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Table 1 Description of included studies

From: Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review

Author/year/ country Study design Population (participants and setting) Vulnerability context Main characteristics of the intervention Other elements
Revision of professional roles
 Gray, 2013/ New Zealand [61] Quantitative descriptive Sample size: 400
Age: not reported.
Patients: Children with rheumatic fever caused by the Group A Streptococcal infections.
Setting: primary school
Children of primary school (1-8 years old), ethnic composition (Pacific and Maori). Nurse-led school-based clinics:
- social worker (ethnicity of whanau) was trained in recognition of skin infection and swabbing of sore throats;
- identification of students with symptoms of a sore throat by the social worker under the supervision of the public health nurse;
- medical treatment by a public health nurse (antibiotics and ointment) guided by the evidence-based guidelines;
- referral of students with skin infection by the social worker to the public health nurse for the full assessment;
- education of the parents on the importance and adherence to the medical treatment;
- regular phone follow-up by the public health nurse;
- assessment and treatment of household members at home.
Annual cost: $510 per student ($10 for consumables, $80 for diagnostic services, $420 for staffing costs).
Clinical multidisciplinary teams
 McDermott, 2001; 2004/ Australia [62] RCT Sample size: 21 primary healthcare centers (921 people)
Age: 53.3 ± 13.6 vs 52.4 ± 14
Patients: Patients with diabetes (type 2)
Setting: primary care
People with diabetes from remote indigenous communities - implementation by the local indigenous health workers supported by a specialist outreach service in the 21 primary healthcare centers of the Torres Strait District:
(i) registers of patients with diabetes;
(ii) recall and reminder systems;
(iii) basic diabetes care plans;
- training of the local indigenous health workers in clinical diabetes care;
- two-monthly newsletters.
 
 Doey, 2008/ Canada [54] NRS Sample size: 380 (survey), 805 (charts)
Age: 40.7 ± 15.2
Sex (female): 51 %
Patients: Patients with mental diseases
Setting: community mental health clinic
Patients with mental diseases such as depression, bipolar disorder, schizophrenia, psychosis, personality disorder Collaborative care:
- nurse practitioner was hired to provide primary care services in collaboration with the existing team of mental healthcare professionals (including nurses, social workers, a psychiatrist, a psychologist) in a community mental health clinic;
- nurse practitioner’s responsibilities were assessment and treatment of non-psychiatric acute and chronic diseases, physical examination, counseling on diet, exercise, substance abuse,
- the hospitalist (PCP) from the hospital treated patients outside the nurse’s scope of practice (5 afternoons per week);
- availability of the physician by phone and e-mail between visits.
External funding was allocated to hire nurse practitioners.
 Crustolo, 2005/ Canada [52] Quantitative descriptive Sample size: 4,280 referrals annually
Age: 45 % were 45-64 years old
Patients: Patients with nutrition-related health conditions.
Setting: primary care
Patients with dyslipidemia, type 2 diabetes, obesity. Shared care model of collaboration of PCP and dietitian:
- primary care practice received 10 h of nutrition services per month (half a day each week);
- registered dietitian provided assessment of patients and consultation of PCP on nutrition-related problems;
- patients were referred by the PCP (within 2 weeks after referral).
The Provincial Ministry of Health funded the intervention program in primary care practices.
 McCuloch, 2000/USA [45] NRS Sample size: 15,000 (approximately)
Age: not reported.
Patients: Patients with diabetes
Setting: Managed care (200 PCPs practicing in 25 clinics)
Patients with diabetes Group Health Cooperative program:
- development of electronic registry of patients with diabetes updated daily;
- joint examination of patients by PCP, diabetologist, and diabetes nurse specialist (at least one visit);
- application of evidence-based diabetes guidelines (retinal screening, microalbuminuria, and glycemic management;
- use of patient-friendly notebook for self-management.
Decrease in diabetic per member per month costs of $62.
 Michelen, 2006/USA [44] NRS Sample size: 1,250
(539 vs 711)
Age (1-5 years): 27.1 %
Ethnicity: 92.1 % of Hispanic
Patients: Uninsured immigrants
Setting: primary care, community health services
Uninsured immigrants with frequent use of the ED for preventable crisis. The Northern Manhattan Community Voices partners program:
- recruitment of a native Spanish speaker Health Priority Specialist experienced and knowledgeable of the target community and medical services;
- recruitment of linguistically similar to the target population Community Health Workers;
- Community Health Workers centered on direct patient and community outreach and assessment;
- Community Health Workers was physically located within their community.
- Health Priority Specialist were located in community medical centers;
- identification of frequent users of ED and assistance to find appropriate primary care services.
 
