Predictors of Older Adult Adherence With Emergency Department Discharge Instructions.

OBJECTIVE: Older adults discharged from the emergency department (ED) are at high risk for adverse outcomes. Adherence to ED discharge instructions is necessary to reduce those risks. The objective of this study is to determine the individual-level factors associated with adherence with ED discharge instructions among older adult ED outpatients. METHODS: We performed a secondary analysis of data from the control group of a randomized controlled trial testing a care transitions intervention among older adults (age ≥ 60 years) discharged home from the ED in two states. Taking data from patient surveys and chart reviews, we used multivariable logistic regression to identify patient characteristics associated with adherence to printed discharge instructions. Outcomes were patient-reported medication adherence, provider follow-up visit adherence, and knowledge of "red flags" (signs of worsening health requiring further medical attention). RESULTS: A total 824 patients were potentially eligible, and 699 had data in at least one pillar. A total of 35% adhered to medication instructions, 76% adhered to follow-up instructions, and 35% recalled at least one red flag. In the multivariate analysis, no factors were significantly associated with failure to adhere to medications. Participants with poor health status (adjusted odds ratio [AOR] = 0.55, 95% confidence interval [CI] = 0.31 to 0.98) were less likely to adhere to follow-up instructions. Participants who were older (AORs trended downward as age category increased) or depressed (AOR = 0.39, 95% CI = 0.17 to 0.85) or had one or more functional limitations (AOR = 0.62, 95% CI = 0.41 to 0.94) were less likely to recall red flags. CONCLUSION: Older adults discharged home from the ED have mixed rates of adherence to discharge instructions. Although it is thought that some subgroups may be higher risk than others, given the opportunity to improve ED-to-home transitions, EDs and health systems should consider providing additional care transition support to all older adults discharged home from the ED.

Association between social isolation and outpatient follow-up in older adults following emergency department discharge.

OBJECTIVES: Follow-up with outpatient clinicians after discharge from the emergency department (ED) reduces adverse outcomes among older adults, but rates are suboptimal. Social isolation, a common factor associated with poor health outcomes, may help explain these low rates. This study evaluates social isolation as a predictor of outpatient follow-up after discharge from the ED. MATERIALS AND METHODS: This cohort study uses the control group from a randomized-controlled trial investigating a community paramedic-delivered Care Transitions Intervention with older patients (age≥60 years) at three EDs in mid-sized cities. Social Isolation scores were measured at baseline using the PROMIS 4-item social isolation questionnaire, grouped into tertiles for analysis. Chart abstraction was conducted to identify follow-up with outpatient primary or specialty healthcare providers and method of contact within 7 and 30 days of discharge. RESULTS: Of 642 patients, highly socially-isolated adults reported significantly worse overall health, as well as increased anxiety, depressive symptoms, functional limitations, and co-morbid conditions compared to those less socially-isolated (p<0.01). We found no effect of social isolation on 30-day follow-up. Patients with high social isolation, however, were 37% less likely to follow-up with a provider in-person within 7 days of ED discharge compared to low social isolation (OR:0.63, 95% CI:0.42-0.96). CONCLUSION: This study adds to our understanding of how and when socially-isolated older adults seek outpatient care following ED discharge. Increased social isolation was not significantly associated with all-contact follow-up rates after ED discharge. However, patients reporting higher social isolation had lower rates of in-person follow-up in the week following ED discharge.

The Impact of Adherence to Clinical Practice Guidelines on Medical Costs.

OBJECTIVE: To examine the association between non-adherence to clinical practice guidelines (CPGs) and medical and indemnity spending among back and shoulder injury patients. METHODS: Workers compensation claims data was used from a large, US insurer (1999 to 2010). Least square regression models were created to examine the association between spending and guideline-discordant care. RESULTS: Non-adherence to CPGs was associated with higher medical and indemnity spending for 11 of the 28 CPG indicators. Failure to adhere to the other CPGs did not increase medical or total spending. After covariate adjustment, non-adherence to these 11 CPGs was associated with spending increases that ranged from $16,000 for physical therapy (PT) to $114,000 for surgery. CONCLUSIONS: Our results demonstrate that failure to adhere to a subset of CPG indicators significantly predicts increased medical and indemnity spending for two important occupational injuries.

Dental, Vision, And Hearing Services: Access, Spending, And Coverage For Medicare Beneficiaries.

