Trial Outcomes & Findings for Minnesota Care Coordination Effectiveness Study (NCT NCT04957979)
NCT ID: NCT04957979
Last Updated: 2025-04-24
Results Overview
The analytic outcome is defined as the absolute change in the percentage of eligible care quality measures met by a patient in the year before and after care coordination initiation. The composite measure of care quality is calculated as the percentage of all applicable care quality measures a patient meets based on clinical guidelines, including control of blood pressure, cardiovascular disease, diabetes, asthma, depression, and cancer screening. Criteria for each of the components was assessed using health outcomes from EHR and insurance claims to capture occurrence and timing of recommended screenings. A positive change (post % - pre % \> 0) reflects an improvement in the percentage of care quality measures met, while a negative change indicates a decline.
Recruitment status
COMPLETED
Target enrollment
25507 participants
Primary outcome timeframe
12 months pre- and post- initiation of care coordination
Results posted on
2025-04-24
Participant Flow
Clinic recruitment was performed in late 2020. Participating clinics identified patients for trial inclusion between 2021 and 2023. Patient surveys were administered in late 2022 (Historical Cohort) and late 2023 (Primary Cohort).
This is an observational trial so patients were identified for inclusion in the trial by their home clinics. Each home clinic was classified to one of the two comparison arms based on the care models they were already performing, and all patients receiving care in that clinic were assigned to that arm. No patients identified by clinics that met inclusion criteria were excluded.
Unit of analysis: Clinics
Participant milestones
| Measure |
Historical Cohort: Medical/Nursing Model
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
Patients starting care coordination in participating clinics between January and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
Patients starting care coordination in participating clinics between January-December 2021.
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: 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
|
|---|---|---|---|---|
|
Overall Study
STARTED
|
4110 107
|
8721 122
|
3572 151
|
9104 129
|
|
Overall Study
COMPLETED
|
4110 107
|
8721 122
|
3572 151
|
9104 129
|
|
Overall Study
NOT COMPLETED
|
0 0
|
0 0
|
0 0
|
0 0
|
Reasons for withdrawal
Withdrawal data not reported
Baseline Characteristics
Minnesota Care Coordination Effectiveness Study
Baseline characteristics by cohort
| Measure |
Historical Cohort: Medical/Nursing Model
n=4110 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=8721 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=3572 Participants
Patients starting care coordination in participating clinics between January-December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=9104 Participants
Patients starting care coordination in participating clinics between January-December 2021.
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: 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
|
Total
n=25507 Participants
Total of all reporting groups
|
|---|---|---|---|---|---|
|
Race/Ethnicity, Customized
Asian
|
112 Participants
n=5 Participants
|
1090 Participants
n=7 Participants
|
681 Participants
n=5 Participants
|
1486 Participants
n=4 Participants
|
3369 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
Black or African American
|
196 Participants
n=5 Participants
|
944 Participants
n=7 Participants
|
198 Participants
n=5 Participants
|
1185 Participants
n=4 Participants
|
2523 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
Hispanic or Latino
|
56 Participants
n=5 Participants
|
149 Participants
n=7 Participants
|
102 Participants
n=5 Participants
|
24 Participants
n=4 Participants
|
331 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
Native Hawaiian/Other Pacific Islander
|
1 Participants
n=5 Participants
|
10 Participants
n=7 Participants
|
11 Participants
n=5 Participants
|
17 Participants
n=4 Participants
|
39 Participants
n=21 Participants
|
|
Age, Continuous
|
63 years
STANDARD_DEVIATION 18 • n=5 Participants
|
62 years
STANDARD_DEVIATION 19 • n=7 Participants
|
62 years
STANDARD_DEVIATION 18 • n=5 Participants
|
63 years
STANDARD_DEVIATION 18 • n=4 Participants
|
62 years
STANDARD_DEVIATION 19 • n=21 Participants
|
|
Sex/Gender, Customized
Female
|
2456 Participants
n=5 Participants
|
5418 Participants
n=7 Participants
|
2250 Participants
n=5 Participants
|
5659 Participants
n=4 Participants
