NCT04957979

Minnesota Care Coordination Effectiveness Study

Comparing Two Approaches to Care Coordination for High-Cost/High-Need Patients in Primary Care

• Status: Completed
• Phase: —
• Study type: Observational
• Enrollment: 25,507 (actual)
• Sponsor: HealthPartners Institute · Academic / Other
• Sex: All
• Age: 18 Years
• Healthy volunteers: Not accepted

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. Control of chronic conditions like diabetes, heart disease, asthma, and depression 2. Hospitalizations 3. Emergency department visits 4. Use of medications and diagnostic tests 5. Use of specialty care 6. General health status 7. Patient satisfaction and access to care 8. Use of shared decision-making (where the doctor and the patient make treatment decisions together) 9. Patient burden (how much time and effort the patient spends trying to get healthy) 10. Patients' out-of-pocket medical costs This project will be important to patients because it could reduce confusion and fragmented care while improving all the items above. Those improvements will be more likely because this project takes advantage of engagement with patients and others. We have four patient partners who will help conduct the study and interpret and broadly share the results. The project was developed with the input from patients, clinic leaders, people from state government, and experts on health and quality care. By measuring a wide variety of outcomes for the adults receiving coordination services in these clinics, we hope to identify the specific actionable information that will allow these and other clinics to improve their services for these patients with complex needs. Throughout the project, we will communicate our findings to clinics and health systems. As a result, many people may receive better care.

Conditions

• Chronic Disease
• Multi-morbidity
• Care Coordination

Interventions

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

Timeline

• Start date: 2021-06-14
• Primary completion: 2024-04-30
• Completion: 2024-04-30
• First posted: 2021-07-12
• Last updated: 2025-04-24
• Results posted: 2025-04-24

Locations

3 sites across 1 country: United States