Among Medicare beneficiaries, dental, vision, and hearing services could be characterized as high need, high cost, and low use. While Medicare does not cover most of these services, coverage has increased recently as a result of changes in state Medicaid programs and increased enrollment in Medicare Advantage (MA) plans, many of which offer these services as supplemental benefits. Using data from the 2016 Medicare Current Beneficiary Survey, this analysis shows that MA plans are filling an important gap in dental, vision, and hearing coverage, particularly among low- and middle-income beneficiaries. In 2016 only 21 percent of beneficiaries in traditional Medicare had purchased a stand-alone dental plan, whereas 62 percent of MA enrollees were in plans with a dental benefit. Among Medicare beneficiaries with coverage overall, out-of-pocket expenses still made up 70 percent of dental spending, 62 percent of vision spending, and 79 percent of hearing spending. While Medicare beneficiaries are enrolling in private coverage options, they are not getting adequate financial protection. This article examines these findings in the context of recent proposals in Congress to expand Medicare coverage of dental, vision, and hearing services.

Complex Patients and Quality of Care in Medicare Advantage.

OBJECTIVES: New federal policies aim to focus Medicare Advantage (MA) plans on the needs of individuals with complex health conditions. Our objective was to examine enrollment patterns of MA beneficiaries with complex needs and the association of enrollment patterns with MA plan performance. DESIGN: Cross-sectional study. SETTING: The 2015 Medicare Health Outcome Survey baseline survey. PARTICIPANTS: A total of 273 336 MA beneficiaries enrolled in 467 MA plans who lived in the community. MEASUREMENTS: Complex patients included individuals 65 years and older with multiple self-reported chronic conditions and functional limitations and all patients with disabilities younger than 65 years. Outcomes included 27 performance measures reported under the 5-Star Part C Star Rating. Linear probability regression was used to examine the association of concentration of complex patients and performance measures. RESULTS: Most complex patients were enrolled in general MA plans. Concentration of complex patients ranged from 25.9% in MA contracts in the lowest quintile to 68.9% in the top quintile. MA contract performance scores generally decreased as the concentration of complex patients increased. After adjusting for contract and enrollee characteristics, MA contracts with more complex patients performed less well on half of the Part C performance measures including patient experience, preventive care, and chronic care measures. CONCLUSION: MA contracts with a high concentration of complex patients have lower performance scores on more than half of Part C measures. Further study is needed to understand whether these performance measures are capturing the delivery of poor care, deficiencies in the health plan's care systems, or whether some measures may not be appropriate for complex patients. J Am Geriatr Soc 68:395-402, 2020.

Targeting High-Need Beneficiaries in Medicare Advantage: Opportunities to Address Medical and Social Needs.

Issue: Serving Medicare beneficiaries with complex health care needs requires understanding both the medical and social factors that may affect their health. Goal: Describe the prevalence and characteristics of high-need individuals enrolled in the Medicare Advantage program. Methods: Analysis of the 2015 Medicare Health Outcomes Survey. Key Findings: Thirty-seven percent of enrollees in large Medicare Advantage plans have high needs, requiring both medical and social services. Individuals with high needs are more likely to report having limited financial resources, low levels of education, social isolation, and poor health. Conclusion: Federal policymakers should consider allowing Medicare Advantage plans to identify high-need beneficiaries based on their medical and social risk factors, rather than just medical diagnoses. Doing so would enable plans to deliver better-targeted services that meet their members' needs and facilitate implementation of the CHRONIC Care Act provision that allows plans to offer nonhealth supplemental benefits.

Familiarity and Communication in the Operating Room.

BACKGROUND: Poor communication is implicated in many adverse events in the operating room (OR); however, many hospitals' scheduling practices permit unfamiliar operative teams. The relationship between unfamiliarity, team communication and effectiveness of communication is poorly understood. We sought to evaluate the relationship between familiarity, communication rates, and communication ineffectiveness of health care providers in the OR. MATERIALS AND METHODS: We performed purposive sampling of 10 open operations. For each case, six providers (anesthesiology attending, in-room anesthetist, circulator, scrub, surgery attending, and surgery resident) were queried about the number of mutually shared cases. We identified communication events and created dyad-specific communication rates. RESULTS: Analysis of 48 h of audio-video content identified 2570 communication events. Operations averaged 58.0 communication events per hour (range, 29.4-76.1). Familiarity was not associated with communication rate (P = 0.69) or communication ineffectiveness (P = 0.21). Cross-disciplinary dyads had lower communication rates than intradisciplinary dyads (P < 0.001). Anesthesiology-nursing, anesthesiology-surgery, and nursing-surgery dyad communication rates were 20.1%, 42.7%, and 57.3% the rate predicted from intradisciplinary dyads, respectively. In addition, cross-disciplinary dyad status was a significant predictor of having at least one ineffective communication event (P = 0.02). CONCLUSIONS: Team members do not compensate for unfamiliarity by increasing their verbal communication, and dyad familiarity is not protective against ineffective communication. Cross-disciplinary communication remains vulnerable in the OR suggesting poor crosstalk across disciplines in the operative setting. Further investigation is needed to explore these relationships and identify effective interventions, ensuring that all team members have the necessary information to optimize their performance.

