Minnesota Care Coordination Effectiveness Study

Study Results

Results available

Outcome measurements, participant flow, baseline characteristics, and adverse events have been published for this study.

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Basic Information

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Recruitment Status

COMPLETED

Total Enrollment

25507 participants

Study Classification

OBSERVATIONAL

Study Start Date

2021-06-14

Study Completion Date

2024-04-30

Brief Summary

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Medical care has improved greatly over the past 50 years. Treatments for most medical conditions can help us lead longer and healthier lives, but there are still problems. Many patients with two or more conditions see many different doctors and sometimes take more medications than needed. These patients can feel lost and confused. In addition, non-medical issues involving housing, food, transportation, employment, income, support from others, and language barriers can have a large impact on our health.

In Minnesota, many primary care clinics are using a method called care coordination to improve the health of patients who have a number of chronic diseases (some examples of chronic diseases include diabetes, heart disease, asthma and depression). With care coordination, a nurse in the clinic helps the various doctors, clinics, and specialists to work together, in the interest of the patient. In some clinics, a social worker also helps with care coordination. These social workers help with issues like housing, transportation, or employment. Care coordination can help reduce patient confusion. It also can improve health and lower patient burdens and costs of getting medical care.

To help find out what types of care coordination are most successful, we are proposing a study. Our plan is to track the health of patients receiving care coordination and compare two types:

A. Care coordination done by a nurse or other clinic staff B. Care coordination where a licensed social worker also assists the patient

In this study, we will measure many things, including:

1. Control of chronic conditions like diabetes, heart disease, asthma, and depression
2. Hospitalizations
3. Emergency department visits
4. Use of medications and diagnostic tests
5. Use of specialty care
6. General health status
7. Patient satisfaction and access to care
8. Use of shared decision-making (where the doctor and the patient make treatment decisions together)
9. Patient burden (how much time and effort the patient spends trying to get healthy)
10. Patients' out-of-pocket medical costs

This project will be important to patients because it could reduce confusion and fragmented care while improving all the items above. Those improvements will be more likely because this project takes advantage of engagement with patients and others. We have four patient partners who will help conduct the study and interpret and broadly share the results. The project was developed with the input from patients, clinic leaders, people from state government, and experts on health and quality care.

By measuring a wide variety of outcomes for the adults receiving coordination services in these clinics, we hope to identify the specific actionable information that will allow these and other clinics to improve their services for these patients with complex needs.

Throughout the project, we will communicate our findings to clinics and health systems. As a result, many people may receive better care.

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Detailed Description

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Conditions

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Chronic Disease Multi-morbidity Care Coordination

Study Design

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Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

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Nursing/Medical Model of Care Coordination

Someone with medical/nursing training coordinates involvement of various medical resources and provides patients with education, self-management support, and referrals to community resources.

Nursing/Medical Model of Care Coordination

Intervention Type OTHER

No social worker on the clinic's care coordination team.

Services provided:

* Coordinated medical care for patients
* Patient education
* Assistance in developing care plan
* Support for patient self-management
* Referrals for continuing care
* Referral to community resources
* Referral to mental health services if needed or requested
* Referral to interventional counseling for behavioral health issues

Medical/Social Model of Care Coordination

In addition to the services provided in the Medical/Nursing Model, a social worker by education has dedicated FTE as a member of the care team at the clinic, providing some direct services for care coordination patients and either spending some time on-site or in regular communication with its clinicians in addition to providing social work services.

Medical/Social Model of Care Coordination

Intervention Type OTHER

Social worker is part of the clinic's care coordination team.

* Need not be licensed as a social worker
* Must have time dedicated to care coordination for a specific clinic or clinics
* Must interact with individual patients to provide them with services
* Must interact with individual clinicians about their individual patients in care coordination

Services provided:

* Coordinated medical care for patients
* Patient education
* Assistance in developing care plan
* Support for patient self-management
* Assistance with referrals for continuing care
* Assessment and plan to address social and resource needs including housing, transportation or financial needs; Assist patient in locating and obtaining needed community resources
* Assistance with identifying and addressing psychological/emotional issues and referrals as needed
* Interventional counseling for behavioral health issues or referrals to interventional counseling, depending on licensure

Interventions

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Nursing/Medical Model of Care Coordination

No social worker on the clinic's care coordination team.

Services provided:

* Coordinated medical care for patients
* Patient education
* Assistance in developing care plan
* Support for patient self-management
* Referrals for continuing care
* Referral to community resources
* Referral to mental health services if needed or requested
* Referral to interventional counseling for behavioral health issues

Intervention Type OTHER

Medical/Social Model of Care Coordination

Social worker is part of the clinic's care coordination team.

* Need not be licensed as a social worker
* Must have time dedicated to care coordination for a specific clinic or clinics
* Must interact with individual patients to provide them with services
* Must interact with individual clinicians about their individual patients in care coordination

Services provided:

* Coordinated medical care for patients
* Patient education
* Assistance in developing care plan
* Support for patient self-management
* Assistance with referrals for continuing care
* Assessment and plan to address social and resource needs including housing, transportation or financial needs; Assist patient in locating and obtaining needed community resources
* Assistance with identifying and addressing psychological/emotional issues and referrals as needed
* Interventional counseling for behavioral health issues or referrals to interventional counseling, depending on licensure

Intervention Type OTHER

Eligibility Criteria

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Inclusion Criteria

* Age 18 or older
* Historical Cohort: Receiving care coordination services in a participating clinic with a care coordination start date between January 2018 and February 2019
* Primary Cohort: Receiving care coordination services in a participating clinic with a care coordination start date between January 2021 and December 2021
* Currently insured by the MN Department of Human Services (DHS), Blue Cross Blue Shield MN (BCBS), UCare, or HealthPartners (HP) (for utilization outcomes only)
* Consents to participate in interview or responds to a survey (for those data collection events only)

Exclusion Criteria

* Cannot complete an interview in English (interviews only)
* Cannot complete a survey in English, Spanish, Somali, or Hmong (for interviews only, reflecting most prevalent languages in MN)
* On a known research exclusion list

Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No