|
15783 Participants
n=21 Participants
|
|
Sex/Gender, Customized
Male
|
1654 Participants
n=5 Participants
|
3299 Participants
n=7 Participants
|
1308 Participants
n=5 Participants
|
3445 Participants
n=4 Participants
|
9706 Participants
n=21 Participants
|
|
Sex/Gender, Customized
Unknown
|
0 Participants
n=5 Participants
|
4 Participants
n=7 Participants
|
14 Participants
n=5 Participants
|
0 Participants
n=4 Participants
|
18 Participants
n=21 Participants
|
|
Ethnicity (NIH/OMB)
Hispanic or Latino
|
107 Participants
n=5 Participants
|
271 Participants
n=7 Participants
|
202 Participants
n=5 Participants
|
285 Participants
n=4 Participants
|
865 Participants
n=21 Participants
|
|
Ethnicity (NIH/OMB)
Not Hispanic or Latino
|
3540 Participants
n=5 Participants
|
7980 Participants
n=7 Participants
|
2642 Participants
n=5 Participants
|
7791 Participants
n=4 Participants
|
21953 Participants
n=21 Participants
|
|
Ethnicity (NIH/OMB)
Unknown or Not Reported
|
463 Participants
n=5 Participants
|
470 Participants
n=7 Participants
|
728 Participants
n=5 Participants
|
1028 Participants
n=4 Participants
|
2689 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
American Indian or Alaska Native
|
34 Participants
n=5 Participants
|
214 Participants
n=7 Participants
|
76 Participants
n=5 Participants
|
272 Participants
n=4 Participants
|
596 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
Other
|
23 Participants
n=5 Participants
|
87 Participants
n=7 Participants
|
57 Participants
n=5 Participants
|
46 Participants
n=4 Participants
|
213 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
White
|
3625 Participants
n=5 Participants
|
5924 Participants
n=7 Participants
|
2335 Participants
n=5 Participants
|
5776 Participants
n=4 Participants
|
17660 Participants
n=21 Participants
|
|
Race/Ethnicity, Customized
Unknown or Choose not to answer
|
63 Participants
n=5 Participants
|
303 Participants
n=7 Participants
|
112 Participants
n=5 Participants
|
298 Participants
n=4 Participants
|
776 Participants
n=21 Participants
|
|
Primary Language
English
|
3905 Participants
n=5 Participants
|
7071 Participants
n=7 Participants
|
3211 Participants
n=5 Participants
|
7244 Participants
n=4 Participants
|
21431 Participants
n=21 Participants
|
|
Primary Language
Hmong
|
11 Participants
n=5 Participants
|
263 Participants
n=7 Participants
|
15 Participants
n=5 Participants
|
349 Participants
n=4 Participants
|
638 Participants
n=21 Participants
|
|
Primary Language
Somali
|
26 Participants
n=5 Participants
|
224 Participants
n=7 Participants
|
39 Participants
n=5 Participants
|
226 Participants
n=4 Participants
|
515 Participants
n=21 Participants
|
|
Primary Language
Spanish
|
62 Participants
n=5 Participants
|
176 Participants
n=7 Participants
|
158 Participants
n=5 Participants
|
185 Participants
n=4 Participants
|
581 Participants
n=21 Participants
|
|
Primary Language
Other
|
90 Participants
n=5 Participants
|
953 Participants
n=7 Participants
|
115 Participants
n=5 Participants
|
1092 Participants
n=4 Participants
|
2250 Participants
n=21 Participants
|
|
Primary Language
Unknown or Choose not to answer
|
16 Participants
n=5 Participants
|
34 Participants
n=7 Participants
|
34 Participants
n=5 Participants
|
8 Participants
n=4 Participants
|
92 Participants
n=21 Participants
|
|
Country of Origin
United States
|
3019 Participants
n=5 Participants
|
5780 Participants
n=7 Participants
|
2552 Participants
n=5 Participants
|
6133 Participants
n=4 Participants
|
17484 Participants
n=21 Participants
|
|
Country of Origin
Non-US country
|
198 Participants
n=5 Participants
|
1787 Participants
n=7 Participants
|
217 Participants
n=5 Participants
|
2062 Participants
n=4 Participants
|
4264 Participants
n=21 Participants
|
|
Country of Origin
Unknown or Choose not to answer
|
893 Participants
n=5 Participants
|
1154 Participants
n=7 Participants
|
803 Participants
n=5 Participants
|
909 Participants
n=4 Participants
|
3759 Participants
n=21 Participants
|
|
Insurance coverage
Government-sponsored insurance plans
|
800 Participants
n=5 Participants
|
3950 Participants
n=7 Participants
|
1076 Participants
n=5 Participants
|
4519 Participants
n=4 Participants
|
10345 Participants
n=21 Participants
|
|
Insurance coverage
Non-government sponsored insurance plans
|
3310 Participants
n=5 Participants
|
4771 Participants
n=7 Participants
|
2496 Participants
n=5 Participants
|
4585 Participants
n=4 Participants
|
15162 Participants
n=21 Participants
|
|
Number of chronic conditions
0
|
322 Participants
n=5 Participants
|
285 Participants
n=7 Participants
