Minnesota Care Coordination Effectiveness Study (MNCARES)

HealthPartners Institute

Status: Completed

Conditions: Chronic Disease; Multi-morbidity; Care Coordination

Treatments: Other: Nursing/Medical Model of Care Coordination; Other: Medical/Social Model of Care Coordination

Study type: Observational

Funder types: Other

Identifiers

NCT04957979

19-110

IHS-2019C1-15625 (Other Identifier)

Details and patient eligibility

About

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.

Enrollment: 25,507 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

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

Exclusion criteria

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

Trial design

25,507 participants in 2 patient groups

Nursing/Medical Model of Care Coordination

Description:

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

Treatment:

Other: Nursing/Medical Model of Care Coordination

Medical/Social Model of Care Coordination

Description:

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.

Treatment:

Other: Medical/Social Model of Care Coordination