Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic

Med Care. 2023 Apr 1;61(Suppl 1):S62-S69. doi: 10.1097/MLR.0000000000001811. Epub 2023 Mar 9.


Background: Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship.

Objective: We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth.

Research design: This was a cohort study.

Participants: Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020.

Methods: Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020.

Results: MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing.

Conclusions: Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • COVID-19* / epidemiology
  • Cohort Studies
  • Community Health Centers
  • Continuity of Patient Care
  • Diabetes Mellitus* / epidemiology
  • Diabetes Mellitus* / therapy
  • Glycated Hemoglobin
  • Humans
  • Hypertension* / epidemiology
  • Hypertension* / therapy
  • Pandemics
  • Telemedicine*


  • Glycated Hemoglobin