title: 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.
  
  
  METHODS
  Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.
  
  
  METHODS
  The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.
  
  
  METHODS
  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.
authors.affiliation: Center of Excellence in Primary Care Education, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America.
authors.forename: Krisda H
authors.initials: KH
authors.lastname: Chaiyachati
authors.affiliation: VA Connecticut Healthcare System, West Haven, Connecticut, United States of America.
authors.forename: Kirsha
authors.initials: K
authors.lastname: Gordon
authors.affiliation: Center of Excellence in Primary Care Education, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America; Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut, United States of America.
authors.forename: Theodore
authors.initials: T
authors.lastname: Long
authors.affiliation: VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Evergreen Design, Guilford, Connecticut, United States of America.
authors.forename: Woody
authors.initials: W
authors.lastname: Levin
authors.affiliation: Center of Excellence in Primary Care Education, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America; Iora Health, Collective Primary Care, Brooklyn, New York, United States of America.
authors.forename: Ali
authors.initials: A
authors.lastname: Khan
authors.affiliation: Center of Excellence in Primary Care Education, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America.
authors.forename: Emily
authors.initials: E
authors.lastname: Meyer
authors.affiliation: Center of Excellence in Primary Care Education, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America; VA Connecticut Healthcare System, West Haven, Connecticut, United States of America.
authors.forename: Amy
authors.initials: A
authors.lastname: Justice
authors.affiliation: Center of Excellence in Primary Care Education, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America; VA Connecticut Healthcare System, West Haven, Connecticut, United States of America.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Brienza
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D010348:Patient Care Team; D018802:Patient-Centered Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D011379:Prognosis; D012189:Retrospective Studies