Neighborhood disadvantage and chronic disease management.

OBJECTIVE: To assess the relationship between a composite measure of neighborhood disadvantage, the Area Deprivation Index (ADI), and control of blood pressure, diabetes, and cholesterol in the Medicare Advantage (MA) population. DATA SOURCES: Secondary analysis of 2013 Medicare Healthcare Effectiveness Data and Information Set, Medicare enrollment data, and a neighborhood disadvantage indicator. STUDY DESIGN: We tested the association of neighborhood disadvantage with intermediate health outcomes. Generalized estimating equations were used to adjust for geographic and individual factors including region, sex, race/ethnicity, dual eligibility, disability, and rurality. DATA COLLECTION: Data were linked by ZIP+4, representing compact geographic areas that can be linked to Census block groups. PRINCIPAL FINDINGS: Compared with enrollees residing in the least disadvantaged neighborhoods, enrollees in the most disadvantaged neighborhoods were 5 percentage points (P < 0.05) less likely to have controlled blood pressure, 6.9 percentage points (P < 0.05) less likely to have controlled diabetes, and 9.9 percentage points (P < 0.05) less likely to have controlled cholesterol. Adjustment attenuated this relationship, but the association remained. CONCLUSIONS: The ADI is a strong, independent predictor of diabetes and cholesterol control, a moderate predictor of blood pressure control, and could be used to track neighborhood-level disparities and to target disparities-focused interventions in the MA population.

Improving the ED-to-Home Transition: The Community Paramedic-Delivered Care Transitions Intervention-Preliminary Findings.

OBJECTIVES: To describe a novel model of care that uses community-based paramedics to deliver a modified version of the evidence-based hospital-to-home Care Transitions Intervention (CTI) to a new context: the emergency department (ED)-to-home transition. DESIGN: Single-blind randomized controlled trial. SETTING: Three EDs in 2 cities. PARTICIPANTS: Through June 2017, 422 individuals discharged home from the EDs who provided consent and were randomized to receive the modified CTI. INTERVENTION: We modified the hospital-to-home CTI, applying it to the ED-to-home transition and delivering services through community paramedics, allowing the program to benefit from the unique attributes of paramedics to deliver care. MEASUREMENTS: Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. RESULTS: Median age of participants was 70.7, 241 (57.1%) were female, and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7% of planned telephone follow-up for call 1, 90.9% for call 2, and 85.8% for call 3. We found high levels of acceptability among participants, with most participants (76.2%) and their caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI program in the future. Coaches reported delivering expected services during contact at least 88% of the time. CONCLUSION: Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213-2220, 2018.

Impact Of Risk Adjustment For Socioeconomic Status On Medicare Advantage Plan Quality Rankings.

Sociodemographically disadvantaged patients have worse outcomes on some quality measures that inform Medicare Advantage plan ratings. Performance measurement that does not adjust for sociodemographic factors may penalize plans that disproportionately serve disadvantaged populations. We assessed the impact of adjusting for socioeconomic and demographic factors (sex, race/ethnicity, dual eligibility, disability, rurality, and neighborhood disadvantage) on Medicare Advantage plan rankings for blood pressure, diabetes, and cholesterol control. After adjustment, 20.3 percent, 19.5 percent, and 11.4 percent of Medicare Advantage plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively. Plans that improved in ranking after adjustment enrolled higher proportions of disadvantaged enrollees. Adjusting quality measures for socioeconomic factors is important for equitable payment and quality reporting. Our study suggests that plans serving disadvantaged populations would have improved relative rankings for three important outcome measures if socioeconomic factors were included in risk-adjustment models.

A scoping review of patient-sharing network studies using administrative data.

