Impact of the PCMH model on post-stroke healthcare utilization

The patient-centered medical home (PCMH) model has aimed to enhance chronic care in a primary care setting where providers are expected to provide timely post-discharge follow-up and decrease potentially preventable hospital readmissions through coordinated disease management. The study examined PCMH and other (risk) factors associated with 30-day unplanned readmission as well as 7- and 28-day follow-up visit with primary care providers (PCPs). We identified 8424 New York State Medicaid patients having initial stroke discharges during 2016–2018 from the Medicaid claims database and Statewide Planning and Research Cooperative System. A patient was in the PCMH group if the attributed provider had a valid National Committee for Quality Assurance PCMH recognition upon patient’s discharge. Cox regression and competing risk analyses were used to estimate the hazard ratios of readmissions and follow-up visits between PCMH and non-PCMH groups. The PCMH group had slightly but not statistically significant lower all-cause and recurrent stroke unplanned readmission rates. While the general follow-up rates between the two groups are similar, the PCMH group had significantly higher rates of stroke-specific 7-day (HR = 1.27, P < 0.01) and 28-day follow-up visits (HR = 1.22, P < 0.01). PCPs play an essential role in post stroke care. Our findings show a significantly higher rate of stroke-specific follow-up visits and a trend towards lower readmissions among patients in the PCMH group. The intervals between stroke discharge and follow-up visit time in our study population were generally greater than the recommended timeframe. We recommend the PCMH care model to improve patients’ primary care follow-up and prevent potential readmissions.