 Driscoll, 2013/ USA [50] Mixed methods study
(sequential explanatory design)
Sample size: 3,213
(390 vs 2,823)
Age: not reported
Participants: Alaska Native/Indian population, adults with asthma
Setting: primary care
The Alaska Native and American Indian population, patients with asthma Patient-centered medical home:
- matching of the patient to the team of medical home (self-selection or assignment);
- open scheduling of the appointment;
- expanded office hours;
- increased ability of electronic communication between patients and healthcare professionals;
- delivery of care by the multidisciplinary team: PCP, physician assistant, nurse, certified medical assistant, behavioral health consultants, nutritionists;
- delegation of more authority by the physicians to non-physician members (behavioral health consultants).
 
Formal integration of services
 Day, 2006/UK [65] NRS Sample size: 289
(126 vs 163)
Age: 0-18
Diseases: Children with mental health conditions.
Setting: primary care
Children 0 to 18 years old with mental health conditions Adolescent mental health outreach clinics:
- staffed with three clinical child psychologists, one child and family therapist;
- assessment and treatment of broad range of mental health problems;
- referral of patients with more complex conditions to the specialist clinics;
- referral to the outreach clinics were accepted from any sources (majority from PCPs).
 
 Garg, 2012/USA [26] Quantitative descriptive Sample size: 1059 families
Age: not reported.
Participants: Low-income people
Setting: Medical home
Low-income people Health lead model:
- completing a brief screening survey for social issues (e.g., food, housing) by parents at well-child care visit;
- referral to the intervention team located in the pediatric clinic;
- volunteer undergraduate students assist with connecting families to community-based resources through in-person meetings and telephone follow-up;
- follow-up by the students;
- update of referring physicians (e.g., pediatric primary care provider, nurse practitioner) on health outcomes.
 
 Lamothe, 2006/ Canada [56] Mixed methods study
(convergent parallel design)
Sample size: 82
Age: 75 and older
Participants: Elderly patients with severe chronic conditions
Setting: primary care and community (home of patients)
Elderly patients with severe chronic conditions: cardiac insufficiency, chronic obstructive pulmonary diseases, hypertension, unstable diabetes Telehomecare to create a network of services between hospital and primary care providers.
- equipment installed at patients’ home (a scale, thermometer, sphyngmomanometer, oxymeter, and pulse; if needed glucometer, spirometer, electrocardiograph, and a system for the measure of blood clotting);
- sending of measures on a daily basis to the primary care setting;
- nurse of primary care responsible for monitoring and responding to alerts from patients;
- telephone and home follow-up by the nurse if needed.
 
 Tourigny, 2004; Hebert, 2010/ Canada [53, 64] NRS Sample size: 920
(501 vs 419)
Age: 83
Sex (female): 67 %
Participants: Elderly people
Setting: primary care
Elderly people at risk of functional decline Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA):
- coordination between decision makers and managers at the regional and local levels;
- the “single entry point” (mechanism of accessing the services such as home care, rehabilitation services, hospital services, voluntary agencies, social economy agencies); it can be access by the telephone or written referral;
- 24/7 access to the general population through Health Info Line;
- use of “the single assessment instrument” for evaluating needs coupled with case-mix management system;
- development of the individualized service plan in collaboration of PCPs with multidisciplinary team;
- computerized clinical chart to facilitate communication between organizations and healthcare professionals.
 
