Elements of the patient-centered medical home associated with health outcomes among veterans: the role of primary care continuity, expanded access, and care coordination

Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review

BACKGROUND

Medication errors are common events that compromise patient safety. Outpatient and ambulatory settings enhance access to healthcare which has been linked to favorable outcomes. While medication errors have been extensively researched in inpatient settings, there is dearth of literature from outpatient settings.

AIM

To synthesize the peer-reviewed literature on the prevalence, nature, contributory factors, and interventions to minimize medication errors in outpatient and ambulatory settings.

METHOD

A systematic review was conducted using Medline, Embase, CINAHL, and Google Scholar which were searched from 2011 to November 2021. Quality assessment was conducted using the quality assessment checklist for prevalence studies tool. Data related to contributory factors were synthesized according to Reason's accident causation model.

RESULTS

Twenty-four articles were included in the review. Medication errors were common in outpatient and ambulatory settings (23-92% of prescribed drugs). Prescribing errors were the most common type of errors reported (up to 91% of the prescribed drugs, high variations in the data), with dosing errors being most prevalent (up to 41% of the prescribed drugs). Latent conditions, largely due to inadequate knowledge, were common contributory factors followed by active failures. The seven studies that discussed interventions were of poor quality and none used a randomized design.

CONCLUSION

Medication errors (particularly prescribing errors and dosing errors) in outpatient settings are prevalent, although reported prevalence range is wide. Future research should be informed by behavioral theories and should use high quality designs. These interventions should encompass system-level strategies, multidisciplinary collaborations, effective integration of pharmacists, health information technology, and educational programs.

Comparison of two GP service provider models in older adults: a register-based follow-up study

BACKGROUND

In Finland, there have been various strategies attempting to provide access to GPs. The 'restricted-List General Practitioner model' (rLGP) was launched in primary health care (PHC) in the city of Vantaa after the 'named General Practitioner model' (nGP) failed to provide sufficient access to GPs. This was done to improve access to GP appointments for those most needing care.

AIM

To evaluate the impact of the transition from nGP to rLGP on access to non-urgent scheduled appointments among patients aged ≥75 years.

DESIGN & SETTING

A register-based follow-up study in public PHC in Vantaa, Finland.

METHOD

The study focused on patients aged ≥75 years who used PHC from 2004-2008. It looked at the number of non-urgent and urgent scheduled appointments, patient contacts, home visits, PHC emergency department appointments, and cancelled appointments, which were recorded 7 years before and after the transition from nGP to rLGP in 2011 and adjusted to patient-years. Non-urgent appointments were booked to the patient's own nGP or rLGP in public PHC, whereas urgent appointments could be to any GP.

RESULTS

The number of non-urgent scheduled appointments to GPs was halved during the time of nGP, before launching the rLGP. Simultaneously, the number of urgent scheduled appointments more than tripled. The number of both started to plateau a year before the rLGP was launched. The number of both non-urgent and urgent scheduled appointments remained mainly at that level after rLGP was implemented.

CONCLUSION

The rLGP model was unsuccessful in improving access to non-urgent scheduled appointments to GPs.

Changes in Primary Care Quality Associated With Implementation of the Veterans Health Administration Preventive Health Inventory

Importance

The COVID-19 pandemic caused significant disruptions in primary care delivery. The Veterans Health Administration (VHA) launched the Preventive Health Inventory (PHI) program-a multicomponent care management intervention, including a clinical dashboard and templated electronic health record note-to support primary care in delivering chronic disease care and preventive care that had been delayed by the pandemic.

Objectives

To describe patient, clinician, and clinic correlates of PHI use in primary care clinics and to examine associations between PHI adoption and clinical quality measures.

Design, Setting, and Participants

This quality improvement study used VHA administrative data from February 1, 2021, through February 28, 2022, from a national cohort of 216 VHA primary care clinics that have implemented the PHI. Participants comprised 829 527 veterans enrolled in primary care in clinics with the highest and lowest decile of PHI use as of February 2021.

Exposure

Templated electronic health record note documenting use of the PHI.

Main Outcomes and Measures

Diabetes and blood pressure clinical quality measures were the primary outcomes. Interrupted time series models were applied to estimate changes in diabetes and hypertension quality measures associated with PHI implementation. Low vs high PHI use was stratified at the facility level to measure whether systematic differences in uptake were associated with quality.

