Care Continuity and Care Coordination

Abstract

Improving care coordinationhas emergedas a key strategyof many payers and policymakers for enhancing the quality and lowering the costs ofhealth care in theUnitedStates.Accountable care organizations and bundled payments aim to bridge the provider-based silos that fragment care. Patient-centeredmedical homes (PCMHs) seek to coordinate the care of patients with chronic disease. And recent changes to Medicarephysicianpaymentsprovideexplicit incentives toenhance transitional care, such as the transition from hospital to outpatient care. To determine if care coordination does indeed have positive effects on quality or cost, the first step is to decide how it can be measured. In 2010, aNationalQuality Forumconsensus report1 identified 10 performancemeasures of care coordination, several focused on transitions in care. Others have identified continuityof careasan importantmeasureof care coordination.For example, the National Committee for Quality Assurance’s PCMH standards assess whether practices monitor the proportion of visits made to a single provider or team.2 More recently, the Centers for Medicare & Medicaid Services proposed a chronic caremanagement fee requiring “[c]ontinuity of care with a designated practitioner or member of the care teamwith whom the patient is able to get successive routine appointments.”3 In this issueof JAMA InternalMedicine,Husseyet al4 shed light on continuity of care as a distinct and eminently measurable component of care coordination. Using a national cohort of Medicare beneficiaries with congestive heart failure, diabetes, or chronic obstructive pulmonary disease, the authors assess whether continuity of outpatient care—as measured by the Bice-Boxerman continuity of care (COC) index5—was associatedwith resource utilization or complications. For all 3 conditions, they found that greater continuity of carebyoutpatientphysicianswasassociatedwith lower365day episode-based costs, fewer inpatient hospitalizations and emergency department visits, and fewer complications. Sensitivity analysesmeasuringcontinuityat thepractice levelproduced similar results. These findings should be interpreted with some caution, especially regarding theassociationbetweencontinuityof care andcomplications. Prior researchusing claimsdatahas shown that residents of higher utilizing areasmay appear sicker than they actually are because they havemore opportunities to be deemed ill.6 Because seeingmore unique providers also produces aworse COC index, the authors adjusted for number of visits to reduce this possible bias. Another potential limitation is reverse causality in this cross-sectional study. While a decline in continuity may plausibly lead to more complications, a patient with more complications may justifiably see moreproviders, leading to lowermeasured continuity of care. Interestingly, in sensitivity analyses, the authors did not find that patient visits increased after a complication. An additional consideration is that relatively few patients (≤10%) in each disease cohortwere hospitalized over 1 year, so the findings may not generalize to more frequently hospitalized patients with greater need for care coordination. Despite these potential limitations, the study by Hussey et al4 provides a timely reintroduction to the concept of continuity.With this reintroduction, should continuity of care be a characteristic that practices strive for and that policymakers measure and perhaps even reward? Placing a sharper focus on continuity of care has several potential benefits. Greater continuity may exert a muchneeded counterweight to the unintended consequences of changingpracticepatterns.Medical subspecializationhas fragmented care, and the growthof thehospitalistmovement has widened the divide between inpatient and outpatient care. These trends showno signs of abating, even as the number of chronically ill patients who require longitudinal care continues to rise. Another plus for measuring continuity is its relative simplicity. In contrast to themore challenging concept of Related article page 742 Figure. Conceptual Model of the Relationship between Care Continuity and Care Coordination