Care Coordination, Chronic Disease, Multi-morbidity
Conditions
Keywords
Care Coordination, Quality of Care, Health Care Utilization
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. 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.
Interventions
OTHERNursing/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
OTHERMedical/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
Sponsors
Patient-Centered Outcomes Research Institute
Minnesota Department of Health
MN Community Measurement
HealthPartners Institute
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
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
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Composite Measure of Care Quality | 12 months pre- and post- initiation of care coordination | 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. |
| Change in Annual Number of Emergency Department Visits | 12 months pre and post start of care coordination | 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. |
| Change in Annual Number of Inpatient Hospitalizations | 12 months pre and post start of care coordination | 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. |
| General Health Status - Top Box Scoring | 6 to 18 months after start of care coordination | Percentage of patients reporting Excellent, Very Good, or Good when asked to rate general health status on 5-level Likert Scale (NHIS) |
| Rating of Primary Care Clinic - Top Box | 6 to 18 months after start of care coordination | Percentage of patients reporting 9 or 10 when asked to rate primary care clinic (CG-CAHPS) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Percent of Patients Meeting Depression Screening Criteria | 12 months pre and post start of care coordination | 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. |
| Change in Percent of Patients Meeting A1c Control | 12 months pre and post start of care coordination | Control criteria defined as Hemoglobin A1c \< or = 7% |
| Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | 12 months pre and post start of care coordination | Recommendation is documented aspirin use in patients unless contraindication or exception |
| Change in Percent of Patients Meeting Blood Pressure Control Criteria | 12 months pre and post start of care coordination | Control defined at BP \< 140/90 mm Hg (SBP/DBP) |
| Change in Percent of Patients Reporting Current Tobacco Use | 12 months pre and post start of care coordination | Current tobacco use (tobacco includes any number of cigarettes, cigars, pipes, or smokeless tobacco) |
| Access to Care | 6 to 18 months after start of care coordination | 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) - |
| Rating of Care Coordinator | 6 to 18 months after start of care coordination | 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. |
| Shared Decision Making | 6 to 18 months after start of care coordination | Self-reported experience of shared decision making as measured by CollaboRATE scale - Ranges 0 to 4 higher scores represented more favorable rating of SDM |
| Change in Percent of Patients Meeting Statin Use Recommendations | 12 months pre and post start of care coordination | Recommendation is documented statin use in patients unless contraindication or exception |
| Going Without Care Due to Cost | 6 to 18 months after start of care coordination | 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) |
| Out-of-pocket Medical Costs | 6 to 18 months after start of care coordination | Percent of patients reporting self reporting \>$500 out-of-pocket medical costs in the past 12 months (Medical expenditure panel survey) |
| Medication and Care Burden | 6 to 18 months after start of care coordination | Self-reported medication and care burden (modified from Treatment Burden Questionnaire) - Scores range from 0 to 100 with higher scores representing more burden/worse |
| Social Needs - Housing Security | 6 to 18 months after start of care coordination | Percent of patients reporting No steady place to live when asked to describe they current living situation (modified from CMS HRSN Screening Tool) |
| Social Needs - Food Security | 6 to 18 months after start of care coordination | 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) |
| Social Needs - Access to Dependable Transportation | 6 to 18 months after start of care coordination | 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) |
| Insurance Coverage | 6 to 18 months after start of care coordination | 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) |
| Perceived Care Integration | 6 to 18 months after start of care coordination | Self-reported experience of care integration as measured by IntegRATE scale - Ranges 0 to 3 lower scores represent more favorable rating of care integration |
| Change in Percent of Patients Meeting Asthma Care at Goal | 12 months pre and post start of care coordination | 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. |
| Change in Percent of Patients Meeting Breast Cancer Screening Criteria | 12 months pre and post start of care coordination | Screening criteria defined as mammogram within the last 2 years. |
| Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date) | 12 months pre and post start of care coordination | Screening criteria defined as approved screening test within the last 1 to 10 years depending on type of test and current recomendations. |
| Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date) | 12 months pre and post start of care coordination | Screening criteria defined as a screening test for chlamydia within the last year. |
Countries
United States
Participant flow
Recruitment details
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).