Results

A total of 216 primary clinics caring for 829 527 unique veterans (mean [SD] age, 64.1 [16.9] years; 755 158 of 829 527 [91%] were men) formed the study cohort. Use of the PHI varied considerably across clinics. The clinics in the highest decile of PHI use completed a mean (SD) of 32 997.4 (14 019.3) notes in the electronic health record per 100 000 veterans compared with 56.5 (35.3) notes per 100 000 veterans at the clinics in the lowest decile of use (P < .001). Compared with the clinics with the lowest use of the PHI, clinics with the highest use had a larger mean (SD) clinic size (12 072 [7895] patients vs 5713 [5825] patients; P < .001), were more likely to be urban (91% vs 57%; P < .001), and served more non-Hispanic Black veterans (16% vs 5%; P < .001) and Hispanic veterans (14% vs 4%; P < .001). Staffing did not differ meaningfully between high- and low-use clinics (mean [SD] ratio of full-time equivalent staff to clinician, 3.4 [1.2] vs 3.4 [0.8], respectively; P < .001). After PHI implementation, compared with the clinics with the lowest use, those with the highest use had fewer veterans with a hemoglobin A1c greater than 9% or missing (mean [SD], 6577 [3216] per 100 000 veterans at low-use clinics; 9928 [4236] per 100 000 veterans at high-use clinics), more veterans with an annual hemoglobin A1c measurement (mean [SD], 13 181 [5625] per 100 000 veterans at high-use clinics; 8307 [3539] per 100 000 veterans at low-use clinics), and more veterans with adequate blood pressure control (mean [SD], 20 582 [12 201] per 100 000 veterans at high-use clinics; 12 276 [6850] per 100 000 veterans at low-use clinics).

Conclusions and Relevance

This quality improvement study of the implementation of the VHA PHI suggests that higher use of a multicomponent care management intervention was associated with improved quality-of-care metrics. The study also found significant variation in PHI uptake, with higher uptake associated with clinics with more racial and ethnic diversity and larger, urban clinic sites.

Continuity of care (COC) and amyloid-β PET scan: the CARE-IDEAS study

BACKGROUND

High continuity of care (COC) is associated with better clinical outcomes among older adults. The impact of amyloid-β PET scan on COC among adults with mild cognitive impairment (MCI) or dementia of uncertain etiology is unknown.

METHODS

We linked data from the CARE-IDEAS study, which assessed the impact of amyloid-β PET scans on outcomes in Medicare beneficiaries with MCI or dementia of uncertain etiology and their care partners, to Medicare claims (2015-2018). We calculated a participant-level COC index using the Bice-Boxerman formula and claims from all ambulatory evaluation and management visits during the year prior to and following the amyloid-β PET scan. We compared baseline characteristics by scan result (elevated or non-elevated) using standardized differences. To evaluate changes in COC, we used multiple regression models adjusting for sociodemographics, cognitive function, general health status, and the Charlson Comorbidity Index.

RESULTS

Among the 1171 cohort members included in our analytic population, the mean age (SD) was 75.2 (5.4) years, 61.5% were male and 93.9% were non-Hispanic white. Over two-thirds (68.1%) had an elevated amyloid-β PET scan. Mean COC for all patients was 0.154 (SD = 0.102; range = 0-0.73) prior to the scan and 0.158 (SD = 0.105; range = 0-1.0) in the year following the scan. Following the scan, the mean COC index score increased (95% CI) by 0.005 (-0.008, 0.019) points more for elevated relative to not elevated scan recipients, but this change was not statistically significant. There was no association between scan result (elevated vs. not elevated) or any other patient covariates and changes in COC score after the scan.

CONCLUSION

COC did not meaningfully change following receipt of amyloid-β PET scan in a population of Medicare beneficiaries with MCI or dementia of uncertain etiology. Future work examining how care continuity varies across marginalized populations with cognitive impairment is needed.

Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care

Importance

Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients.

Objective

To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death.

Design, Setting, and Participants

This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022.

Exposures

Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner.

Main Outcomes and Measures

Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015.

Results

Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]).

Conclusions and Relevance

Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.

Impact of relational continuity of primary care in aged care: a systematic review

Background

Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes.

Methods

Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions.

Results

Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335).

