Continuity in a VA Patient-Centered Medical Home Reduces Emergency Department Visits

Krisda H Chaiyachati,Woody Levin,Rebecca Brienza,Ali Khan,Emily Meyer,Theodore Long,Kirsha Gordon,Amy Justice,Antony Bayer

doi:10.1371/journal.pone.0096356

Krisda H Chaiyachati, Woody Levin + Show 7 more

Open Access

https://doi.org/10.1371/journal.pone.0096356

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Abstract

BackgroundOne major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED).ObjectiveTo characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits.DesignRetrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.PatientsThe 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.Main MeasuresOur exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit.ResultsThe patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (<33% of visits), individuals with medium (33–50%) and high (>50%) continuity were less likely to utilize the ED.ConclusionsStrong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services.

Highlights

The U.S healthcare system has become disjointed, a challenge for achieving patient-centered care [1,2,3]
Strong continuity of care is associated with decreased emergency department (ED) utilization in a Patient-Centered Medical Home (PCMH) model and improving continuity may help reduce the utilization of non-primary care services
The work is made available under the Creative Commons CC0 public domain dedication

Summary

Introduction

The U.S healthcare system has become disjointed, a challenge for achieving patient-centered care [1,2,3]. The patient-centered medical home (PCMH) model was conceived almost a halfcentury ago to facilitate greater integration and continuity, but did not gain prominence until a 2007 joint collaborative established a During the study period, over 40 internal medicine resident trainees and two NP fellow trainees were supervised by PCPs and assigned to PACT teams as part of their outpatient training requirements. One hallmark goal of PACT involves improved continuity of care between a patient and their primary care provider (PCP), partly because poor continuity is believed to contribute to the inappropriate use of healthcare services like emergency departments (ED) [13,14,15,16,17]. One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED)

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