level B

is accomplished through a designated staff person or resource responsible for connecting patients with community resources.
789

Level A

is accomplished through active coordination between the health system, community service agencies and patients and accomplished by a designated staff person.
101112