Conclusion

Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed.

Review registration

CRD42021215698.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03131-2.

Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization

OBJECTIVE

To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.

DATA SOURCES

Veterans Affairs (VA) and Medicare data.

STUDY DESIGN

We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.

DATA EXTRACTION METHODS

We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year.

PRINCIPAL FINDINGS

Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).

CONCLUSIONS

Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

Predictors of Temporary Profile Days Among U.S. Army Active Duty Soldiers

Introduction

More than 40,000 soldiers cannot deploy every year, which undermines readiness. The medical readiness of soldiers is a critical component of the overall operational readiness of the U.S. Army. Acute musculoskeletal injuries (MSIs) are the greatest threat to medical readiness. Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs. Poorly managed temporary profiles negatively impact a soldier’s work attendance, resulting in the loss or limitation of over 25 million workdays annually. Upgrading the electronic profile system and implementing the Army Medical Home has led to improvements in managing temporary profiles over the last decade. The Army Medical Home encompasses care delivery platforms, including the Patient-Centered Medical Home (PCMH) and Soldier-Centered Medical Home (SCMH). The structure of U.S. Army PCMHs and SCMHs differ in ways that may affect care processes and patient outcomes. Temporary profile management is an important soldier health outcome that has not been studied in relation to the U.S. Army’s PCMH and SCMH structures or care processes. Access to care, continuity, and communication are three care processes that have been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury. Understanding the impact of the medical home on temporary profile days is vital to medical readiness. This study aimed to (1) compare temporary profile days between the U.S. Army PCMHs and SCMHs and (2) determine the influence of medical home structures and care processes on temporary profile days among active duty U.S. Army soldiers receiving care for MSIs.

Materials and Methods

This was a retrospective, cross-sectional, and correlational study guided by Donabedian’s conceptual framework. We used secondary data from the Military Data Repository collected in 2018. The sample included 27,214 temporary profile records of active duty U.S. Army soldiers and 266 U.S. Army PCMH and SCMH teams. We evaluated bivariate and multivariate associations between outcomes and predictors using general and generalized linear mixed regression models. The U.S. Army Medical Department Center and School Institutional Review Board approved this study.

Results

Total temporary profile days ranged from 1 to 357, with a mean of 37 days (95% CI [36.2, 37.0]). There was a significant difference in mean temporary profile days between PCMHs (43) and SCMHs (35) (P &lt; 0.001). Soldiers in PCMHs were more likely to have temporary profiles over 90 days (OR = 1.54, 95% CI [1.17, 2.03]). Soldiers in the heavy physical demand category had fewer temporary profile days (P &lt; 0.001) than those in the moderate physical demand category. Age, sex, rank level, physical demand category, profile severity, medical home type, the “explain things” communication subscale, and primary care manager continuity were significant predictors of temporary profile days.

Conclusions

Excessive temporary profile days threaten medical readiness and overall soldier health. Aspects of the medical home structure and care processes were predictors of temporary profile days for musculoskeletal conditions. This work supports continued efforts to improve MSI-related outcomes among soldiers. Knowledge gained from this study can guide future research questions and help the U.S. Army better meet soldier needs.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Association of Team-Based Care and Continuity of Care with Hospitalizations for Veterans with Comorbid Mental and Physical Health Conditions

BACKGROUND

Integrating mental health in primary care settings is associated with improved screening and detection of mental illness. In 2010, the Veterans Health Administration launched a patient-centered medical home (PCMH) model nationally across all clinical sites that integrated mental health into primary care-the Patient Aligned Care Team (PACT) initiative. Team-based delivery of continuous primary and mental health care, as found in effective collaborative care models, is thought to be crucial to managing veterans with mental health disorders. The association between clinic implementation of specific aspects of PACT and clinical outcomes of veterans with mental health disorders remains unknown.

OBJECTIVE

To examine the association between clinic implementation of team-based care and continuity of care and subsequent hospitalizations among veterans with mental health disorders.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 1,444,942 veterans with comorbid mental health disorders and physical health conditions receiving primary care in 831 VA PACT clinics in fiscal year (FY) 2015.

MAIN MEASURES

We examined the clinic-level implementation of team-based care and continuity of care in the clinic where veterans received their primary care. Our primary outcome was any hospitalization in the VA or fee-based service in FY2016. We examined the impact of clinic-level implementation of team-based care and continuity of care on having a hospitalization, adjusting for patient demographic, clinical characteristics, and facility characteristics.