Pre-assignment details
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.
Participants by arm
| Arm | Count |
|---|---|
| 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 | 4,110 |
| 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 | 8,721 |
| Primary Cohort: Medical/Nursing Model 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 | 3,572 |
| 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 | 9,104 |
| Total | 25,507 |
Baseline characteristics
| Characteristic | Historical Cohort: Medical/Nursing Model | Historical Cohort: Medical/Social Model | Primary Cohort: Medical/Nursing Model | Primary Cohort: Medical/Social Model | Total |
|---|---|---|---|---|---|
| Age, Continuous | 63 years STANDARD_DEVIATION 18 | 62 years STANDARD_DEVIATION 19 | 62 years STANDARD_DEVIATION 18 | 63 years STANDARD_DEVIATION 18 | 62 years STANDARD_DEVIATION 19 |
| Country of Origin Non-US country | 198 Participants | 1787 Participants | 217 Participants | 2062 Participants | 4264 Participants |
| Country of Origin United States | 3019 Participants | 5780 Participants | 2552 Participants | 6133 Participants | 17484 Participants |
| Country of Origin Unknown or Choose not to answer | 893 Participants | 1154 Participants | 803 Participants | 909 Participants | 3759 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 107 Participants | 271 Participants | 202 Participants | 285 Participants | 865 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 3540 Participants | 7980 Participants | 2642 Participants | 7791 Participants | 21953 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 463 Participants | 470 Participants | 728 Participants | 1028 Participants | 2689 Participants |
| Insurance coverage Government-sponsored insurance plans | 800 Participants | 3950 Participants | 1076 Participants | 4519 Participants | 10345 Participants |
| Insurance coverage Non-government sponsored insurance plans | 3310 Participants | 4771 Participants | 2496 Participants | 4585 Participants | 15162 Participants |
| Number of chronic conditions 0 | 322 Participants | 285 Participants | 295 Participants | 346 Participants | 1248 Participants |
| Number of chronic conditions 1 | 233 Participants | 369 Participants | 186 Participants | 420 Participants | 1208 Participants |
| Number of chronic conditions 11+ | 462 Participants | 1733 Participants | 461 Participants | 1940 Participants | 4596 Participants |
| Number of chronic conditions 2 | 267 Participants | 595 Participants | 257 Participants | 522 Participants | 1641 Participants |
| Number of chronic conditions 3-4 | 711 Participants | 1496 Participants | 601 Participants | 1371 Participants | 4179 Participants |
| Number of chronic conditions 5-6 | 908 Participants | 1571 Participants | 708 Participants | 1596 Participants | 4783 Participants |
| Number of chronic conditions 7-8 | 741 Participants | 1490 Participants | 641 Participants | 1623 Participants | 4495 Participants |
| Number of chronic conditions 9-10 | 466 Participants | 1182 Participants | 423 Participants | 1286 Participants | 3357 Participants |
| Prevalent chronic conditions Anemia | 696 Participants | 2114 Participants | 629 Participants | 2360 Participants | 5799 Participants |
| Prevalent chronic conditions Anxiety disorders | 1403 Participants | 3833 Participants | 1350 Participants | 3968 Participants | 10554 Participants |
| Prevalent chronic conditions Blindness and vision loss | 1088 Participants | 2723 Participants | 941 Participants | 3169 Participants | 7921 Participants |
| Prevalent chronic conditions Chronic kidney disease | 962 Participants | 2556 Participants | 817 Participants | 2912 Participants | 7247 Participants |
| Prevalent chronic conditions Depressive disorders | 1481 Participants | 4026 Participants | 1341 Participants | 4298 Participants | 11146 Participants |
| Prevalent chronic conditions Diabetes | 2005 Participants | 4129 Participants | 1764 Participants | 4379 Participants | 12277 Participants |
| Prevalent chronic conditions Drug use disorders | 613 Participants | 2004 Participants | 653 Participants | 2112 Participants | 5382 Participants |
| Prevalent chronic conditions Hyperlipidemia | 2282 Participants | 4881 Participants | 1872 Participants | 5097 Participants | 14132 Participants |
| Prevalent chronic conditions Hypertension | 2412 Participants | 5308 Participants | 1992 Participants | 5529 Participants | 15241 Participants |
