Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?

Marisa E. Domino, Carlos Jackson, Christopher A. Beadles, Jesse C. Lichstein, Alan R. Ellis, Joel F. Farley, Joseph P. Morrissey, C. Annette DuBard

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Objective: Primary-care-based medical homes may facilitate care transitions for persons with multiple chronic conditions (MCC) including serious mental illness. The purpose of this manuscript is to assess outpatient follow-up rates with primary care and mental health providers following psychiatric discharge by medical home enrollment and medical complexity. Methods: Using a quasi-experimental design, we examined data from North Carolina Medicaid-enrolled adults with MCC hospitalized with an inpatient diagnosis of depression or schizophrenia during 2008-2010. We used inverse-probability-of-treatment weighting and assessed associations between medical home enrollment and outpatient follow-up within 7 and 30 days postdischarge. Results: Medical home enrollees (n=16,137) were substantially more likely than controls (n= 11,304) to receive follow-up care with any provider 30 days post discharge. Increasing patient complexity was associated with a greater probability of primary care follow-up. Medical complexity and medical home enrollment were not associated with follow-up with a mental health provider. Conclusions: Hospitalized persons with MCC including serious mental illness enrolled in a medical home were more likely to receive timely outpatient follow-up with a primary care provider but not with a mental health specialist. These findings suggest that the medical home model may be more adept at linking patients to providers in primary care rather than to specialty mental health providers.

Original languageEnglish (US)
Pages (from-to)59-65
Number of pages7
JournalGeneral Hospital Psychiatry
StatePublished - Mar 1 2016

Bibliographical note

Funding Information:
Agency for Healthcare Research and Quality (AHRQ): R24 HS019659-01. Additional funding for Dr. Beadles was provided by grant no. 5T32-HS000032 from the AHRQ and grant no. TPP 21-023 from the Department of Veteran Affairs Office of Academic Affiliations. Additional funding for Dr. Lichstein was provided by 2T32NR008856 from the National Institute of Nursing Research at the National Institutes of Health.

Publisher Copyright:
© 2016 Elsevier Inc.


  • Medical home
  • Multiple chronic conditions
  • Outpatient follow-up
  • Psychiatric hospitalization


Dive into the research topics of 'Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?'. Together they form a unique fingerprint.

Cite this