In the present study of 473 migrant patients, patients perceived PHC service quality to be better in higher-quality CHCs. All observed associations were stronger for migrants older than 60 years. To our best knowledge, this is the first report globally to explore the relationship between PCMH achievement by CHCs (institutional quality) and the quality of migrant patients’ PHC experiences (individual quality) service quality.
The structure–process–outcome model propounded by Donabedian states that better processes lead to better outcomes.[31, 32] In the present study, “process quality” reflected how CHCs administered PHC services. “Outcome quality” was reflected in the patients’ experiences. Thus, to improve patients’ experiences, CHCs must progress in their ability to provide PHC services.
The PCMH personalizes, prioritizes, and integrates PHC services to improve the health of individuals, families, communities, and the nation’s population by identifying and implementing new organizational practices and enhancing CHCs’ internal capabilities.[33] NCQA-PCMH recognition is important for assuring quality PHC services. The NCQA-PCMH can serve as a model when attempting to improve the quality of PHC services delivered by CHCs to migrant patients in China.[24, 34]
In the present study, patients seen at Level 3 CHCs had higher PCAT and total sub-dimension scores compared to patients seen at Levels 1 or 2 CHCs. Furthermore, we found associations between PCMH achievement by CHCs and migrant patients’ PHC experiences, even after adjusting for confounders. Thus, the highest-level NCQA-PCMH CHCs provided the best care, consistent with the structure–process–outcome model proposed by Donabedian.[31, 32]
Of the ten participating CHCs, six were NCQA-PCMH Level 1, the “worst” level. Level 1 CHCs may provide substandard care and require more improvement, especially in Patient-centered Access and Team-based Care. Similarly, migrant patients had the worst “First-contact” experiences pertaining to care access and ongoing care, consistent with Wu’s prior report.[14]
Dimension D (“ongoing care”) was the lowest-scoring dimension. There are three types of continuity of care: informational, management, and relational.[35] Long-term relationships between physicians and patients develop over time. Migrants and other short-term residents may not have sufficient time to find and strengthen such relationships.[36] Most general practitioners (GPs) in China are unfamiliar with migrants’ preferences, values, and backgrounds. This lack of familiarity is non-conducive to consistent management of long-term diseases. Team-based care models are better equipped to address health and social inequities.[37] The experiences of migrant patients accessing PHC can be improved by improving continuity-of-care in CHCs, as per PCMH 2 (“Team-based Care”) standards. To ensure ongoing demand for their available PHC services, CHCs should strive to provide personalized healthcare using a relatively fixed team of GP physicians. CHCs that create dynamic management systems will be better positioned to serve migrant patients, given their unique residency status.[38]
Accessing PHC through CHCs was seen as difficult. This sentiment was reflected in the relatively low scores for PCAT C and PCMH 1. Accessibility refers to the ease with which a patient can converse with clinicians about any health issue (such as by telephone) and includes efforts to eliminate geographical, administrative, financial, cultural, and language barriers.[39] CHCs could strengthen their contacts with migrant patients by providing services in multiple ways, such as online consultations during off-work hours. Such changes would improve scores on both the NCQA-PCMH and PCAT.
Age might affect how CHC-provided PHC services are perceived. As demonstrated by our PCAT score results, stronger associations were observed among older migrants. Some studies [40, 41] found that elderly individuals use more PHC services than their younger counterparts. As such, older patients might be more sensitive to the effects of PHC service quality. Older adults are vulnerable and require considerable PHC services; thus, their health equity is a national priority. We extend this focus to include the population of elderly migrant patients. CHCs should focus on older migrant patients to improve PHC quality, in agreement with the initiative of developing elderly-friendly communities in China, considered a “rapidly aging country.”[42]
Although objective in quality assessment, our study had some limitations which warrant consideration. First, our data were obtained from a cross-sectional study, so we cannot infer a temporal association between process and outcomes. Second, the use of self-reported questionnaires is subject to recall bias which could have affected the between-group differences we observed. Finally, the sample size was limited because only ten CHCs participated.