| Prevalent chronic conditions Ischaemic heart disease | 766 Participants | 1909 Participants | 678 Participants | 1949 Participants | 5302 Participants |
| Prevalent chronic conditions Low back pain | 1040 Participants | 2811 Participants | 968 Participants | 3172 Participants | 7991 Participants |
| Prevalent chronic conditions Osteoarthritis | 1182 Participants | 2832 Participants | 1076 Participants | 3166 Participants | 8256 Participants |
| Primary Language English | 3905 Participants | 7071 Participants | 3211 Participants | 7244 Participants | 21431 Participants |
| Primary Language Hmong | 11 Participants | 263 Participants | 15 Participants | 349 Participants | 638 Participants |
| Primary Language Other | 90 Participants | 953 Participants | 115 Participants | 1092 Participants | 2250 Participants |
| Primary Language Somali | 26 Participants | 224 Participants | 39 Participants | 226 Participants | 515 Participants |
| Primary Language Spanish | 62 Participants | 176 Participants | 158 Participants | 185 Participants | 581 Participants |
| Primary Language Unknown or Choose not to answer | 16 Participants | 34 Participants | 34 Participants | 8 Participants | 92 Participants |
| Race/Ethnicity, Customized American Indian or Alaska Native | 34 Participants | 214 Participants | 76 Participants | 272 Participants | 596 Participants |
| Race/Ethnicity, Customized Asian | 112 Participants | 1090 Participants | 681 Participants | 1486 Participants | 3369 Participants |
| Race/Ethnicity, Customized Black or African American | 196 Participants | 944 Participants | 198 Participants | 1185 Participants | 2523 Participants |
| Race/Ethnicity, Customized Hispanic or Latino | 56 Participants | 149 Participants | 102 Participants | 24 Participants | 331 Participants |
| Race/Ethnicity, Customized Native Hawaiian/Other Pacific Islander | 1 Participants | 10 Participants | 11 Participants | 17 Participants | 39 Participants |
| Race/Ethnicity, Customized Other | 23 Participants | 87 Participants | 57 Participants | 46 Participants | 213 Participants |
| Race/Ethnicity, Customized Unknown or Choose not to answer | 63 Participants | 303 Participants | 112 Participants | 298 Participants | 776 Participants |
| Race/Ethnicity, Customized White | 3625 Participants | 5924 Participants | 2335 Participants | 5776 Participants | 17660 Participants |
| Sex/Gender, Customized Female | 2456 Participants | 5418 Participants | 2250 Participants | 5659 Participants | 15783 Participants |
| Sex/Gender, Customized Male | 1654 Participants | 3299 Participants | 1308 Participants | 3445 Participants | 9706 Participants |
| Sex/Gender, Customized Unknown | 0 Participants | 4 Participants | 14 Participants | 0 Participants | 18 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 |
| other Total, other adverse events | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 |
Outcome results
Primary
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.
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they were covered by participating insurers in both the year pre- and post-care coordination initiation.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Annual Number of Emergency Department Visits | -0.261 Change in encounters per 100 people per | Standard Deviation 127.8 |
| Historical Cohort: Medical/Social Model | Change in Annual Number of Emergency Department Visits | -0.523 Change in encounters per 100 people per | Standard Deviation 174.5 |
| Primary Cohort: Medical/Nursing Model | Change in Annual Number of Emergency Department Visits | -5.51 Change in encounters per 100 people per | Standard Deviation 185.3 |
| Primary Cohort: Medical/Social Model | Change in Annual Number of Emergency Department Visits | -2.97 Change in encounters per 100 people per | Standard Deviation 248.8 |
Comparison: Generalized Linear Mixed Models with Poisson link function. Pre-care coordination measures were included as an independent variable when modeling post-measures to capture change related to care coordination initiation.p-value: 0.0295% CI: [1.04, 1.58]Mixed Models Analysis
Comparison: Generalized Linear Mixed Models with Poisson link function. Pre-care coordination measures were included as an independent variable when modeling post-measures to capture change related to care coordination initiation.p-value: 0.4595% CI: [0.868, 1.38]Mixed Models Analysis
Primary
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.