|
295 Participants
n=5 Participants
|
346 Participants
n=4 Participants
|
1248 Participants
n=21 Participants
|
|
Number of chronic conditions
1
|
233 Participants
n=5 Participants
|
369 Participants
n=7 Participants
|
186 Participants
n=5 Participants
|
420 Participants
n=4 Participants
|
1208 Participants
n=21 Participants
|
|
Number of chronic conditions
2
|
267 Participants
n=5 Participants
|
595 Participants
n=7 Participants
|
257 Participants
n=5 Participants
|
522 Participants
n=4 Participants
|
1641 Participants
n=21 Participants
|
|
Number of chronic conditions
3-4
|
711 Participants
n=5 Participants
|
1496 Participants
n=7 Participants
|
601 Participants
n=5 Participants
|
1371 Participants
n=4 Participants
|
4179 Participants
n=21 Participants
|
|
Number of chronic conditions
5-6
|
908 Participants
n=5 Participants
|
1571 Participants
n=7 Participants
|
708 Participants
n=5 Participants
|
1596 Participants
n=4 Participants
|
4783 Participants
n=21 Participants
|
|
Number of chronic conditions
7-8
|
741 Participants
n=5 Participants
|
1490 Participants
n=7 Participants
|
641 Participants
n=5 Participants
|
1623 Participants
n=4 Participants
|
4495 Participants
n=21 Participants
|
|
Number of chronic conditions
9-10
|
466 Participants
n=5 Participants
|
1182 Participants
n=7 Participants
|
423 Participants
n=5 Participants
|
1286 Participants
n=4 Participants
|
3357 Participants
n=21 Participants
|
|
Number of chronic conditions
11+
|
462 Participants
n=5 Participants
|
1733 Participants
n=7 Participants
|
461 Participants
n=5 Participants
|
1940 Participants
n=4 Participants
|
4596 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Anemia
|
696 Participants
n=5 Participants
|
2114 Participants
n=7 Participants
|
629 Participants
n=5 Participants
|
2360 Participants
n=4 Participants
|
5799 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Anxiety disorders
|
1403 Participants
n=5 Participants
|
3833 Participants
n=7 Participants
|
1350 Participants
n=5 Participants
|
3968 Participants
n=4 Participants
|
10554 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Blindness and vision loss
|
1088 Participants
n=5 Participants
|
2723 Participants
n=7 Participants
|
941 Participants
n=5 Participants
|
3169 Participants
n=4 Participants
|
7921 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Chronic kidney disease
|
962 Participants
n=5 Participants
|
2556 Participants
n=7 Participants
|
817 Participants
n=5 Participants
|
2912 Participants
n=4 Participants
|
7247 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Depressive disorders
|
1481 Participants
n=5 Participants
|
4026 Participants
n=7 Participants
|
1341 Participants
n=5 Participants
|
4298 Participants
n=4 Participants
|
11146 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Diabetes
|
2005 Participants
n=5 Participants
|
4129 Participants
n=7 Participants
|
1764 Participants
n=5 Participants
|
4379 Participants
n=4 Participants
|
12277 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Drug use disorders
|
613 Participants
n=5 Participants
|
2004 Participants
n=7 Participants
|
653 Participants
n=5 Participants
|
2112 Participants
n=4 Participants
|
5382 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Hyperlipidemia
|
2282 Participants
n=5 Participants
|
4881 Participants
n=7 Participants
|
1872 Participants
n=5 Participants
|
5097 Participants
n=4 Participants
|
14132 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Hypertension
|
2412 Participants
n=5 Participants
|
5308 Participants
n=7 Participants
|
1992 Participants
n=5 Participants
|
5529 Participants
n=4 Participants
|
15241 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Ischaemic heart disease
|
766 Participants
n=5 Participants
|
1909 Participants
n=7 Participants
|
678 Participants
n=5 Participants
|
1949 Participants
n=4 Participants
|
5302 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Low back pain
|
1040 Participants
n=5 Participants
|
2811 Participants
n=7 Participants
|
968 Participants
n=5 Participants
|
3172 Participants
n=4 Participants
|
7991 Participants
n=21 Participants
|
|
Prevalent chronic conditions
Osteoarthritis
|
1182 Participants
n=5 Participants
|
2832 Participants
n=7 Participants
|
1076 Participants
n=5 Participants
|
3166 Participants
n=4 Participants
|
8256 Participants
n=21 Participants
|
PRIMARY outcome
Timeframe: 12 months pre- and post- initiation of care coordinationPopulation: Patients included in analytic comparison if they qualify for at least one care quality outcome in both the year pre- and post-care coordination initiation.