KEY RESULTS

Veterans receiving care in clinics with the greatest versus lowest quartile of implementation of team-based care had lower rates of hospitalization (8.8% vs. 12.3%; adjusted OR = 0.92, 95% CI 0.85-0.99, p < 0.035). There was not a statistically significant association between clinic-level implementation of continuity of care and hospitalization.

CONCLUSIONS

Veterans receiving care in clinics with greater implementation of team-based care had statistically significant lower rates of hospitalization.

Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia

BACKGROUND

Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization.

METHODS

National Veterans Health Administration data linked to Medicare claims in fiscal years 2014-2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0-1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities.

RESULTS

Veterans with a 0.1 higher BBC were 4.6% (p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities.

CONCLUSION

Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship-based care

AIMS

To identify the process that homecare nurses use when recognizing serious illness, engaging patients and families in goals-for-care discussions and guiding transitions to comfort-focused care.

DESIGN

Constructivist grounded theory.

METHODS

Semi-structured focus group interviews of 31 homecare Registered Nurses were recorded and transcribed (June-August 2019). Line-by-line coding using the constant comparative method until saturation was achieved and a grounded theory was identified. Credibility, transferability, and confirmability establish study rigor.

RESULTS

A grounded theory of relationship-based care. Nurses cogitate and act when recognizing serious illness. They have difficult conversations and support care transitions with wisdom and knowing, by identifying changes in illness trajectories and being informed and alert to diminishing quality of life. Nurses are skilled at engaging patients, families, and the team and accommodate care in the home for as long as possible, while manoeuvring through complex systems of care; ultimately relinquishing and guiding care to other providers and settings. However, nurses feel inadequately prepared and frustrated with a fragmented healthcare system and lack of collaboration among the team.

CONCLUSION

This study identifies a grounded theory to support clinical decision-making and position homecare nurses as leaders in guiding goal care discussions and transitions to comfort-focused care. These findings reinforce the importance of developing health policy that ensures care continuity in serious illness. Further research is needed to improve relationships across care settings and enhance training for the delivery of comfort-focused care in the home as changing needs emerge during serious illness management.

Can Continuity of Care Reduce Hospitalization Among Community-dwelling Older Adult Veterans Living With Dementia?

BACKGROUND

Hospitalization is a difficult experience, especially for patients with dementia. Understanding whether better continuity of care (COC) reduces hospitalizations can indicate interventions that might help curb hospitalizations.

OBJECTIVE

To estimate the causal impact of COC on hospitalizations and different reasons for hospitalization among community-dwelling older veterans with dementia.

RESEARCH DESIGN

Population-based observational study using nationwide Veterans Health Administration data linked to Medicare claims in Fiscal Years (FYs) 2014-2015. To account for unobserved confounders we used an instrumental variable for COC-whether veteran changed residence by more than 10 miles.

SUBJECTS

Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (n=105,528).

MEASURES

Bice-Boxerman Continuity of Care (BBC) index (0-worst to 1-best COC); binary indicators of any hospitalization for all causes, for ambulatory care sensitive conditions (ACSCs) and for reasons grouped by major diagnostic category.

RESULTS

The mean BBC in FY 2014 was 0.32 (SD, 0.23). In FY 2015 43.3% of the cohort veterans were hospitalized. A 0.1 higher BBC resulted in 2.4% (95% confidence interval, 0.5%-4.4%) lower probability of hospitalization for all causes. BBC was not associated with hospitalization for ACSCs. Grouped by major diagnostic category, a 0.1 higher BBC resulted in 3.8% (95% confidence interval, 2.1%-5.4%) lower probability of hospitalization for neuropsychiatric diseases/disorders, with no impact on hospitalizations for circulatory, respiratory, infectious, kidney and urinary, digestive, musculoskeletal, and endocrine-metabolic diseases/disorders.

CONCLUSIONS

Among community-dwelling older veterans with dementia, better COC resulted in less hospitalizations, and this effect was primarily due to less hospitalization for neuropsychiatric diseases/disorders but not hospitalization for ACSCs, or other hospitalization reasons.