 Levkoff, 2004; Chen, 2006/USA [41, 42] RCT Sample size: 2,022
(999 vs 1,023)
Age: 65 and older
Patients: Patient with mental health conditions
Setting: primary care
Patients with mental health conditions such as depression, anxiety, at risk drinking Integrated care model:
- co-location of mental health and substance abuse services in primary care facility;
- mental health and substance abuse services include assessment, care planning, counseling, psychotherapy, pharmacological treatment);
- PCPs required to be closely involved in the patient’s care.
 
 Brown, 2005/ USA [29] NRS Sample size: 17
Age: 41
Sex (female): 65 %
Patients: Patients with mental health problems
Setting: primary care
Patients with psychiatric health conditions (e.g., depression, panic disorder) and with high level of medical admission, ED visits, frequent outpatient visits, and frequent telephone calls. Primary intensive care:
Integration of mental health services in primary care facility:
- location of an internist, psychiatrist-internist, nurse practitioner, and social worker in primary care;
- initial assessment (2–3 sessions) lasted longer than usual time;
- multidisciplinary assessment and follow-up;
- frequent visits to the clinic (weekly initially);
- 24/7 availability of a team member on call via pager.
- development of care plan in collaboration with PCP.
Post-intervention total hospital cost was lower (p = NS).
 MacKinney, 2013/USA [33] NRS Sample size: 278
(278 vs 278)
Age: not reported.
Patients: Uninsured population
Setting: primary care
Uninsured patients (18 years old and older) with income less than 200 % of the Federal Poverty Level Project Access Program (Milwaukee):
- identification of uninsured individuals via an administrative system by the county social worker;
- identification of healthcare providers willing to provide free services via online, radio, newspaper public advertising;
- connections of the person in need of primary care services with a provider;
- delivery of full-spectrum basic laboratory and non-invasive radiology services;
- no pharmacy component.
 