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they were covered by participating insurers in both the year pre- and post-care coordination initiation.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Annual Number of Inpatient Hospitalizations | -1.173 Change in encounters per 100 people per | Standard Deviation 106.6 |
| Historical Cohort: Medical/Social Model | Change in Annual Number of Inpatient Hospitalizations | 7.197 Change in encounters per 100 people per | Standard Deviation 178.4 |
| Primary Cohort: Medical/Nursing Model | Change in Annual Number of Inpatient Hospitalizations | -7.459 Change in encounters per 100 people per | Standard Deviation 164.2 |
| Primary Cohort: Medical/Social Model | Change in Annual Number of Inpatient Hospitalizations | -4.828 Change in encounters per 100 people per | Standard Deviation 161.3 |
Comparison: Generalized Linear Mixed Models with Poisson link function. Pre-care coordination measures were included as an independent variable when modeling post-measures to capture change related to care coordination initiation.p-value: 0.0195% CI: [1.08, 1.69]Mixed Models Analysis
Comparison: Generalized Linear Mixed Models with Poisson link function. Pre-care coordination measures were included as an independent variable when modeling post-measures to capture change related to care coordination initiation.p-value: 0.0895% CI: [0.969, 1.81]Mixed Models Analysis
Primary
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.
Time frame: 12 months pre- and post- initiation of care coordination
Population: 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.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Composite Measure of Care Quality | 7.0 Change in percent | Standard Deviation 31.2 |
| Historical Cohort: Medical/Social Model | Change in Composite Measure of Care Quality | 4.5 Change in percent | Standard Deviation 34.3 |
| Primary Cohort: Medical/Nursing Model | Change in Composite Measure of Care Quality | 5.9 Change in percent | Standard Deviation 31.1 |
| Primary Cohort: Medical/Social Model | Change in Composite Measure of Care Quality | 5.9 Change in percent | Standard Deviation 35.7 |
Comparison: Null hypothesis: Average change in composite care quality outcome is not different between patients receiving care in Medical/Nursing Model clinics and those receiving care in Medical/Social Model clinics.p-value: 0.1995% CI: [-4.1, 0.1]Mixed Models Analysis
Comparison: Null hypothesis: Average change in composite care quality outcome is not different between patients receiving care in Medical/Nursing Model clinics and those receiving care in Medical/Social Model clinics.p-value: 0.00595% CI: [-5.6, -1]Mixed Models Analysis
Primary
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)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | General Health Status - Top Box Scoring | 221 Participants |
| Historical Cohort: Medical/Social Model | General Health Status - Top Box Scoring | 365 Participants |
| Primary Cohort: Medical/Nursing Model | General Health Status - Top Box Scoring | 609 Participants |
| Primary Cohort: Medical/Social Model | General Health Status - Top Box Scoring | 1002 Participants |
Comparison: Generalized Linear Mixed Models with Binomial link function.p-value: 0.000195% CI: [0.51, 0.81]Mixed Models Analysis
Comparison: Generalized Linear Mixed Models with Binomial link function.p-value: 0.3295% CI: [0.84, 1.72]Mixed Models Analysis
Primary
Rating of Primary Care Clinic - Top Box
Percentage of patients reporting 9 or 10 when asked to rate primary care clinic (CG-CAHPS)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Rating of Primary Care Clinic - Top Box | 188 Participants |
| Historical Cohort: Medical/Social Model | Rating of Primary Care Clinic - Top Box | 235 Participants |
| Primary Cohort: Medical/Nursing Model | Rating of Primary Care Clinic - Top Box | 480 Participants |
| Primary Cohort: Medical/Social Model | Rating of Primary Care Clinic - Top Box | 898 Participants |
Comparison: Generalized Linear Mixed Models with Binomial link function.p-value: 0.1495% CI: [0.69, 1.05]Mixed Models Analysis
Comparison: Generalized Linear Mixed Models with Binomial link function.p-value: 0.1295% CI: [0.51, 1.08]Mixed Models Analysis
Secondary
Access to Care
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) -
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Access to Care | 231 Participants |
| Historical Cohort: Medical/Social Model | Access to Care | 276 Participants |
| Primary Cohort: Medical/Nursing Model | Access to Care | 644 Participants |
