Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care

Abstract

IMPORTANCE Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients. OBJECTIVE To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia

“…We performed the multivariable regression analyses as described above, although here we used linear regression for the continuous care fragmentation indices, logistic regression for the binary indicators of highly fragmented care, and negative binomial regression for the count variables of E&M visits and distinct clinicians visited. Because the care fragmentation index is invalid for patients with <2 E&M visits, we limited this part of our analysis to patients with ≥2 E&M visits 14,39,40 …”

“…36,37 Although some tradeoff of continuity for more specialty care may benefit patients with complex chronic conditions, such fragmentation is usually considered harmful when it occurs within the primary care setting. 36,38 Because dementia patients are more likely to experience fragmentation of care, 13,14 we assessed 4 previously validated measures of care fragmentation as the inverse of the Bice-Boxerman continuity of care index on patients' E&M visits. 14,39,40 The care fragmentation index ranges from 0 to 100 and represents the dispersion of E&M visits across multiple unique clinicians.…”

“…36,38 Because dementia patients are more likely to experience fragmentation of care, 13,14 we assessed 4 previously validated measures of care fragmentation as the inverse of the Bice-Boxerman continuity of care index on patients' E&M visits. 14,39,40 The care fragmentation index ranges from 0 to 100 and represents the dispersion of E&M visits across multiple unique clinicians.…”

“…This is concerning because patients with dementia have complex care needs and suffer adverse outcomes that may be exacerbated without early detection and regular treatment 1,7–12 . In addition, patients with dementia may be more likely to experience highly fragmented care spread across multiple medical providers, which is also associated with negative outcomes 13,14 . As a result, the federal government created a national strategy to increase timely dementia diagnoses, access to dementia treatment, and improved care coordination and continuity 15…”

“…1,[7][8][9][10][11][12] In addition, patients with dementia may be more likely to experience highly fragmented care spread across multiple medical providers, which is also associated with negative outcomes. 13,14 As a result, the federal government created a national strategy to increase timely dementia diagnoses, access to dementia treatment, and improved care coordination and continuity. 15 Accountable care organizations (ACOs) are becoming the dominant care model in traditional fee-for-service Medicare (TM), the Medicare program in which the majority of patients with dementia are enrolled.…”