The analytic outcome is defined as the absolute change in the percentage of eligible care quality measures met by a patient in the year before and after care coordination initiation. The composite measure of care quality is calculated as the percentage of all applicable care quality measures a patient meets based on clinical guidelines, including control of blood pressure, cardiovascular disease, diabetes, asthma, depression, and cancer screening. Criteria for each of the components was assessed using health outcomes from EHR and insurance claims to capture occurrence and timing of recommended screenings. A positive change (post % - pre % \> 0) reflects an improvement in the percentage of care quality measures met, while a negative change indicates a decline.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=2514 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=5326 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=2097 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=5546 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Composite Measure of Care Quality
|
7.0 Change in percent
Standard Deviation 31.2
|
4.5 Change in percent
Standard Deviation 34.3
|
5.9 Change in percent
Standard Deviation 31.1
|
5.9 Change in percent
Standard Deviation 35.7
|
PRIMARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they were covered by participating insurers in both the year pre- and post-care coordination initiation.
Change in # of encounters with CPT-4 E\&M codes (99281-99288) at emergency departments across the year before and year after care coordination initiation per 100 people. Negative values of change represent improvement, positive values represent a increase in number of admissions.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=767 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=2487 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=925 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=3811 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Annual Number of Emergency Department Visits
|
-0.261 Change in encounters per 100 people per
Standard Deviation 127.8
|
-0.523 Change in encounters per 100 people per
Standard Deviation 174.5
|
-5.51 Change in encounters per 100 people per
Standard Deviation 185.3
|
-2.97 Change in encounters per 100 people per
Standard Deviation 248.8
|
PRIMARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they were covered by participating insurers in both the year pre- and post-care coordination initiation.
Change in # of hospital inpatient admissions ≥ 1 days across the year before and year after care coordination initiation per 100 people. Negative values of change represent improvement, positive values represent a increase in number of admissions.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=767 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=2487 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=925 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=3811 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Annual Number of Inpatient Hospitalizations
|
-1.173 Change in encounters per 100 people per
Standard Deviation 106.6
|
7.197 Change in encounters per 100 people per
Standard Deviation 178.4
|
-7.459 Change in encounters per 100 people per
Standard Deviation 164.2
|
-4.828 Change in encounters per 100 people per
Standard Deviation 161.3
|
PRIMARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percentage of patients reporting Excellent, Very Good, or Good when asked to rate general health status on 5-level Likert Scale (NHIS)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=335 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=486 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=929 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1841 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
General Health Status - Top Box Scoring
|
221 Participants
|
365 Participants
|
609 Participants
|
1002 Participants
|
PRIMARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percentage of patients reporting 9 or 10 when asked to rate primary care clinic (CG-CAHPS)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=329 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=469 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=914 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1825 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Rating of Primary Care Clinic - Top Box
|
188 Participants
|
235 Participants
|
480 Participants
|
898 Participants
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they have a diagnosis of asthma in both the year pre- and post-care coordination initiation.
The analytic outcome is defined as the absolute change in the percentage of eligible patients (those with a current asthma diagnosis) demonstrating asthma control (Asthma Control Test (ACT) score \<19) within each arm in the year before and after care coordination initiation. A positive change reflects an improvement in the percentage of eligible patients with asthma control while a negative change indicates a decline.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=43 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=117 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=28 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=136 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Asthma Care at Goal
|
-2.3 Change in percent
|
-2.6 Change in percent
|
-7.1 Change in percent
|
-6.6 Change in percent
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they were women, 50-74 years old, and covered by participating insurer in both the year pre- and post-care coordination initiation
Screening criteria defined as mammogram within the last 2 years.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=396 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=1351 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=410 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1420 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Breast Cancer Screening Criteria
|
2.8 percentage of patients
|
-0.4 percentage of patients
|
0.2 percentage of patients
|
4.7 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they were 50-75 years old and had available claims data the year pre- and post-care coordination initiation.