| Primary Cohort: Medical/Social Model | Access to Care | 1121 Participants |
p-value: <0.00195% CI: [5.6, 13]Chi-squared
p-value: 0.00295% CI: [4.2, 18]Chi-squared
Secondary
Change in Percent of Patients Meeting A1c Control
Control criteria defined as Hemoglobin A1c \< or = 7%
Time frame: 12 months pre and post start of care coordination
Population: 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.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting A1c Control | 15.2 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting A1c Control | 6.2 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting A1c Control | 0.6 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting A1c Control | -1.8 percentage of patients |
p-value: 0.40595% CI: [0.594, 1.234]Mixed Models Analysis
p-value: 0.00495% CI: [0.374, 0.834]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations
Recommendation is documented aspirin use in patients unless contraindication or exception
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they had vascular disease in the year pre- and post-care coordination initiation.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | 2.6 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | -3.1 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | 3.6 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | 1.2 percentage of patients |
p-value: 0.07195% CI: [0.02, 1.173]Mixed Models Analysis
p-value: 0.00395% CI: [0.002, 0.268]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Asthma Care at Goal
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.
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they have a diagnosis of asthma in both the year pre- and post-care coordination initiation.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Asthma Care at Goal | -2.3 Change in percent |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Asthma Care at Goal | -2.6 Change in percent |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Asthma Care at Goal | -7.1 Change in percent |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Asthma Care at Goal | -6.6 Change in percent |
p-value: 0.91495% CI: [0.243, 4.861]Mixed Models Analysis
p-value: 0.98795% CI: [0.327, 3.114]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Blood Pressure Control Criteria
Control defined at BP \< 140/90 mm Hg (SBP/DBP)
Time frame: 12 months pre and post start of care coordination
Population: 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.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Blood Pressure Control Criteria | 3.7 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Blood Pressure Control Criteria | -0.8 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Blood Pressure Control Criteria | 3.1 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Blood Pressure Control Criteria | 1.7 percentage of patients |
p-value: 0.55795% CI: [0.587, 1.333]Mixed Models Analysis
p-value: 0.06995% CI: [0.376, 1.037]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Breast Cancer Screening Criteria
Screening criteria defined as mammogram within the last 2 years.
Time frame: 12 months pre and post start of care coordination
Population: 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
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Breast Cancer Screening Criteria | 2.8 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Breast Cancer Screening Criteria | -0.4 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Breast Cancer Screening Criteria | 0.2 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Breast Cancer Screening Criteria | 4.7 percentage of patients |
p-value: 0.20495% CI: [0.883, 1.79]Mixed Models Analysis
p-value: 0.0495% CI: [0.166, 0.958]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date)
Screening criteria defined as a screening test for chlamydia within the last year.
Time frame: 12 months pre and post start of care coordination
Population: 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.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date) | -7.5 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date) | 2.1 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date) | 0.0 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date) | -18.5 percentage of patients |
p-value: 0.31895% CI: [0.086, 2.22]Mixed Models Analysis
p-value: 0.42195% CI: [0.433, 7.426]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date)
Screening criteria defined as approved screening test within the last 1 to 10 years depending on type of test and current recomendations.