 Bradley, 2012/USA [34] NRS Sample size: 26,000
Age (mean): 34.2
Sex (female): 63 %
Patients: Uninsured population
Setting: primary care
Uninsured patients with income less than 200 % of the Federal Poverty Level Community-based coordinated care program:
- identification of uninsured patients in ED, outpatient or inpatient settings;
- assistance with financial eligibility forms;
- assignment of the primary care provider willing to provide primary care services to this category of patients;
- remuneration of primary care providers: monthly management fee and fee-for-services
Over 3 years, inpatient costs per year fell by 50 % (p < 0.01)
 Kaufman, 2000/USA [31] NRS Sample size: 23,143
(10,029 vs 13,114)
Age (19–49): 69.5 %
Sex (female): 68.6 %
Patients: Uninsured patients
Setting: primary care
Uninsured patients below 235 % of the Federal Poverty Level not eligible for Medicaid Managed care:
- relocation of county funds to primary care sites from hospitals;
- assignment of eligible patients to preferred PCPs;
- each patient received a care plan identification card listing his/her PCP;
- monthly premium ranged from $0 to $10 for primary care visits depending upon income level;
- the benefit package also includes reduced out-of-pocket cost of medications, access to 24/7 telephone triage system; behavioral health service is not covered.
- increase of staff (12 new PCPs and 5 new family nurse practitioners);
- extension of clinic hours;
- relocation of case managers and social workers from inpatient to primary care clinics;
- relocation of alcohol and substance abuse counselors to primary care clinics.
The primary care clinics received:
- capitation of $4 per plan member per month as compensation;
- Medicaid professional primary care services capitation rate;
- reduced fee-for-service rate for specialists.
Savings of $148 per member per year on the cost of outpatient and inpatient care.
 Roby, 2010/USA [46] NRS Sample size: 2,708
(20,663 vs 34,079)
Age (55 and older): 67 %
Sex (female): 69 %
Patients: Low-income uninsured population
Setting: primary care
Uninsured patients (21–64 years old) with income less than 200 % of the Federal Poverty Level Medical services initiative program (a safety-net-based system):
- eligible patients are identified at the time they seek for health services;
- patient is assigned to a medical home within which they choose or are assigned to the primary care provider;
- patients were eligible for at least one visit to medical home within 12 months;
- patients with diabetes, congestive heart failure, hypertension, asthma are required to see a doctor at least twice within 12 months;
- multidisciplinary team consists of PCP, nurses, nurse practitioners, case managers/social workers;
- information system connected emergency rooms and community clinics to get a history of disease by the physicians of ED;
- this electronic system allowed to refer patients to their PCPs in case of nonemergent conditions;
- emergency phone line staffed with registered nurses is available 24/7;
- reimbursement: $15 to ED physicians for entering clinical information in the electronic system and $100 to community clinics for acceptance of referral from emergency.
PCPs are reimbursed on a fee-for-service rate based on 70 % of the Medicare fee schedule. Private providers received incentives to join the network and pay-for-performance payments for primary and preventive services.
Continuity of care via case management
 Beland, 2006/Canada [55] RCT Sample size: 1230
(606 vs 624)
Age: 82 vs 82
Sex (female):
71 % vs 72 %
Participants: Disabled elderly patients
Setting: primary care
Elderly patients with chronic diseases and functional disabilities System of Integrated Care for Older Persons (SIPA):
Two public community organizations responsible for home care (Centre Local de Services Communautaires) conducted:
- comprehensive geriatric assessment;
- assessment of patients’ needs;
- development of care plan in collaboration with PCP;
- mobilization and delivery of community services;
- availability of 24-h on-call services;
- patients were followed between hospital and community.
- compensation of PCPs for their time communicating with the research team ($400 per patient annually);
- 44 % higher community costs;
- 22 % lower total institutional costs;
- overall the intervention was neutral;
- no difference in out-of-pocket costs.
 Glendenning-Napoli, 2012/ USA [30] NRS Sample size: 83
Age (50–65): 76 %
Sex (female): 60.2 %
Patients: Uninsured patients
Setting: primary care
Uninsured patients with one or more chronic diseases (diabetes mellitus, hypertension, congestive heart failure, coronary artery disease) with frequent admissions to the ED and hospital Intensive case management program:
- identification of patients with frequent use of ED and frequent hospitalizations;
- in-home assessment of patient’s needs by a registered nurse (identification of barriers to accessing health care, health literacy level);
- accompany of patients to PCP to engage patients in their care;
- development of preventive care plan;
- in collaboration with social worker identification of patient’s need for social programs;
- telephone follow-up and home visits to reinforce the intervention;
- in-home education sessions on available pharmacy assistance programs.
- reduction in cost for acute outpatient visits (p < 0.009) and inpatient hospitalizations (p < 0.002);
- increase in cost for primary care visits (p < 0.02).
 Leff, 2009; Boult, 2011/USA [35, 59] RCT Sample size: 835
(433 vs 402)
Age: not reported.
Patients: Older patients
Setting: Managed care
Older patients (65 years and older) at high risk of using health services Practice-based team intervention:
- in-home comprehensive assessment of needs by a nurse (caseload 50 to 60 patients);
- development of the care plan;
- facilitation of the access to community resources;
- monthly follow-up;
- coordination of all patient care providers;
- facilitation of transition between care practices;
- education and support of caregivers.
Net savings (2/3 due to reductions in hospital utilization).
 Shah, 2011/USA [47] NRS Sample size: 258
(98 vs 160)
Age: 46.4 ± 9.6 vs 46 ± 10.7
Sex (female): 40.8 % vs 53.1 %
Patients: Uninsured population
Setting: Managed care
Uninsured Medicaid population, frequent users of ED (4 or more ED admissions, 3 or more admissions, 2 or more admissions and one ED visit within 1 year) Managed Care program:
- identification of uninsured frequent users of emergency room;
- assignment of a personal care manager who assists with access to social and medical resources;
- personal care manager helps schedule an appointment with a PCP;
- personal care manager helps bridge barriers between patients and health care system;
- monthly meeting of case manager with patients (at home, resource centers, at appointment);
- individually developed care plan;
- daily work of case manager with a patient in case of hospital admission.
Decrease of ED (p < 0.0001) and inpatient admission costs (p < 0.001)
 Wang, 2012/USA [43] RCT Sample size: 200
(98 vs 102)
Age: 42.9 ± 9.7 vs 43.6 ± 8.3
Sex (female): 8.2 % vs 3.5 %
Patients: Individuals released from prison
Setting: primary care
Formerly incarcerated people Primary care-based, complex care management:
- primary care services provided by a provider with experience working with this population and a community health worker with a personal history of incarceration ;
Community health worker provides:
- case management support, referrals to community-based housing, education, and employment support;
- medical and social service navigation (accompanying patients to pharmacies, social services, medical and behavioral health appointments;
- chronic disease self-management support (home visit for health education and medication adherence support).
The program utilized the existing resources in the community health center. The additional costs included the salary of community health worker and time of supervision.
 Wohl, 2011/USA [37] RCT Sample size: 89 (43 vs 46)
Age: not reported.
Sex (female): 23.3 % vs 30.4 %
Patients: Individuals with HIV released from prison
Setting: community settings
Formerly incarcerated HIV patients Bridge case management:
- training of case managers prior to start working with incarcerated patients (focus on the identification of the talents, resources, goals in non-judgmental environment);
- case managers were well aware of the services available in their home and neighboring counties;
- regular meeting with incarcerated people prior to and after release to identify medical and non-medical needs;
- development of care plan including housing, employment, medical care, substance abuse counseling;
- transition to community case management and local services after 6 months of follow-up;
- caseload of 15 clients per patient
 
