Continuity of Primary Care in Community Health Centers.

Continuity of care is a key aspect of high-quality primary care. Vulnerable populations often experience fragmented care. Some US Department of Veterans Affairs (VA) clinics offer primary care in patient aligned care teams (PACTS) tailored for veterans with homeless experience (VHE), termed H-PACTs. To test the hypothesis that primary care continuity would be higher for VHEs in H-PACTs than for VHEs in mainstream VA PACTs and to compare other service utilization patterns by primary care clinic type. Retrospective observational cohort study including national survey data combined with VA electronic health records data from primary care clinics at 26 VA medical centers. Participants were VHEs who completed the national survey and had 2 or more primary care visits in the 12 months before the survey. The survey was completed between April and October 2018 and data were analyzed from April 2020 to November 2025. Enrollment in H-PACTs or mainstream PACTs. Continuity was calculated using the usual provider of care (UPC) measure, which is the proportion of primary care visits with the most frequently seen clinician. High continuity was defined as a UPC of 0.75 or higher. Multivariable regression models examined the association of H-PACT enrollment with high continuity, and other utilization measures included mental health, specialty visits, emergency department (ED) visits, and hospitalizations. A total of 2271 VHEs in H-PACTs (2140 [94.2%] male; 932 [41.0%] Black, 1050 [46.2%] White, and 263 [11.6%] other; mean [SD] age, 58.1 [9.3]) and 1627 VHE in mainstream PACTs (1393 [85.6%] male; 674 [41.4%] Black, 740 [45.5%] White, and 192 [11.8%] other; mean [SD] age, 60.7 [12.1]) were included. Compared with those in mainstream PACTs, VHEs in H-PACTs had a higher mean (SD) UPC (0.81 [0.23] vs 0.77 [0.25]; χ21 = 21.6; P < .001) and were more likely to achieve high continuity (1483 patients [65.3%] vs 938 [57.7%]; χ22 = 25.0; P < .001). After multivariable adjustment, care in H-PACTs remained associated with high continuity (odds ratio [OR], 1.48; 95% CI, 1.33-1.66). In adjusted analyses, compared with those in mainstream PACTs, VHEs in H-PACTs had significantly more primary care visits (4.6 vs 4.0; z score = 5.28; P < .001), fewer specialty visits (6.2 vs 7.9 visits; z score = -4.66; P < .001), and were less likely to have an ED visit (OR, 0.83; 95% CI, 0.75-0.92). In this study, VHEs in H-PACT clinics had higher primary care continuity with no indication of substitution of specialty or emergency visits for primary care. The H-PACT model is associated with less intensive health care delivery.

ObjectiveWhile research suggests that higher continuity of primary and specialty physician care can improve patient outcomes, their effects have rarely been examined and compared concurrently. We investigated associations between continuity of primary and specialty physician care and emergency department visits and hospital admissions among community-dwelling older adults with complex care needs.MethodsWe conducted a retrospective cohort study of home care patients in Ontario, Canada, from October 2014 to September 2016. We measured continuity of primary and specialty physician care over the two years prior to a home care assessment and categorized them into low, medium, and high groups using terciles of the distribution. We used Cox regression models to concurrently test the associations between continuity of primary and specialty care and risk of an emergency department visit and hospital admission within six months of assessment, controlling for potential confounders. We examined interactions between continuity of care and count of chronic conditions, count of physician specialties seen, functional impairment, and cognitive impairment.ResultsOf 178,686 participants, 49% had an emergency department visit during follow-up and 27% had a hospital admission. High vs. low continuity of primary care was associated with a reduced risk of an emergency department visit (HR = 0.90 (0.89–0.92)) as was continuity of specialty care (HR = 0.93 (0.91–0.95)). High vs. low continuity of primary care was associated also with a reduced risk of a hospital admission (HR = 0.94 (0.92–0.96)) as was continuity of specialty care (HR = 0.92 (0.90–0.94)). The effect of continuity of specialty care was moderately stronger among patients who saw four or more physician specialties.ConclusionHigher continuity of primary physician and specialty physician care had independent, protective effects of similar magnitude against emergency department use and hospital admissions. Improving continuity of specialty care should be a priority alongside improving continuity of primary care in complex, older adult populations with significant specialist use.

