Background: Safety-net hospitals have higher-than-expected readmission rates. The relative roles of the mean disadvantage of neighborhoods the hospitals serve and the disadvantage of individual patients in predicting a patient's readmission are unclear.

Objective. To examine the effects of an intervention comprising (1) a practice-based care coordination program, (2) augmented by pay for performance (P4P) for meeting quality targets, and (3) complemented by a third-party disease management on quality of care and resource use for older adults with diabetes. Data Sources/Study Setting. Claims files of a managed care organization (MCO) for 20,943 adults aged 65 and older with diabetes receiving care in Alabama, Tennessee, or Texas, from January 2004 to March 2007. Study Design. A quasi-experimental, longitudinal study in which pre-and postdata from 1,587 patients in nine intervention primary care practices were evaluated against 19,356 patients in MCO comparison practices (4900). Five incentivized quality measures, two nonincentivized measures, and two resource-use measures were investigated. We examined trends and changes in trends from baseline to follow-up, contrasting intervention and comparison group member results. Principal Findings. Quality of care generally improved for both groups during the study period. Only slight differences were seen between the intervention and comparison group trends and changes in trends over time.Conclusions. This study did not generate evidence supporting a beneficial effect of an on-site care coordination intervention augmented by P4P and complemented by thirdparty disease management on diabetes quality or resource use.

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OBJECTIVES:To quantify the association between community-dwelling older persons' level of morbidity and their perceptions of the quality of their primary care. DESIGN: Cross-sectional study. SETTING: Urban primary care practice. PARTICIPANTS: A sample of community-dwelling members of a capitated health plan aged 65 and older who were patients of four general internists in one urban practice (N 5 120). MEASUREMENTS: The Johns Hopkins Adjusted ClinicalGroups case-mix system was used to designate a person's aggregate morbidity level as moderate or high depending on the number and types of chronic conditions they had. Aspects of quality of primary care (physician-patient communication, interpersonal treatment, knowledge of patient, integration of care, and trust in physician) were assessed using the Primary Care Assessment Survey. RESULTS: All participants were classified as having moderate (41%) or high morbidity (59%). Older adults with high morbidity assigned a lower rating to all aspects of quality of primary care (physician-patient communication (P 5.001), interpersonal treatment (P 5.002), knowledge of patient (P 5.03), integration of care (P 5.004), and trust in physician (P 5.01)) than those with moderate morbidity. The differences in quality of primary care remained statistically significant after controlling for age, sex, race, and education level. CONCLUSION: Older persons with multiple chronic conditions report inadequate quality of primary care and dissatisfaction with their care. Those with high morbidity levels experience poorer quality of primary care than those with moderate morbidity in all five aspects measured here.

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