Assessing the effect of primary care models and access on unplanned, repeat hospitalizations across communities in Nova Scotia

Background: When patients move from hospital back home, there are often lots of changes to their care. They may, for example, have new health problems, medications, and health care appointments. Trouble managing these changes often lead to health problems that could result in another hospitalization. Good primary care (e.g. from family doctors or nurses) may help patients successfully manage these changes. We know from a previous study that there are differences in the rates of repeat hospitalizations across communities. The differences in these rates suggest that there might be differences in how well communities support patients in transitioning from hospital to home. Goal: The goal of this study is to see if the kinds of primary care that patients have access to affects their chance of being re-hospitalized after transitioning from hospital to home. Methods: To do this, we will study the people in Nova Scotia who had an unplanned hospitalization and were then discharged home over a three-year period (about 40,000 people). We will identify who their usual primary care provider is to learn about the kinds of primary care services available to each of them, such as: how long people have to wait to see their doctor or nurse practitioner; the kinds of services their provider offers; and if their provider collaborates with other providers, like nurses; plus other characteristics. We will then see if the characteristics of primary care influence whether or not patients are more likely to have an unplanned, repeat hospitalization. Impact: Understanding the role of primary care in helping patients move from hospital to home will help governments and health authorities to plan better health and social services for patients and their families. This study has the potential to play a central role in communities in making patient transitions easier and in preventing re-hospitalizations.