 Dorr, 2008/USA [49] RCT Sample size: 3,432 (1,144 vs 2,288)
Age (mean): 76.2 ± 7.2 vs 76.2 ± 7.1
Sex (female): 64.6 % vs 64.6 %
Patients: Elderly patients with chronic diseases
Setting: primary care
Elderly patients with chronic diseases: diabetes, depression, hypertension, congestive heart failure Care Management Plus:
- training of care managers (nurses) on care for seniors, caregivers, chronic disease assessment, care standards;
- integration of the information technology tools (structured protocols, guidelines, tracking database) and electronic health record system in primary care facilities;
- placement of care managers in primary care facilities;
- referral of patients with chronic care needs by PCPs to care managers for assessment and enrolment in care management services.
 
 Sylvia, 2008/USA [39] NRS Sample size: 127 (62 vs 65)
Age (mean): 74.1 vs 75.8
Sex (female): 60.3 % vs 47.7 %
Patients: High risk elderly patients with chronic diseases
Setting: primary care
Elderly patients with chronic diseases congestive heart failure, hypertension, diabetes, dementia, depression Guided Care:
Trained registered nurses working in primary care practices, in close collaboration with PCPs (1 nurse per 2 PCPs):
- assess patient and caregiver needs;
- develop an individualized care plan;
- promote patient self-management;
- monitor patient’s condition;
- coordinate transitions between healthcare services;
- facilitate access to community resources.
Lower insurance expenditures (p = 0.35)
 Gravelle, 2007/UK [60] NRS Sample size: 64 intervention primary care practices
Age: not reported.
Patients: Elderly patients (≥65 years old) and a history of emergency admission
Setting: primary care
Elderly patients at high risk of emergency admission Case management:
- development of individualized care plan by the nurse practitioners in collaboration with PCP;
- coordination of services to prevent fragmentation of services;
- arrangement of access to community-based services.
 
 Horwitz, 2005/USA [40] RCT Sample size: 230 (121 vs 109)
Age (mean): 51.2 % vs 50.5 % (less than 30 years old)
Patients: Uninsured population
Setting: primary care
Uninsured patients (except substance abuse and mental health issues) The Community Access Program:
- identification of uninsured patients before discharge from the hospital who don’t have a PCP;
- assistance with enrolment to one of four PCPs;
- faxing the patient data to a case managers of the primary care facility;
- case managers contacted the patients to arrange an appointment.
Reduction in average cost of an emergency room visit
 Palfrey, 2002/USA [32] NRS Sample size: 267
(150 vs 117)
Age (0–5): 56 % vs 55.6 %
Sex (female): 33.3 % vs 33.3 %
Patients: Children with special health care needs
Setting: primary care
Children with special health care needs Pediatric Medical Home:
- designation of a pediatric nurse practitioner (PNP);
- designation of a lead PCP;
- arrangement of the schedule for the PNP (8 h per week devoted to the management of children with special needs) by the lead physician;
- in-home follow-up by the PNP;
- assistance with appointments and medication supply;
- development of the individualized health plan;
- sharing of the health plan and evolution of the condition with specialists;
- participation of a local parent consultant.
 
