Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits.

CONTEXT: Emergency department utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination. A primary care group visit (i.e., several patients meeting together with the provider at the same time) may reduce fragmentation of care and subsequent emergency department utilization.

OBJECTIVE: To determine whether primary care group visits reduce emergency department utilization in chronically ill older adults.

DESIGN: Randomized trial conducted over a 2-year period.

SETTING: Group-model HMO in Denver, Colorado.

PATIENTS: 295 older adults (> or = 60 years of age) with frequent utilization of outpatient services and one or more chronic illnesses.

INTERVENTION: Monthly group visits (generally 8 to 12 patients) with a primary care physician, nurse, and pharmacist held in 19 physician practices. Visits emphasized self-management of chronic illness, peer support, and regular contact with the primary care team.

MEASURES: Emergency department visits, hospitalizations, and primary care visits.

RESULTS: On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. 1.08 visits; P = 0.005) and were less likely to have any emergency department visits (34.9% vs. 52.4%; P = 0.003) than controls. These differences remained statistically significant after controlling for demographic factors, comorbid conditions, functional status, and prior utilization. Adjusted mean difference in visits was -0.42 visits (95% CI, -0.13 to -0.72), and adjusted RR for any emergency department visit was 0.64 (CI, 0.44 to 0.86).

CONCLUSION: Monthly group visits reduce emergency department utilization for chronically ill older adults.