Association between continuity and access in primary care: a retrospective cohort study

BACKGROUND

Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care.

METHODS

We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department.

RESULTS

We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access.

INTERPRETATION

Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.

Primary medical care continuity and patient mortality: a systematic review

BACKGROUND

A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care.

AIM

This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care.

DESIGN AND SETTING

Systematic review of studies published in English or French from database and source inception to July 2019.

METHOD

Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality.

RESULTS

Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated.

CONCLUSION

This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

Continuity of care and health care cost among community-dwelling older adult veterans living with dementia

OBJECTIVES

To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia.

DATA SOURCES

Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015.

STUDY DESIGN

FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.

DATA COLLECTION

Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).

PRINCIPAL FINDINGS

Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost.

CONCLUSIONS

COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.

Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans

IMPORTANCE

Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described.

OBJECTIVE

To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA).

DESIGN, SETTING, AND PARTICIPANTS

This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019.

EXPOSURES

Risk of hospitalization and assignment to general vs specialized primary care.

MAIN OUTCOME AND MEASURES

High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care).

RESULTS

The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall.

CONCLUSIONS AND RELEVANCE

The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.

Staff Perspectives on Primary Care Teams as De Facto "Hubs" for Care Coordination in VA: a Qualitative Study

BACKGROUND

Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed.

OBJECTIVE

To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA).

DESIGN

Qualitative study using semi-structured formative evaluation interviews.

PARTICIPANTS

Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems.

INTERVENTIONS

This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings.

APPROACH

We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers.

KEY RESULTS

PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs.

CONCLUSION

In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals.

Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia

OBJECTIVE

To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia.

DATA SOURCES/STUDY SETTING

National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension.

STUDY DESIGN

We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives.

DATA COLLECTION/EXTRACTION METHODS

Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply.

PRINCIPAL FINDINGS

Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes.

CONCLUSIONS

Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

Association between Continuity and Team-Based Care and Health Care Utilization: An Observational Study of Medicare-Eligible Veterans in VA Patient Aligned Care Team

OBJECTIVE

It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes.

DATA SOURCE

Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization.

STUDY DESIGN

Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013.

PRINCIPAL FINDINGS

A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits.

CONCLUSIONS

In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.

Independent home use of a brain-computer interface by people with amyotrophic lateral sclerosis

OBJECTIVE

To assess the reliability and usefulness of an EEG-based brain-computer interface (BCI) for patients with advanced amyotrophic lateral sclerosis (ALS) who used it independently at home for up to 18 months.

METHODS

Of 42 patients consented, 39 (93%) met the study criteria, and 37 (88%) were assessed for use of the Wadsworth BCI. Nine (21%) could not use the BCI. Of the other 28, 27 (men, age 28-79 years) (64%) had the BCI placed in their homes, and they and their caregivers were trained to use it. Use data were collected by Internet. Periodic visits evaluated BCI benefit and burden and quality of life.

RESULTS

Over subsequent months, 12 (29% of the original 42) left the study because of death or rapid disease progression and 6 (14%) left because of decreased interest. Fourteen (33%) completed training and used the BCI independently, mainly for communication. Technical problems were rare. Patient and caregiver ratings indicated that BCI benefit exceeded burden. Quality of life remained stable. Of those not lost to the disease, half completed the study; all but 1 patient kept the BCI for further use.

CONCLUSION

The Wadsworth BCI home system can function reliably and usefully when operated by patients in their homes. BCIs that support communication are at present most suitable for people who are severely disabled but are otherwise in stable health. Improvements in BCI convenience and performance, including some now underway, should increase the number of people who find them useful and the extent to which they are used.

Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality

OBJECTIVE

Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

MEDLINE, Embase and the Web of Science, from 1996 to 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients.

RESULTS

Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors.

CONCLUSIONS

This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important.

PROSPERO REGISTRATION NUMBER

CRD42016042091.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

Background

The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.

Objectives

To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.

Design

Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.

Data sources

Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.

Results

The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.

Limitations

The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.

Conclusions

Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

Study registration

This study is registered as PROSPERO CRD42016038900.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature

BACKGROUND

Continuity between patients and physicians is a core principle of primary care and an accreditation requirement. Resident continuity clinics face challenges in nurturing continuity for their patients and trainees.