There is a robust literature examining social networks and health, which draws on the network traditions in sociology and statistics. However, the application of social network approaches to understand the organization of health care is less well understood. The objective of this work was to examine approaches to conceptualizing, measuring, and analyzing provider patient-sharing networks. These networks are constructed using administrative data in which pairs of physicians are considered connected if they both deliver care to the same patient. A scoping review of English language peer-reviewed articles in PubMed and Embase was conducted from inception to June 2017. Two reviewers evaluated article eligibility based upon inclusion criteria and abstracted relevant data into a database. The literature search identified 10,855 titles, of which 63 full-text articles were examined. Nine additional papers identified by reviewing article references and authors were examined. Of the 49 papers that met criteria for study inclusion, 39 used a cross-sectional study design, 6 used a cohort design, and 4 were longitudinal. We found that studies most commonly theorized that networks reflected aspects of collaboration or coordination. Less commonly, studies drew on the strength of weak ties or diffusion of innovation frameworks. A total of 180 social network measures were used to describe the networks of individual providers, provider pairs and triads, the network as a whole, and patients. The literature on patient-sharing relationships between providers is marked by a diversity of measures and approaches. We highlight key considerations in network identification including the definition of network ties, setting geographic boundaries, and identifying clusters of providers, and discuss gaps for future study.

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

BACKGROUND: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

OBJECTIVE: The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. METHODS: This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. RESULTS: We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. CONCLUSIONS: Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

Can Claims Data Algorithms Identify the Physician of Record?

BACKGROUND: Claims-based algorithms based on administrative claims data are frequently used to identify an individual's primary care physician (PCP). The validity of these algorithms in the US Medicare population has not been assessed. OBJECTIVE: To determine the agreement of the PCP identified by claims algorithms with the PCP of record in electronic health record data. DATA: Electronic health record and Medicare claims data from older adults with diabetes. SUBJECTS: Medicare fee-for-service beneficiaries with diabetes (N=3658) ages 65 years and older as of January 1, 2008, and medically housed at a large academic health system. MEASURES: Assignment algorithms based on the plurality and majority of visits and tie breakers determined by either last visit, cost, or time from first to last visit. RESULTS: The study sample included 15,624 patient-years from 3658 older adults with diabetes. Agreement was higher for algorithms based on primary care visits (range, 78.0% for majority match without a tie breaker to 85.9% for majority match with the longest time from first to last visit) than for claims to all visits (range, 25.4% for majority match without a tie breaker to 63.3% for majority match with the amount billed tie breaker). Percent agreement was lower for nonwhite individuals, those enrolled in Medicaid, individuals experiencing a PCP change, and those with >10 physician visits. CONCLUSIONS: Researchers may be more likely to identify a patient's PCP when focusing on primary care visits only; however, these algorithms perform less well among vulnerable populations and those experiencing fragmented care.

Continuity of Care in Older Adults With Multiple Chronic Conditions: How Well Do Administrative Measures Correspond With Patient Experiences?

Continuity of care (COC) is a fundamental component of primary care and particularly important to older adults who are managing multiple chronic conditions. Administrative measures of continuity are often used to evaluate care coordination interventions, but it is not known whether administrative continuity are correlated with patient reports of continuity among older adults with multiple chronic conditions (MCCs). The objective of this study is to assess the concordance of administrative continuity indices and patient reports of continuity among older adults with MCCs. We use patient survey data collected from July to October 2011 linked to administrative claims data collected from July 2010 to December 2011 for 710 Medicare Advantage Chronic Care Special Needs Plan beneficiaries living in the US South. Among older adults with two or more conditions, the Usual Provider of Care Index was not associated with any patient experience measure; COC Index was associated with informational and management continuity items. These findings suggest that among older adults with MCCs, the administrative continuity measures have limited concordance with patient reported continuity measures.

Geographic Variations in Physician Relationships Over Time: Implications for Care Coordination.

Care coordination may be more challenging when the specific physicians with whom primary care physicians (PCPs) are expected to coordinate care change over time. Using Medicare data on physician patient-sharing relationships and the Dartmouth Atlas, we explored the extent to which PCPs tend to share patients with other physicians over time. We found that 70.7% of ties between PCPs and other physicians that were present in 2012 persisted in 2013, and additional shared patients in 2012 increased the odds of being connected in 2013. Regions with higher persistent ties tended to have lower rates of emergency room visits, and regions where PCPs had more physician connections were more likely to have higher emergency room visits. The results point to potential opportunities and challenges faced by health care reforms that seek to improve coordination.

