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

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.

Availability of Care Concordant With Patient-centered Medical Home Principles Among Those With Chronic Conditions

“…The available literature indicated that ED use should decline for chronically ill populations with PCMH concordant care. 16,44,45 Lack of an association between PCMH concordant care and any ED visit in this study is consistent with the available literature that indicate no impact for patients without chronic conditions and patients seen in small individual practices. Lack of association might be due to inherent limitations of cross-sectional analyses.…”

Frequent emergency department visitors are frequent primary care visitors and report unmet primary care needs

“…PCMH providers can conduct needs assessments for these patients, develop individualized care plans, and reach out to members of the “medical neighborhood” to coordinate medical and social services . Some PCMH evaluations have shown reduced ED utilization among PCMH patients although no studies have examined the impact of a PCMH transformation on frequent ED visitors. “Super utilizer” care management programs are also increasingly common and vary in their level of integration with primary care.…”

Patient Centered Medical Home transformation at an academic medical center

“…[10] The Veterans Health Administration Patient Aligned Care team found that patients with a PCP had a 45% lower emergency department ED utilization rate. [11] WESTMED Medical Group who participated in the Aetna PCMH Program earned over $300,000 in incentive payments in the first year with 35% reduction in hospitalization. [12] Although a number of organizations recognize PCMH status, the National Committee for Quality Assurance (NCQA) is the recognition most often used.…”