OBJECTIVE

We undertook a scoping review of the literature to better understand published benchmarks for resident continuity; the effectiveness of interventions to improve continuity; and the impact of continuity on resident and patient satisfaction, patient outcomes, and resident career choice.

METHODS

We developed a MEDLINE search strategy to identify articles that defined continuity in residency programs in internal medicine, family medicine, and pediatrics published prior to December 31, 2015, and used a quality evaluation tool to assess included studies.

RESULTS

The review includes 34 articles describing 12 different measures of continuity. The usual provider of care and continuity for physician formulas were most commonly utilized, and mean baseline continuity was 56 and 55, respectively (out of a total possible score of 100). Clinic and residency program redesign innovations (eg, advanced access scheduling, team-based care, and block scheduling) were studied and had mixed impact on continuity. Continuity in resident clinics is lower than published continuity rates for independently practicing physicians.

CONCLUSIONS

Interventions to enhance continuity in resident clinics have mixed effects. More research is needed to understand how changes in continuity affect resident and patient satisfaction, patient outcomes, and resident career choice. A major challenge to research in this area is the lack of empanelment of residents' patients, creating difficulties in scheduling and measuring continuity visits.

Patient-Rated Access to Needed Care: Patient-Centered Medical Home Principles Intertwined

BACKGROUND

Primary care teams can facilitate access to care by helping patients to determine whether and when care is needed, and coordinating care across multiple clinicians and settings. Appointment availability metrics may or may not capture these contributions, but patients' own ratings of their access to care provide an important alternative view of access that may be more closely related to these key functions of care teams.

PROCEDURES

We used a 2015 telephone survey of 1,395 women veterans to examine associations between key care team functions and patient-rated access to needed care. The care team functions were care coordination, in-person communication (between patient and care team), and phone communication (timely answers to health questions). We controlled for sociodemographics, health status, care settings, and other experience of care measures.

KEY FINDINGS

Overall, 74% of participants reported always or usually being able to see a provider for routine care, and 68% for urgent care. In adjusted analyses, phone communication was associated with better ratings of access to routine care (odds ratio [OR], 4.31; 95% CI, 2.65-6.98) and urgent care (OR, 2.26; 95% CI, 1.23-4.18). Care coordination was also associated with better ratings of access to routine care (OR, 1.66; 95% CI, 1.01-2.74) and urgent care (OR, 2.26; 95% CI, 1.23-4.18). Associations with in-person communication were not significant.

CONCLUSIONS

Access, communication, and care coordination are interrelated. Approaches to improving access may prove counterproductive if they compromise the team's ability to coordinate care, or diminish the team's role as a primary point of contact for patients.

The Geriatrics in Primary Care Demonstration: Integrating Comprehensive Geriatric Care into the Medical Home: Preliminary Data

Three thousand nine hundred thirty-one veterans aged 75 and older receive primary care (PC) in two large practices of the Department of Veterans Affairs (VA) Boston Healthcare System. Cognitive and functional disabilities are endemic in this group, creating needs that predictably exceed available or appropriate resources. To address this problem, Geriatrics in Primary Care (GPC) embeds geriatric services directly into primary care. An on-site consulting geriatrician and geriatric nurse care manager work directly with PC colleagues in medicine, nursing, social work, pharmacy, and mental health within the VA medical home. This design delivers interdisciplinary geriatric care within PC that emphasizes comprehensive evaluations, care management, planned transitions, informed resource use, and a shift in care focus from multiple subspecialties to PC. Four hundred thirty-five veterans enrolled during the project's 4-year course. Complex, fragmented care was evident in a series of 50 individuals (aged 82 ± 7) enrolled during Months 1 to 6. The year before, these individuals made 372 medical or surgical subspecialty clinic visits (7.4 ± 9.8); 34% attended five or more subspecialty clinics, 48% had dementia, and 18% lacked family caregivers. During the first year after enrollment the mean number of subspecialty clinic visits declined significantly (4.7 ± 5.0, P = .01), whereas the number of PC-based visits remained stable (3.1 ± 1.5 and 3.3 ± 1.5, respectively, P = .50). Telephone contact by GPC (2.3 ± 2.0) and collaboration with PC clinicians replaced routine follow-up geriatric care. GPC facilitated planned transitions to rehabilitation centers (n = 5), home hospice (n = 2), dementia units (n = 3), and home care (n = 37). GPC provides efficient, comprehensive geriatric care and case management while preserving established relationships between patients and the PC team. Preliminary results suggest "care defragmentation," as reflected by a significant reduction in subspecialty clinic use. Model simplicity and flexibility facilitated ready implementation.