While research suggests that higher continuity of primary and specialty physician care can improve patient outcomes, their effects have rarely been examined and compared concurrently. We investigated associations between continuity of primary and specialty physician care and emergency department visits and hospital admissions among community-dwelling older adults with complex care needs. We conducted a retrospective cohort study of home care patients in Ontario, Canada, from October 2014 to September 2016. We measured continuity of primary and specialty physician care over the two years prior to a home care assessment and categorized them into low, medium, and high groups using terciles of the distribution. We used Cox regression models to concurrently test the associations between continuity of primary and specialty care and risk of an emergency department visit and hospital admission within six months of assessment, controlling for potential confounders. We examined interactions between continuity of care and count of chronic conditions, count of physician specialties seen, functional impairment, and cognitive impairment. Of 178,686 participants, 49% had an emergency department visit during follow-up and 27% had a hospital admission. High vs. low continuity of primary care was associated with a reduced risk of an emergency department visit (HR = 0.90 (0.89-0.92)) as was continuity of specialty care (HR = 0.93 (0.91-0.95)). High vs. low continuity of primary care was associated also with a reduced risk of a hospital admission (HR = 0.94 (0.92-0.96)) as was continuity of specialty care (HR = 0.92 (0.90-0.94)). The effect of continuity of specialty care was moderately stronger among patients who saw four or more physician specialties. Higher continuity of primary physician and specialty physician care had independent, protective effects of similar magnitude against emergency department use and hospital admissions. Improving continuity of specialty care should be a priority alongside improving continuity of primary care in complex, older adult populations with significant specialist use.

Despite patient preference and many known benefits, continuity of care is in decline in general practice. The most common method of measuring continuity is the Usual Provider of Care (UPC) index. This requires a number of appointments per patient and a relatively long timeframe for accuracy, reducing its applicability for day-to-day performance management. To describe the St Leonard's Index of Continuity of Care (SLICC) for measuring GP continuity regularly, and demonstrate how it has been used in service in general practice. Analysis of appointment audit data from 2016-2017 in a general practice with 8823-9409 patients and seven part-time partners, in Exeter, UK. The percentage of face-to-face appointments for patients on each doctor's list, with the patient's personal doctor (the SLICC), was calculated monthly. The SLICC for different demographic groupings of patients (for example, sex and frequency of attendance) was compared. The UPC index over the 2 years was also calculated, allowing comparisons between indices. In the 2-year study period, there were 35 622 GP face-to-face appointments; 1.96 per patient per year. Overall, 51.7% (95% confidence interval = 51.2 to 52.2) of GP appointments were with the patients' personal doctor. Patients aged ≥65 years had a higher level of continuity with 64.9% of appointments being with their personal doctor. The mean whole-practice UPC score was 0.61 (standard deviation 0.23), with 'usual provider' being the personal GP for 52.8% and a trainee or locum for 8.1% of patients. This method could provide working GPs with a simple way to track continuity of care and inform practice management and decision making.

Continuity of primary care and prenatal care adequacy among women with disabilities in Ontario: A population-based cohort study

Diabetic ketoacidosis is the leading cause of death among children with type 1 diabetes mellitus, and is an avoidable complication at first-time diagnosis of diabetes. Because having a usual provider of primary care is important in improving health outcomes for children, we tested the association between having a usual provider of care and risk of diabetic ketoacidosis at onset of diabetes. Using linked health administrative data for the province of Quebec, we conducted a population-based retrospective cohort study of children aged 1-17 years in whom diabetes was diagnosed from 2006 to 2015. We estimated adjusted risk ratios (RRs) for an episode of diabetic ketoacidosis at the time of diabetes diagnosis in relation to usual provider of care (family physician, pediatrician or none) using Poisson regression models with robust error variance. We identified 3704 new cases of diabetes in Quebec children from 2006 to 2015. Of these, 996 (26.9%) presented with diabetic ketoacidosis. A decreased risk of this complication was associated with having a usual provider of care; the association was stronger with increasing age, reaching statistical significance among those aged 12-17 years. Within this age group, those who had a family physician or a pediatrician were 31% less likely (adjusted RR 0.69, 95% confidence interval [CI] 0.56-0.85) or 38% less likely (adjusted RR 0.62, 95% CI 0.45-0.86), respectively, to present with diabetic ketoacidosis, relative to those without a usual provider of care. For children with newly diagnosed diabetes, having a usual provider of care appears to be important in decreasing the risk of diabetic ketoacidosis at the time of diabetes diagnosis. Our results provide further evidence concerning the need for initiatives that promote access to primary care for children.

