The Impact of the PCMH Model on Poststroke Follow‐up Visits and Hospital Readmissions
Authors: Chen K.‐S. , Robertson T. , Wu M. , Alicandro J. , Friedrich M. 
Published: August 2020

Research ObjectiveThe patient‐centered medical home (PCMH) model has been developed to improve overall quality of care delivered by primary care providers. PCMH recognized providers are expected to reduce gaps of transitions from hospitals to home care and community services, provide better disease management for patients, and avoid hospital readmissions due to recurrent disease exacerbations. In this study, we examined the impact of PCMH among stroke patients. Stroke generally involves complications that require coordinated care. Timely follow‐up is an essential component of transition to outpatient care. The study evaluated follow‐up visits and hospital readmissions after stroke discharges to better understand whether PCMH leads to better quality of care for the stroke population.Study DesignRecords of inpatient and follow‐up visits between January 1, 2016, and January 31, 2018, were extracted from the New York State Department of Health Medicaid claims database. Additional inpatient records for dual eligible members were obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Consecutive or overlapping inpatient records due to transferring to other facilities or nonacute inpatient settings (eg, rehabilitation, skill nursing facility) were concatenated and treated as a single inpatient stay. Stroke hospitalizations were identified by inpatient stays starting with an acute phase and with stroke primary diagnosis codes. Follow‐up visits were defined as outpatient services rendered by primary care providers. Each patient was attributed to a primary care provider based on the number of primary care services during a 2‐year period prior to the stroke admission date. A patient is in the PCMH group if the attributed provider obtained PCMH recognition anytime during the study period. Cox regression analyses were performed to examine 7‐day follow‐up visit and 30‐day unplanned readmission rates. Model variables include patients’ demographics and chronic conditions, stroke type, and characteristics of the inpatient stay.Population StudiedThe study population included New York State Medicaid members aged 18 or older having their first stroke discharge between January 1, 2016, and December 31, 2017. Patients without attributed providers or who died within 30 days of discharge were excluded. The final sample for readmission analysis consisted of 5,692 (PCMH n = 3,160) index stroke hospitalizations, and 3,970 (PCMH n = 2,288) of these inpatient stays contributed by nondual eligible members were used for follow‐up visit analysis.Principal FindingsThere were 974 (43%) discharges in the PCMH group (n = 2,288) followed by all‐condition 7‐day follow‐up visit, while the non‐PCMH group (n = 1682) had 686 (41%). In particular, the PCMH group had a higher rate of stroke‐specific 7‐day follow‐up visits (hazard ratio = 1.394, P < .01). Among all 5,692 index stroke hospitalizations, there were 269 (8.5%) 30‐day all‐caused readmissions and 68 (2.2%) recurrent strokes from the PCMH group (n = 3160), while the non‐PCMH group had 233 (9.2%) 30‐day all‐caused readmissions and 66 (2.6%) recurrent strokes.ConclusionsThe PCMH patients had better quality for timely follow‐up visits and fewer unplanned readmissions. The stroke‐specific follow‐up visit rate is significantly higher for the PCMH group.Implications for Policy or PracticePCMH may benefit stroke patients, and PCMH primary care providers could play a more active role in stroke condition management.