 Farmer, 2005/USA [27] NRS Sample size: 102 (51 vs 51)
Age: 7.4 ± 5.1
Participants: Children with special health care needs
Setting: primary care
Children with special health care needs (mental and neurological disorders, congenital anomalies) Medical home:
- delivery of care by PCP, nurse practitioner, a parent consultant;
- nurse practitioner provides: a home visit to conduct comprehensive assessment of medical and non-medical needs, a personalized letter describing health and services available to meet these needs, an individualized health plan for the child, at least 1 follow-up;
- nurse practitioner acted as consultant for 3 primary care practices;
- nurse practitioner interacts regularly with referring physicians and a designated nurse at each primary care practice;
- medical care was provided by these practices;
- a web-site was developed to ease access to additional supports and recourses by families and physicians.
 
 Druss, 2001/USA [36] RCT Sample size: 120 (59 vs 61)
Age (mean): 45.7 ± 8.4 vs 44.8 ± 8.0
Sex (female): 0 % vs 1.6 %
Patients: Patients with mental disorders
Setting: primary care
Patients with mental disorders: schizophrenia, posttraumatic stress disorder, major affective disorder, substance abuse Integrated care:
Integrated mental health service in the primary care (a multidisciplinary team of a nurse practitioner, PCP, a nurse case manager, physicians in the psychiatry and mental health clinics):
- supervision of the nurse practitioner (providing basic medical care) by the primary care provider;
- primary care provider is a liaison of primary and specialized services;
- the nurse provides education, preventive services, follow-up (telephone, e-mail, face-to-face), schedules an appointment;
- the nurse practitioner serves as a liaison of 3 mental health teams.
 
 Counsell, 2007/USA [38] RCT Sample size: 951 (474 vs 477)
Age (mean): 71.8 ± 5.6 vs 71.6 ± 5.8
Sex (female): 75.5 % vs 76.5 %
Patients: Low-income seniors
Setting: primary care
Low-income seniors (less than 200 % of the Federal Level of Poverty) with geriatric conditions such as difficulty walking, falls, pain, urinary incontinence, depression, vision and hearing problems, dementia Geriatric Resources for Assessment and Care of Elders (GRACE):
- in-home comprehensive geriatric assessment by a nurse/social worker;
- development of individualized care plan by a multidisciplinary team (a geriatrician, pharmacist, physical therapist, mental health social worker, community-based services representatives);
- regular meeting of the multidisciplinary team and PCP;
- ongoing support via en electronic medical records and web-based tracking system.
 
 Landi, 2001/Italy [63] NRS Sample size: 1204 (before-after)
Age (mean): 77.4 ± 9.7
Sex (female): 58.5 %
Patients: Frail older people
Setting: primary care
Frail older people Home care program:
- development of the community Geriatric Evaluation Unit (“a single enter center”) consisting of a geriatrician, a social worker, a physiotherapist, nurses jointly with a PCP;
- initial and follow-up assessments by case manager (a nurse);
- coordination of services delivery;
- facilitation of access to community-based services;
- PCP involved directly in care planning, case finding, and emergency situations.
27 % cost reduction with an estimated saving of $1,200 for each patient
 Callahan, 2006/USA [51] RCT Sample size: 153 (84 vs 69)
Age (mean): 77.4 ± 5.9 vs 77.7 ± 5.7
Sex (female): 46.4 % vs 39.1 %
Patients: dementia patients
Setting: primary care
Patients with dementia living in the community Collaborative care model:
- development of individualized care plan for the patient-caregiver dyad;
- regular assessment of patients’ condition;
- medication management by PCP;
- weekly review of care and adherence to guidelines by multidisciplinary team (geriatric nurse practitioner, PCP, geriatrician, geriatric psychiatrist, psychologist)
- monitoring of health condition and communication of healthcare professionals via web-based system.
$1000 annual cost of the case manager per patient (75 patients per year)
Continuity of care via arrangement for follow-up
 Sin, 2004/Canada [57] NRS Sample size: 125
(63 vs 62)
Age: 22.5 ± 13.7 vs 22.7 ± 12.6
Sex (female): 46 % vs 74 %
Patients: Patients with asthma
Setting: primary care
Patients with asthma Enhanced care:
- follow-up appointment with PCP within 4 weeks of discharge;
- a study coordinator makes an appointment on behalf of the patient;
- in case a patient does not have a PCP, he is offered to choose from a list of physicians willing to accept new patients;
- a reminder telephone call 1 or 2 days before the scheduled follow-up visit;
 