Screening criteria defined as approved screening test within the last 1 to 10 years depending on type of test and current recomendations.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=2146 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=4428 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=1790 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=4442 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date)
|
3.3 percentage of patients
|
2.0 percentage of patients
|
3.2 percentage of patients
|
4.2 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they were women and 16-24 years old and covered by participating insurer the year pre- and post-care coordination initiation.
Screening criteria defined as a screening test for chlamydia within the last year.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=40 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=47 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=17 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=54 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date)
|
-7.5 percentage of patients
|
2.1 percentage of patients
|
0.0 percentage of patients
|
-18.5 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they had at least one PHQ9 score in both the year pre- and post-care coordination initiation.
Screening for depression, based on Patient Health Questionnaire (PHQ-9) screen score used to quantify presence and severity of depression. Total scores range from 0 to 27, with higher score indicating more severe depression. Meeting depression screening criteria defined as the most recent PHQ-9 score \< 5, indicating no or minimal depression at the time of assessment.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=285 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=1014 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=431 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1685 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Depression Screening Criteria
|
7.4 percentage of patients
|
4.4 percentage of patients
|
5.1 percentage of patients
|
3.9 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they had a diagnosis of diabetes and had at least one available A1c results the year pre- and post-care coordination initiation.
Control criteria defined as Hemoglobin A1c \< or = 7%
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=454 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=1095 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=535 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1213 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting A1c Control
|
15.2 percentage of patients
|
6.2 percentage of patients
|
0.6 percentage of patients
|
-1.8 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they had vascular disease in the year pre- and post-care coordination initiation.
Recommendation is documented aspirin use in patients unless contraindication or exception
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=153 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=420 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=224 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=590 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations
|
2.6 percentage of patients
|
-3.1 percentage of patients
|
3.6 percentage of patients
|
1.2 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they had a diabetes and/or vascular disease diagnosis and at least one blood pressure available the year pre- and post-care coordination initiation.
Control defined at BP \< 140/90 mm Hg (SBP/DBP)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=427 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=1067 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=541 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1227 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Blood Pressure Control Criteria
|
3.7 percentage of patients
|
-0.8 percentage of patients
|
3.1 percentage of patients
|
1.7 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they had vascular disease diagnosis the year pre- and post-care coordination initiation.
Recommendation is documented statin use in patients unless contraindication or exception
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=499 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=1294 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=673 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1567 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Meeting Statin Use Recommendations
|
6.0 percentage of patients
|
5.8 percentage of patients
|
4.3 percentage of patients
|
4.0 percentage of patients
|
SECONDARY outcome
Timeframe: 12 months pre and post start of care coordinationPopulation: Patients included in analytic comparison if they had a diabetes and/or vascular disease diagnosis in the year pre- and post-care coordination initiation.
Current tobacco use (tobacco includes any number of cigarettes, cigars, pipes, or smokeless tobacco)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=491 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=1271 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=656 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1561 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Change in Percent of Patients Reporting Current Tobacco Use
|
1.8 percentage of patients
|
0.9 percentage of patients
|
0.2 percentage of patients
|
-0.3 percentage of patients
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of responders reporting 'Always' or 'Usually' able to get an appointment for care they need right away on survey items assessing rating of satisfaction with access to care (CG-CAHPS) -
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=301 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=420 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=855 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1699 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Access to Care
|
231 Participants
|
276 Participants
|
644 Participants
|
1121 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date , reported recent interaction with care coordinator, provided answer to relevant survey item.
The analytic outcome is defined as the percentage of patients who rated their care coordinator as a 9 or 10 on a 0-10 scale adapted from the Clinician \& Group Survey (CG-CAHPS) assessment. The rating reflects patients' overall satisfaction with their care coordinator. Higher scores (9 or 10) indicate a more positive assessment of care coordination, while lower scores suggest less favorable experiences. This measure is limited to patients who recalled a recent interaction with their care coordinator.
