Continuity in a VA patient-centered medical home reduces emergency department visits

Abstract

Background: 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).

Objective: To 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.

Design: Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.

Patients: The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.

Main measures: Our 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.

Results: The 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.

Conclusions: Strong 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.

Figure 1. Potential Patient Visit Interactions with a Provider and/or Trainee and the Relationship with Continuity.

PCP: primary care provider. Grey boxes indicate visits with continuity of care and white boxes indicate visits without continuity.

Figure 2. Adjusted Odds Ratio of Association Between ED Visit and Continuity of Care and Levels of Continuity.

The first row illustrates the adjusted odds ratio between ED visits and continuity of care for individuals with at least one visit having continuity with their primary care provider. The second and third rows are the adjusted odds ratio for individuals who had high and medium levels of continuity and are compared to individuals with low levels of continuity, indicated by the asterisk (*).