 DeHaven, 2012/ USA [48] NRS Sample size: 574
(265 vs 309)
Age: 35.7 ± 12 vs 35 ± 12.1
Participants: Uninsured adults
Setting: primary care
Uninsured low-income working individuals Project Access Dallas:
- monthly meeting with a community health worker;
- patients assigned to a PCP;
- referral to the specialist if needed;
- pharmacy benefits ($750 a year);
- PCPs and specialists donated their services depending on their capacity
The intervention resulted in less direct (p < 0.01) and indirect costs (p < 0.01).
Institution incentivesa
 Addink, 2011/UK [58] NRS Sample size: 24 practices in three local primary care trusts
Age: not reported.
Participants: Ethnic minority.
Setting: primary care
Patients from ethnic minority groups (non-white ethnicity) Pay for performance scheme:
Primary care practices received payment according to their performance based on the reporting of their patients.
- £36 million received for participation;
- £72 million received based on the positive responses of patients (£1.37 per highly satisfied registered patient).
 Tan, 2012/New Zealand [66] Mixed methods study
(convergent parallel design)
Sample size: the whole population
Age: not reported.
Patients: Ethnic and refugee communities, young people
Setting: primary care
Prioritized population: high deprivation, Maori, Pacific communities, refugees, young people Primary care framework:
Sustained and targeted investments over five years in:
- development of service delivery for equitable access (community health workers, additional nurses and outreach services, youth service);
- engagement of healthcare professionals to develop these services;
- development of health approaches in collaboration with ethnic groups (e.g., iwi);
- information sharing across the range of support services;
- building on intersectoral relationships;
- promotion of preventive programs (e.g., increase of physical activity);
- support of leadership by clinicians in more community-based care.
$6 M of annual funding over five years
 Feinglass, 2014/USA [28] NRS Sample size: 293
(138 vs 158)
Age (45–64): 48.8 % vs 58.8 %
Sex (female): 68 % vs 60 %
Participants: Uninsured adults
Setting: primary care
Uninsured adults with a household income below 200 % of Federal Poverty Level. County Health Care program (Access DuPage):
- assigns patients to PCPs;
- pays a small capitated fee to primary care clinics and PCPs while most of funding comes from county hospitals, county government, and foundations;
- coordinates purchase of medications with small enrollee copays;
- handles applications for Drug Assistance Programs which provides enrollees with medications.
Decrease of amount of payment/copayment for a visit (p < 0.0001).
 Capitationa
 Davidoff, 2008/USA [25, 67] NRS Sample size: 574
(265 vs 309)
Age: 2–17
Participants: Children with chronic health conditions
Setting: primary care
Children with common chronic health conditions such as attention deficit disorder, mental retardation, Down syndrome, asthma, cerebral palsy, sickle cell anemia, muscular dystrophy, autism, congenital or other heart diseases, diabetes. Primary care case management:
- PCPs are paid for care coordination to serve as “gatekeeper” for referrals to specialty services;
- care provided by PCPs is focused on early intervention, appropriateness, and coordination.
 
  1. RCT Randomized Controlled Trial, NRS Non-Randomized Study, NS Non-significant
  2. a Financial interventions according to the EPOC classification