title: Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents.
abstract: BACKGROUND
  Care by Design™ (CBD) (Canada), a model of coordinated team-based primary care, was implemented in long-term care facilities (LTCFs) in Halifax, Nova Scotia, Canada, to improve access to and continuity of primary care and to reduce high rates of transfers to emergency departments (EDs).
  
  
  METHODS
  This was an observational time series before and after the implementation of CBD (Canada). Participants are LTCF residents with 911 Emergency Health Services calls from 10 LTCFs, representing 1424 beds. Data were abstracted from LTCF charts and Emergency Health Services databases. The primary outcome was ambulance transports from LTCFs to EDs. Secondary outcomes included access (primary care physician notes in charts) and continuity (physician numbers and contacts).
  
  
  RESULTS
  After implementation of CBD (Canada), transports from LTCFs to EDs were reduced by 36%, from 68 to 44 per month (P = .01). Relational and informational continuity of care improved with resident charts with ≥10 physician notes, increasing 38% before CBD to 55% after CBD (P = .003), and the median number of chart notes increased from 7 to 10 (P = .0026). Physicians contacted before 911 calls and onsite assessment increased from 38% to 54% (P = .01) and 3.7% to 9.2% (P = .03), respectively, before CBD to after CBD.
  
  
  CONCLUSIONS
  A 34% reduction in overall transports from LTCFs to EDs is likely attributable to improved onsite primary care, with consistent physician and team engagement and improvements in continuity of care.
authors.affiliation: From the Department of Family Medicine, Dalhousie University, Halifax, NS, Canada (EGM, FB, NV, GA); the Capital District Health Authority, Integrated Continuing Care, Halifax, NS, Canada (BC); and the Center for Health Care of the Elderly, Department of Medicine (Geriatrics), Dalhousie University, Halifax, NS, Canada (MKA). emily.marshall@dal.ca.
authors.forename: Emily Gard
authors.initials: EG
authors.lastname: Marshall
authors.affiliation: From the Department of Family Medicine, Dalhousie University, Halifax, NS, Canada (EGM, FB, NV, GA); the Capital District Health Authority, Integrated Continuing Care, Halifax, NS, Canada (BC); and the Center for Health Care of the Elderly, Department of Medicine (Geriatrics), Dalhousie University, Halifax, NS, Canada (MKA).
authors.forename: Barry
authors.initials: B
authors.lastname: Clarke
authors.affiliation: From the Department of Family Medicine, Dalhousie University, Halifax, NS, Canada (EGM, FB, NV, GA); the Capital District Health Authority, Integrated Continuing Care, Halifax, NS, Canada (BC); and the Center for Health Care of the Elderly, Department of Medicine (Geriatrics), Dalhousie University, Halifax, NS, Canada (MKA).
authors.forename: Frederick
authors.initials: F
authors.lastname: Burge
authors.affiliation: From the Department of Family Medicine, Dalhousie University, Halifax, NS, Canada (EGM, FB, NV, GA); the Capital District Health Authority, Integrated Continuing Care, Halifax, NS, Canada (BC); and the Center for Health Care of the Elderly, Department of Medicine (Geriatrics), Dalhousie University, Halifax, NS, Canada (MKA).
authors.forename: Nirupa
authors.initials: N
authors.lastname: Varatharasan
authors.affiliation: From the Department of Family Medicine, Dalhousie University, Halifax, NS, Canada (EGM, FB, NV, GA); the Capital District Health Authority, Integrated Continuing Care, Halifax, NS, Canada (BC); and the Center for Health Care of the Elderly, Department of Medicine (Geriatrics), Dalhousie University, Halifax, NS, Canada (MKA).
authors.forename: Greg
authors.initials: G
authors.lastname: Archibald
authors.affiliation: From the Department of Family Medicine, Dalhousie University, Halifax, NS, Canada (EGM, FB, NV, GA); the Capital District Health Authority, Integrated Continuing Care, Halifax, NS, Canada (BC); and the Center for Health Care of the Elderly, Department of Medicine (Geriatrics), Dalhousie University, Halifax, NS, Canada (MKA).
authors.forename: Melissa K
authors.initials: MK
authors.lastname: Andrew
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data; D006297:Health Services Accessibility; D006801:Humans; D008134:Long-Term Care / Q000379:methods; D008297:Male; D009674:Nova Scotia; D058007:Physicians, Primary Care / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000379:methods*; D017064:Process Assessment, Health Care; D014187:Transportation of Patients / Q000706:statistics & numerical data*
keywords: Continuity of Patient Care; Emergency Departments; Long-Term Care; Primary Health Care