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=155 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=205 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=535 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1171 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Rating of Care Coordinator
|
97 Participants
|
128 Participants
|
317 Participants
|
623 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Self-reported experience of shared decision making as measured by CollaboRATE scale - Ranges 0 to 4 higher scores represented more favorable rating of SDM
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=331 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=471 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=920 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1838 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Shared Decision Making
|
2.9 score on a scale
Standard Deviation 0.91
|
2.7 score on a scale
Standard Deviation 0.99
|
3.0 score on a scale
Standard Deviation 0.89
|
2.89 score on a scale
Standard Deviation 0.9
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Self-reported experience of care integration as measured by IntegRATE scale - Ranges 0 to 3 lower scores represent more favorable rating of care integration
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=331 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=469 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=922 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1832 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Perceived Care Integration
|
0.59 score on a scale
Standard Deviation 0.54
|
0.71 score on a scale
Standard Deviation 0.62
|
0.64 score on a scale
Standard Deviation 0.59
|
0.75 score on a scale
Standard Deviation 0.62
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of patients reporting "Yes" when asked if there was any time when you needed medical care, but did not get it because you couldn't afford it in the last 12-months to cost (NHIS)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=326 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=455 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=914 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1797 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Going Without Care Due to Cost
|
23 Participants
|
58 Participants
|
81 Participants
|
203 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of patients reporting self reporting \>$500 out-of-pocket medical costs in the past 12 months (Medical expenditure panel survey)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=318 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=445 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=884 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1757 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Out-of-pocket Medical Costs
|
168 Participants
|
181 Participants
|
373 Participants
|
552 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Self-reported medication and care burden (modified from Treatment Burden Questionnaire) - Scores range from 0 to 100 with higher scores representing more burden/worse
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=329 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=463 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=908 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1792 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Medication and Care Burden
|
35 score on a scale
Standard Deviation 31
|
41 score on a scale
Standard Deviation 32
|
38 score on a scale
Standard Deviation 31
|
45 score on a scale
Standard Deviation 31
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of patients reporting "No steady place to live" when asked to describe they current living situation (modified from CMS HRSN Screening Tool)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=326 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=460 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=911 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1801 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Social Needs - Housing Security
|
18 Participants
|
46 Participants
|
73 Participants
|
189 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of patients reporting "Often", "Sometimes", or "Rarely" when asked to describe how often they or other adults in their household eat less/skip a meal because there wasn't enough money or food - (modified from CMS HRSN Screening Tool)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=328 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=459 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=910 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1807 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Social Needs - Food Security
|
51 Participants
|
124 Participants
|
165 Participants
|
510 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of patients reporting "Yes" when asked if lack of reliable transportation has kept them from participating in ADLs (modified from CMS HRSN Screening Tool)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=327 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=456 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=913 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1802 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Social Needs - Access to Dependable Transportation
|
32 Participants
|
82 Participants
|
123 Participants
|
373 Participants
|
SECONDARY outcome
Timeframe: 6 to 18 months after start of care coordinationPopulation: Patients included in analytic comparison if they responded to patient survey sent at least 6 months after care coordination initiation date and provided answer to relevant survey item.
Percent of patients reporting "No" when asked if they have any type of health care coverage (modified from CMS HRSN Screening Tool)Self-reported insurance coverage (SHADAC survey)
Outcome measures
| Measure |
Historical Cohort: Medical/Nursing Model
n=327 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Historical Cohort: Medical/Social Model
n=458 Participants
Patients starting care coordination in participating clinics between January 2018 and February 2019.
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: 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
|
Primary Cohort: Medical/Nursing Model
n=906 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
Primary Cohort: Medical/Social Model
n=1798 Participants
Patients starting care coordination in participating clinics between January 2021 and December 2021.
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: 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
|
|---|---|---|---|---|
|
Insurance Coverage
|
18 Participants
|
36 Participants
|
49 Participants
|
159 Participants
|
Adverse Events
Historical Cohort: Medical/Nursing Model
Serious events: 0 serious events
Other events: 0 other events
Deaths: 0 deaths
Historical Cohort: Medical/Social Model
Serious events: 0 serious events
Other events: 0 other events
Deaths: 0 deaths
Primary Cohort: Medical/Nursing Model
Serious events: 0 serious events
Other events: 0 other events
Deaths: 0 deaths
Primary Cohort: Medical/Social Model
Serious events: 0 serious events
Other events: 0 other events
Deaths: 0 deaths
Serious adverse events
Adverse event data not reported
Other adverse events
Adverse event data not reported
Additional Information
Results disclosure agreements
- Principal investigator is a sponsor employee
- Publication restrictions are in place