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  1. Hearld, Larry R. PhD
  2. Hearld, Kristine R. PhD
  3. Budhwani, Henna PhD


Poor transitions in care represent opportunities for improvement. The purpose of this study was to examine whether early follow-up by patients discharged from a hospital varied as a function of patient-centered medical home (PCMH) capacity. The PCMH capacity was not significantly associated with early follow-up; however, higher levels of capacity were associated with early follow-up among patients with more chronic conditions. Policy makers and practitioners should consider how the PCMH may be targeted to maximize its potential to improve transitions in care for these patients and ways it may be modified to improve transitions for other types of patients.