Minnesota Care Coordination Effectiveness Study

NCT04957979 | Completed Results

• 2 other identifiers: 19-110IHS-2019C1-15625
• Study Type: observational
• Target: 25,507
• Locations: 1 country
• Sites: 3

Brief Summary

Medical care has improved greatly over the past 50 years. Treatments for most medical conditions can help us lead longer and healthier lives, but there are still problems. Many patients with two or more conditions see many different doctors and sometimes take more medications than needed. These patients can feel lost and confused. In addition, non-medical issues involving housing, food, transportation, employment, income, support from others, and language barriers can have a large impact on our health. In Minnesota, many primary care clinics are using a method called care coordination to improve the health of patients who have a number of chronic diseases (some examples of chronic diseases include diabetes, heart disease, asthma and depression). With care coordination, a nurse in the clinic helps the various doctors, clinics, and specialists to work together, in the interest of the patient. In some clinics, a social worker also helps with care coordination. These social workers help with issues like housing, transportation, or employment. Care coordination can help reduce patient confusion. It also can improve health and lower patient burdens and costs of getting medical care. To help find out what types of care coordination are most successful, we are proposing a study. Our plan is to track the health of patients receiving care coordination and compare two types: A. Care coordination done by a nurse or other clinic staff B. Care coordination where a licensed social worker also assists the patient In this study, we will measure many things, including:

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

Conditions

Chronic Disease; Multi-morbidity; Care Coordination

Keywords

Care Coordination; Quality of Care; Health Care Utilization

Outcome Measures

Primary Outcomes (5)

• Change in Composite Measure of Care Quality

  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.

  12 months pre- and post- initiation of care coordination

• Change in Annual Number of Emergency Department Visits

  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.

  12 months pre and post start of care coordination

• Change in Annual Number of Inpatient Hospitalizations

  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.

  12 months pre and post start of care coordination

• General Health Status - Top Box Scoring

  Percentage of patients reporting Excellent, Very Good, or Good when asked to rate general health status on 5-level Likert Scale (NHIS)

  6 to 18 months after start of care coordination

• Rating of Primary Care Clinic - Top Box

  Percentage of patients reporting 9 or 10 when asked to rate primary care clinic (CG-CAHPS)

  6 to 18 months after start of care coordination

Secondary Outcomes (21)

• Change in Percent of Patients Meeting Asthma Care at Goal

  12 months pre and post start of care coordination

• Change in Percent of Patients Meeting Breast Cancer Screening Criteria

  12 months pre and post start of care coordination

• Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date)

  12 months pre and post start of care coordination

• Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date)

  12 months pre and post start of care coordination

• Change in Percent of Patients Meeting Depression Screening Criteria

  12 months pre and post start of care coordination

Study Arms (2)

Nursing/Medical Model of Care Coordination

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

Other: Nursing/Medical Model of Care Coordination

Medical/Social Model of Care Coordination

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

Other: Medical/Social Model of Care Coordination

Interventions

Nursing/Medical Model of Care Coordination OTHER

No social worker on the clinic's care coordination team. Services provided: * Coordinated medical care for patients * Patient education * Assistance in developing care plan * Support for patient self-management * Referrals for continuing care * Referral to community resources * Referral to mental health services if needed or requested * Referral to interventional counseling for behavioral health issues

Nursing/Medical Model of Care Coordination

Medical/Social Model of Care Coordination OTHER

Social worker is part of the clinic's care coordination team. * Need not be licensed as a social worker * Must have time dedicated to care coordination for a specific clinic or clinics * Must interact with individual patients to provide them with services * Must interact with individual clinicians about their individual patients in care coordination Services provided: * Coordinated medical care for patients * Patient education * Assistance in developing care plan * Support for patient self-management * Assistance with referrals for continuing care * Assessment and plan to address social and resource needs including housing, transportation or financial needs; Assist patient in locating and obtaining needed community resources * Assistance with identifying and addressing psychological/emotional issues and referrals as needed * Interventional counseling for behavioral health issues or referrals to interventional counseling, depending on licensure

Medical/Social Model of Care Coordination

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Study participants are patients receiving care coordination in Minnesota's Health Care Homes certified adult primary care clinics, starting during the specified date ranges.

You may qualify if:

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

You may not qualify if:

• Cannot complete an interview in English (interviews only)
• Cannot complete a survey in English, Spanish, Somali, or Hmong (for interviews only, reflecting most prevalent languages in MN)

Sponsors & Collaborators

• HealthPartners Institute: lead
• Patient-Centered Outcomes Research Institute: collaborator
• Minnesota Department of Health: collaborator
• MN Community Measurement: collaborator

Study Sites (3)

MN Community Measurement

Minneapolis, Minnesota, 55413, United States

Location

HealthPartners Institute

Minneapolis, Minnesota, 55425, United States

Location

Minnesota Department of Health (MDH)

Saint Paul, Minnesota, 55164, United States

Location

MeSH Terms

Conditions

Chronic Disease; Patient Acceptance of Health Care

Interventions

Nursing

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Treatment Adherence and Compliance; Health Behavior; Behavior

Intervention Hierarchy (Ancestors)

Professional Practice; Organization and Administration; Health Services Administration

Results Point of Contact

• Title: Steven P. Dehmer, PhD
• Organization: HealthPartners Institute

steven.p.dehmer@healthpartners.com

952-967-5216

Study Officials

• Leif I Solberg, MD

  HealthPartners Institute

  PRINCIPAL INVESTIGATOR

• Steven P Dehmer, PhD

  HealthPartners Institute

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: July 1, 2021
• First Posted: July 12, 2021
• Study Start: June 14, 2021
• Primary Completion: April 30, 2024
• Study Completion: April 30, 2024
• Last Updated: April 24, 2025
• Results First Posted: April 24, 2025

Record last verified: 2025-04

Locations

US (3)