Patient-Centered Medical Home Recognition and Clinical Performance in U.S. Community Health Centers

INTRODUCTION

America's community health centers (HCs) are uniquely poised to implement the patient-centered medical home (PCMH) model, as they are effective in providing comprehensive, accessible, and continuous primary care. This study aims to evaluate the relationship between PCMH recognition in HCs and clinical performance.

METHODS

Data for this study came from the 2012 Uniform Data System (UDS) as well as a survey of HCs' PCMH recognition achievement. The dependent variables included all 16 measures of clinical performance collected through UDS. Control measures included HC patient, provider, and practice characteristics. Bivariate analyses and multiple logistic regressions were conducted to compare clinical performance between HCs with and without PCMH recognition.

FINDINGS

Health centers that receive PCMH recognition generally performed better on clinical measures than HCs without PCMH recognition. After controlling for HC patient, provider, and practice characteristics, HCs with PCMH recognition reported significantly better performance on asthma-related pharmacologic therapy, diabetes control, pap testing, prenatal care, and tobacco cessation intervention.

CONCLUSION

This study establishes a positive association between PCMH recognition and clinical performance in HCs. If borne out in future longitudinal studies, policy makers and practices should advance the PCMH model as a strategy to further enhance the quality of primary care.

Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

Objectives

To evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans.

Design

Retrospective cohort study.

Setting

Department of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities.

Participants

Medicare‐eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007–08 (baseline period) (N = 243,881).

Measurements

Two measures of longitudinal continuity were estimated using merged VA–Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services.

Results

The incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02–1.07), intermediate (IRR = 1.04, 95% CI = 1.02–1.07), and low (IRR = 1.06, 95% CI = 1.03–1.09) UPC than in those with very high UPC (0.9–1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01–1.07), intermediate (OR = 1.03, 95% CI = 1.00–1.06), and low (OR = 1.04, 95% CI = 1.01–1.07) UPC were also more likely to be hospitalized during follow‐up. Results were similar for MMCI continuity scores.

Conclusion

Even slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.

Usual Primary Care Provider Characteristics of a Patient-Centered Medical Home and Mental Health Service Use

BACKGROUND

The benefits of the patient-centered medical home (PCMH) over and above that of a usual source of medical care have yet to be determined, particularly for adults with mental health disorders.

OBJECTIVE

To examine qualities of a usual provider that align with PCMH goals of access, comprehensiveness, and patient-centered care, and to determine whether PCMH qualities in a usual provider are associated with the use of mental health services (MHS).

DESIGN

Using national data from the Medical Expenditure Panel Survey, we conducted a lagged cross-sectional study of MHS use subsequent to participant reports of psychological distress and usual provider and practice characteristics.

PARTICIPANTS

A total of 2,358 adults, aged 18-64 years, met the criteria for serious psychological distress and reported on their usual provider and practice characteristics.

MAIN MEASURES

We defined "usual provider" as a primary care provider/practice, and "PCMH provider" as a usual provider that delivered accessible, comprehensive, patient-centered care as determined by patient self-reporting. The dependent variable, MHS, included self-reported mental health visits to a primary care provider or mental health specialist, counseling, and psychiatric medication treatment over a period of 1 year.

RESULTS

Participants with a usual provider were significantly more likely than those with no usual provider to have experienced a primary care mental health visit (marginal effect [ME] = 8.5, 95 % CI = 3.2-13.8) and to have received psychiatric medication (ME = 15.5, 95 % CI = 9.4-21.5). Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist (ME = 7.6, 95 % CI = 0.7-14.4) and receive mental health counseling (ME = 8.5, 95 % CI = 1.5-15.6). Among those who reported having had any type of mental health visit, participants with a PCMH were more likely to have received mental health counseling than those with only a usual provider (ME = 10.0, 95 % CI = 1.0-19.0).

CONCLUSIONS

Access to a usual provider is associated with increased receipt of needed MHS. Patients who have a usual provider with PCMH qualities are more likely to receive mental health counseling.