The National Health Service Corps (NHSC) is a federal program to increase the supply of health professionals in underserved communities, but its role in enhancing the capacity of community health centers (CHCs) has not been investigated. This study examined the role of NHSC clinicians in improving staffing and patient care capacity in primary, dental, and mental health care in CHCs. Using 2013-2016 administrative data from CHCs and the NHSC, we used a generalized estimating equation approach to examine whether NHSC clinicians [staff full-time equivalents (FTEs)] complement non-NHSC clinicians in CHCs and whether their productivity (patient visits per staff FTE) was greater than that of non-NHSC clinicians in primary, dental, and mental health care. Each additional NHSC clinician FTE was associated with a significant gain of 0.72 non-NHSC clinician FTEs in mental health care in CHCs and an increase of 0.04 non-NHSC FTEs in primary care in CHCs with more severe staffing shortages. On average, every additional NHSC clinician was associated with an increase of 2216 primary care visits, 2802 dental care visits, and 1296 mental health care visits per center-year. The adjusted visits per additional staff for NHSC clinicians were significantly greater in dental (difference=992) and mental health (difference=423) care, compared with non-NHSC clinicians. The NHSC clinicians complement non-NHSC clinicians in primary care and mental health care. They help enhance the provision of patient care in CHCs, particularly in dental and mental health services, the 2 major areas of service gaps.

We examine whether primary care continuity of care (PCCOC) improved for Medicare beneficiaries under a 3-year demonstration to help federally qualified health centers (FQHCs) become patient-centered medical homes (PCMH). We used a difference-in-differences analysis to compare changes over time in PCCOC for beneficiaries in 503 demonstration sites to those in 827 comparison sites. We measured PCCOC using the claims-based usual provider of care (UPC) index (range 0–1) indicating the proportion of visits to the most commonly seen provider or practice over a 1-year period. Average baseline UPC index values were 0.77 at the provider level and 0.88 at the practice level, with similar values for demonstration and comparison sites. UPC decreased more over time in demonstration clinics than comparison clinics, but the magnitude of these changes were small. FQHCs already have high levels of PCCOC. These levels did not increase in association with the 3-year PCMH demonstration. Continuity for practices is higher than for providers, suggesting that Medicare beneficiaries may see multiple providers within one FQHC.

Continuity of care between patients and physicians is a defining element of primary care and a pillar of the Patient Centered Medical Home (PCMH) program. We aimed to investigate the level of short- and long-term continuity within a network of Federally Qualified Health Centers (FQHCs) and the relationship of continuity to PCMH recognition. This multi-method study utilized Electronic Health Record data to investigate patient continuity, and survey data to investigate PCMH history. The study population included patients with at least 2 visits between 2008 and 2023 to one of 18 FQHCs. Continuity was measured by calculating the number of primary care providers (PCPs) seen by the patient and the usual provider of care index (UPC Index [the number of visits with the most frequent PCP/total visits]). Our population consisted of 1,323,547 patients and 19,768,516 encounters. The mean (SD) number of PCPs per patient over one year was 2.01 (1.1). For patients who had visits spanning at least 5 years, the mean was 7.2 (4.7). The mean one-year UPC was .72 (.25) and 5+ year UPC was .47 (.21). No meaningful association was found between continuity measures and PCMH recognition. These findings show, on average, high numbers of PCPs and poor continuity with a single "usual provider of care" for each patient's care over time at FQHCs. Leveraging performance measures, such as PCMH recognition, to incentivize continuity may be inadequate. Different approaches should be considered to preserve the long-term continuity at the heart of primary care.

Continuity of care is important for patients with chronic conditions. Assigning patients to a named GP may increase continuity. To examine whether patients who were registered with a named GP at the onset of their first chronic disease had higher continuity of care at subsequent visits than patients who were only registered at a practice. Registry-based observational study in Skåne County, Sweden. The study population included 66 063 patients registered at the same practice at least 1 year before the onset of their first chronic condition between 2009 and 2015. We compared patients registered with a named GP with patients only registered at a practice over a 4-year follow-up period. The primary outcome was the usual provider of care (UPC) index for all visits and for visits related to the chronic disease. Secondary outcomes were the number of GP, nurse, and out-of-hours visits; emergency department visits; hospital admissions; and mortality. We used linear regression models, adjusted for patient characteristics (using entropy balancing weights) and for practice-level fixed effects, to compare the UPC between those registered with a named GP and those who were not. Patients with a named GP at onset of their condition had a UPC that was 3-4 percentage points higher than patients who did not have a named GP, but the difference decreased and was not statistically significant after adjusting for patient and practice characteristics. Patients with a named GP made more visits, although not specifically for the chronic condition. There were no statistically significant differences for the other outcomes. Patient registration with a GP at diagnosis of their first chronic condition does not demonstrate higher continuity of care at subsequent GP visits and is not linked to other relevant outcomes for patients.

