Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

OBJECTIVES: To evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans. DESIGN: Retrospective cohort study. SETTING: Department of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities. PARTICIPANTS: Medicare-eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007-08 (baseline period) (N = 243,881). MEASUREMENTS: Two measures of longitudinal continuity were estimated using merged VA-Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services. RESULTS: The incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02-1.07), intermediate (IRR = 1.04, 95% CI = 1.02-1.07), and low (IRR = 1.06, 95% CI = 1.03-1.09) UPC than in those with very high UPC (0.9-1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01-1.07), intermediate (OR = 1.03, 95% CI = 1.00-1.06), and low (OR = 1.04, 95% CI = 1.01-1.07) UPC were also more likely to be hospitalized during follow-up. Results were similar for MMCI continuity scores. CONCLUSION: Even slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.

Reducing avoidable hospital readmissions effectively: a statewide campaign.

BACKGROUND: The Reducing Avoidable Readmissions Effectively (RARE) Campaign was designed to engage hospitals and care providers in Minnesota across the continuum of care to prevent avoidable hospital readmissions within 30 days of hospital discharge. METHODS: Support for hospitals was provided on a one-on-one basis by a RARE resource consultant, as well as through the campaign website and a monthly newsletter. Hospitals had the opportunity to participate in any of three learning collaboratives-Care Transitions Intervention, Project RED (ReEngineered Discharge), or SAFE Transitions of Care. The operating and supporting partners of the RARE Campaign offered monthly webinars for sharing of best practices, and hosted Action Learning Days and celebratory events. Potentially preventable readmissions (PPRs) were tracked over time, and a ratio of actual-to-expected PPRs (A/E PPRs) was calculated for each hospital and reported quarterly. RESULTS: As of December 31, 2013, 82 hospitals were participating, with 58 (71%) taking part in at least one learning collaborative. More than 7,000 readmissions have been prevented, and patients have spent more than 28,000 nights of sleep in their own beds rather than in a hospital. By the end of September 2013, the A/E PPR ratio was reduced by 12%-from .98 to .86. CONCLUSIONS: The peer-to-peer networking and collaboration between hospitals facing similar issues, coupled with statewide resources, collaborating Operating Partners, and support for system improvements, have led to improved discharge planning, better management of care transitions and medications, engaged patients and families, and lower readmission rates.

Does improved continuity of primary care affect clinician-patient communication in VA?

BACKGROUND: Recent changes in health care delivery may reduce continuity with the patient's primary care provider (PCP). Little is known about the association between continuity and quality of communication during ongoing efforts to redesign primary care in the Veterans Administration (VA). OBJECTIVE: To evaluate the association between longitudinal continuity of care (COC) with the same PCP and ratings of patient-provider communication during the Patient Aligned Care Team (PACT) initiative. DESIGN: Cross-sectional survey. PARTICIPANTS: Four thousand three hundred ninety-three VA outpatients who were assigned to a PCP, had at least three primary care visits to physicians or physician extenders during Fiscal Years 2009 and 2010 (combined), and who completed the Survey of Healthcare Experiences of Patients (SHEP) following a primary care visit in Fiscal Year (FY)2011. MAIN MEASURES: Usual Provider of Continuity (UPC), Modified Modified Continuity Index (MMCI), and duration of PCP care were calculated for each primary care patient. UPC and MMCI values were categorized as follows: 1.0 (perfect), 0.75-0.99 (high), 0.50-0.74 (intermediate), and < 0.50 (low). Quality of communication was measured using the four-item Consumer Assessment of Healthcare Providers and Systems-Health Plan program (CAHPS-HP) communication subscale and a two-item measure of shared decision-making (SDM). Excellent care was defined using an "all-or-none" scoring strategy (i.e., when all items within a scale were rated "always"). KEY RESULTS: UPC and MMCI continuity remained high (0.81) during the early phase of PACT implementation. In multivariable models, low MMCI continuity was associated with decreased odds of excellent communication (OR = 0.74, 95 % CI = 0.58-0.95) and SDM (OR = 0.70, 95 % CI = 0.49, 0.99). Abbreviated duration of PCP care (< 1 year) was also associated with decreased odds of excellent communication (OR = 0.35, 95 % CI = 0.18, 0.71). CONCLUSIONS: Reduced PCP continuity may significantly decrease the quality of patient-provider communication in VA primary care. By improving longitudinal continuity with the assigned PCP, while redesigning team-based roles, the PACT initiative has the potential to improve patient-provider communication.

Introducing quality improvement methods into local public health departments: structured evaluation of a statewide pilot project.

OBJECTIVE: To test the feasibility and assess the preliminary impact of a unique statewide quality improvement (QI) training program designed for public health departments. DATA SOURCES/STUDY SETTING: One hundred and ninety-five public health employees/managers from 38 local health departments throughout Minnesota were selected to participate in a newly developed QI training program and 65 of those engaged in and completed eight expert-supported QI projects over a period of 10 months from June 2007 through March 2008. STUDY DESIGN: As part of the Minnesota Quality Improvement Initiative, a structured distance education QI training program was designed and deployed in a first large-scale pilot. To evaluate the preliminary impact of the program, a mixed-method evaluation design was used based on four dimensions: learner reaction, knowledge, intention to apply, and preliminary outcomes. DATA: Subjective ratings of three dimensions of training quality were collected from participants after each of the scheduled learning sessions. Pre- and post-QI project surveys were administered to collect participant reactions, knowledge, future intention to apply learning, and perceived outcomes. Monthly and final QI project reports were collected to further inform success and preliminary outcomes of the projects. PRINCIPAL FINDINGS: The participants reported (1) high levels of satisfaction with the training sessions, (2) increased perception of the relevance of the QI techniques, (3) increased perceived knowledge of all specific QI methods and techniques, (4) increased confidence in applying QI techniques on future projects, (5) increased intention to apply techniques on future QI projects, and (6) high perceived success of, and satisfaction with, the projects. Finally, preliminary outcomes data show moderate to large improvements in quality and/or efficiency for six out of eight projects. CONCLUSIONS: QI methods and techniques can be successfully implemented in local public health agencies on a statewide basis using the collaborative model through distance training and expert facilitation. This unique training can improve both core and support processes and lead to favorable staff reactions, increased knowledge, and improved health outcomes. The program can be further improved and deployed and holds great promise to facilitate the successful dissemination of proven QI methods throughout local public health departments.

Correlates of gay and lesbian couples' relationship satisfaction and relationship dissolution.

A sample of committed gay and lesbian cohabiting couples engaged in two conversations after being apart for at least 8 hours: (a) an events of the day conversation and (b) a conflict resolution conversation. Physiological data were collected during the conversations and a videotape record was made. Couples viewed the videotapes and rated their affect during the interaction. The video records were coded with a system that categorized specific affects displayed. Models derived from physiology, from the perception of interaction, and from specific affective behavior were related to relationship satisfaction, and to the prediction of relationship dissolution over a 12-year period. Results supported previous findings that satisfaction and stability in gay and lesbian relationships are related to similar emotional qualities as in heterosexual relationships.