Differences in Receipt of Three Preventive Health Care Services by Race/Ethnicity in Medicare Advantage Plans: Tracking the Impact of Pay for Performance, 2010 and 2013.

INTRODUCTION: In 2012, the Centers for Medicare and Medicaid Services (CMS) introduced the Quality Bonus Payment Demonstration, a pay-for-performance (P4P) program, into Medicare Advantage plans. Previous studies documented racial/ethnic disparities in receipt of care among participants in these plans. The objective of this study was to determine whether P4P incentives have affected these disparities in Medicare Advantage plans. METHODS: We studied 411 Medicare Advantage health plans that participated in the Medicare Health Outcome Survey in 2010 and 2013. Preventive health care was defined as self-reported receipt of health care provider communication or treatment to reduce risk of falling, improve bladder control, and monitor physical activity among individuals reporting these problems. Logistic regression stratified by health care plan was used to examine racial/ethnic disparities in receipt of preventive health care before and after the introduction of the P4P program in 2012. RESULTS: We found similar racial/ethnic differences in receipt of preventive health care before and after the introduction of P4P. Blacks and Asians were less likely than whites to receive advice to improve bladder control and more likely to receive advice to reduce risk of falling and improve physical activity. Hispanics were more likely to report receiving advice about all 3 health issues than whites. After the introduction of P4P, the gap decreased between Hispanics and whites for improving bladder control and monitoring physical activity and increased between blacks and whites for monitoring physical activity. CONCLUSION: Racial/ethnic differences in receipt of preventive health care are not always in the expected direction. CMS should consider developing a separate measure of equity in preventive health care services to encourage health plans to reduce gaps among racial/ethnic groups in receiving preventive care services.

Comparing Prognostic Tools for Cancer Screening: Considerations for Clinical Practice and Performance Assessment.

OBJECTIVES: To compare the agreement and rates of cancer screening using four prognostic tools that require different types of clinical information. DESIGN: Observational retrospective cohort study. SETTING: 2009 and 2010 waves of the Medicare Current Beneficiary Survey. PARTICIPANTS: Adults aged 66-90 with survey and claims data (N = 9,469). MEASUREMENTS: Agreement between four indices predicting short-term (4-5 years) and long-term (9-10 years) survival; self-reported breast and prostate cancer screening. RESULTS: Agreement between the four prognostic tools was high. Pearson correlation coefficients ranged from 0.63 to 0.90 for short-term survival and 0.68 to 0.94 for long-term survival. When defining limited short-term life expectancy as less than 25% chance of surviving 4 or 5 years, all four tools agreed in 96.4% of the sample. All four tools agreed in their placement of participants into limited or not-limited long-term life expectancy in 77.1% of participants (<25% chance of surviving 9 or 10 years). Rates of cancer screening were similarly high in individuals with limited long-term life expectancy regardless of the tool used: greater than 31% for mammographic screening in women and greater than 69% for prostate cancer screening. CONCLUSION: There is substantial agreement among different prognostic tools for short- and long-term survival in Medicare beneficiaries. The high rates of cancer screening of individuals with limited life expectancy suggest the importance of incorporating tools into clinical decision-making.

Relationship between continuity of care and adverse outcomes varies by number of chronic conditions among older adults with diabetes.

BACKGROUND: Continuity of care is a basic tenant of primary care practice. However, the evidence on the importance of continuity of care for older adults with complex conditions is mixed. OBJECTIVE: To assess the relationship between measurement of continuity of care, number of chronic conditions, and health outcomes. DESIGN: We analyzed data from a cohort of 1,600 US older adults with diabetes and ≥1 other chronic condition in a private Medicare health plan from July 2010 to December 2011. Multivariate regression models were used to examine the association of baseline continuity (the first 6 months) and the composite outcome of any emergency room use or inpatient hospitalization occurring in the following 12-month period. RESULTS: After adjusting for baseline covariates, high known provider continuity (KPC) was associated with an 84% (adjusted odds ratio 0.16; 95% confidence interval 0.09-0.26) reduction in the risk of the composite outcome. High KPC was significantly associated with a lower risk of the composite outcome among individuals with ≥6 conditions. However, the usual provider of care and continuity of care indices were not significantly related with the composite outcome in the overall sample or in those with ≥6 conditions. CONCLUSION: The relationship between continuity of care and adverse outcomes depends on the measure of continuity of care employed. High morbidity patients are more likely to benefit from continuity of care interventions as measured by the KPC, which measures the proportion of a patient's visits that are with the same providers over time.