Optimizing telehealth pain care after COVID-19.

Coordination of Care Is Associated With Survival and Health Care Utilization in a Population-Based Study of Patients With Cirrhosis

High continuity in primary care has a positive impact on the health of patients and populations, but the traditional long-term relationship of a patient with one specific primary care provider is no longer given. Insight into the underlying mechanisms of continuity in primary care can help to design effective teams and networks of healthcare providers. Eight different mechanisms of continuity of care are proposed: matching of patient and provider, time for patient care, healing relationship, effective information delivery, effective counselling, monitoring in care episodes, coherence of treatment, and absence of interruption due to hand-overs. Empirical research on the mechanisms of continuity in modern primary care is required.

IntroductionResearch has demonstrated continuity and regularity of general practitioner (GP) contacts to be associated with reduced hospitalisations and emergency department (ED) presentations. Opportunities for improved medication management are often cited as a potential causal mechanism, but little research has directly addressed this.&#x0D; Objectives and ApproachTo determine associations between continuity of primary care and adherence with statin medications amongst individuals at risk of cardiovascular disease outcomes, taking statins through the exposure period of July 2011 - June 2012. We used self-report and administrative data from 267,153 participants of the 45 and Up Study conducted in New South Wales, Australia from 2006-2009. Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data, from the Australian Government Department of Human Services, were linked to survey, hospital and death data by the NSW Centre for Health Record Linkage. Exposures were the Usual Provider of Care (UPC) index, i.e. the proportion of visits made to the usual GP; and a regularity index assessing whether patients were visiting the GP on a regular basis. Cox regression estimated associations between these exposures and time to cessation of statin medication, defined as a 30-day period without supply.&#x0D; ResultsPreliminary findings amongst a cohort of approximately 48,000 indicated that increases in both regularity and continuity of primary care were associated with reduced likelihood of statin cessation. After controlling for socio-demographic and health status indicators the hazard ratio for cessation in the most regular quintile (baseline least) was 0.84 (95%CI 0.80 – 0.87) and in the highest continuity quintile was 0.93 (95%CI 0.89 – 0.96).&#x0D; Conclusion / ImplicationsPrevious work assessed relationships between continuity of care and downstream hospital and ED outcomes. This work complements existing literature by assessing intermediate outcomes, aiding understanding of potential causal pathways. These findings are relevant given adherence to statin medication is often sub-optimal.

Relational continuity is a cornerstone of primary care. In developing countries, however, little research has been conducted to determine the perception and experiences of patients in view of relational continuity in primary care. To study the role of relational continuity in primary care settings and its effect on patients' perceptions and experiences. A questionnaire-based survey was conducted at eight primary care health centres (PCHCs) in Al-Seeb province, Muscat, the capital city of Oman. All Omani patients aged 18 years and above attending their PCHCs during the study period were invited to participate in the study. From a total of 1300 patients invited, 958 Omani patients agreed to participate in the study (response rate = 74%). More than half of the patients (61%) expressed the preference of consulting the same primary care physician (PCP) to whom they were accustomed. This increased to 69% if the patients had psychosocial problems and to 71% if the patients had chronic medical conditions. A significant proportion of the respondents (72%) felt comfortable and relaxed when consulting the same PCP and 67% expressed an interest in maintaining continuity with the same PCP. The general perspective held by the majority of the studied patients (61%) indicated that relational continuity improved both the patients' medical conditions (51%) and the quality of services (61%). In actuality, however, only 18% experienced relational continuity in their PCHCs. The preference for relational continuity was significantly increased among patients who identified a favourite PCP (P = 0.029) and among educated patients (P = 0.023). Although it is relatively difficult to consult with the same PCP, the majority of Omani patients have experienced several benefits from relational continuity within the context of patient-physician relationship. The preference for relational continuity was highly expressed by patients with chronic or psychosocial problems, patients who were educated and those who identified a named PCP. In view of these findings, the basis of relational continuity if progressed, a great effort is needed to develop and implement strategies to promote relational continuity in primary health care in Oman.