Time frame: 12 months pre and post start of care coordination
Population: 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.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date) | 3.3 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date) | 2.0 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date) | 3.2 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Colorectal Cancer Screening (Up-to-date) | 4.2 percentage of patients |
p-value: 0.30295% CI: [0.814, 1.939]Mixed Models Analysis
p-value: 0.19295% CI: [0.647, 1.092]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Depression Screening Criteria
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.
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they had at least one PHQ9 score in both the year pre- and post-care coordination initiation.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Depression Screening Criteria | 7.4 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Depression Screening Criteria | 4.4 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Depression Screening Criteria | 5.1 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Depression Screening Criteria | 3.9 percentage of patients |
p-value: 0.63295% CI: [0.606, 1.356]Mixed Models Analysis
p-value: 0.49295% CI: [0.523, 1.366]Mixed Models Analysis
Secondary
Change in Percent of Patients Meeting Statin Use Recommendations
Recommendation is documented statin use in patients unless contraindication or exception
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they had vascular disease diagnosis the year pre- and post-care coordination initiation.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Statin Use Recommendations | 6.0 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Meeting Statin Use Recommendations | 5.8 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Meeting Statin Use Recommendations | 4.3 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Meeting Statin Use Recommendations | 4.0 percentage of patients |
p-value: 0.25695% CI: [0.185, 1.565]Mixed Models Analysis
p-value: 0.86695% CI: [0.308, 4.047]Mixed Models Analysis
Secondary
Change in Percent of Patients Reporting Current Tobacco Use
Current tobacco use (tobacco includes any number of cigarettes, cigars, pipes, or smokeless tobacco)
Time frame: 12 months pre and post start of care coordination
Population: Patients included in analytic comparison if they had a diabetes and/or vascular disease diagnosis in the year pre- and post-care coordination initiation.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Change in Percent of Patients Reporting Current Tobacco Use | 1.8 percentage of patients |
| Historical Cohort: Medical/Social Model | Change in Percent of Patients Reporting Current Tobacco Use | 0.9 percentage of patients |
| Primary Cohort: Medical/Nursing Model | Change in Percent of Patients Reporting Current Tobacco Use | 0.2 percentage of patients |
| Primary Cohort: Medical/Social Model | Change in Percent of Patients Reporting Current Tobacco Use | -0.3 percentage of patients |
p-value: 0.64195% CI: [0.307, 2.069]Mixed Models Analysis
p-value: 0.3295% CI: [0.187, 1.729]Mixed Models Analysis
Secondary
Going Without Care Due to Cost
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)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Going Without Care Due to Cost | 23 Participants |
| Historical Cohort: Medical/Social Model | Going Without Care Due to Cost | 58 Participants |
| Primary Cohort: Medical/Nursing Model | Going Without Care Due to Cost | 81 Participants |
| Primary Cohort: Medical/Social Model | Going Without Care Due to Cost | 203 Participants |
p-value: 0.05995% CI: [-4.9, 0]Chi-squared
p-value: 0.01495% CI: [-10, -1.3]Chi-squared
Secondary
Insurance Coverage
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)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Insurance Coverage | 18 Participants |
| Historical Cohort: Medical/Social Model | Insurance Coverage | 36 Participants |
| Primary Cohort: Medical/Nursing Model | Insurance Coverage | 49 Participants |
| Primary Cohort: Medical/Social Model | Insurance Coverage | 159 Participants |
p-value: 0.00295% CI: [-5.5, -1.4]Chi-squared
p-value: 0.395% CI: [-6.1, 1.4]Chi-squared
Secondary
Medication and Care Burden
Self-reported medication and care burden (modified from Treatment Burden Questionnaire) - Scores range from 0 to 100 with higher scores representing more burden/worse
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Historical Cohort: Medical/Nursing Model | Medication and Care Burden | 35 score on a scale | Standard Deviation 31 |
| Historical Cohort: Medical/Social Model | Medication and Care Burden | 41 score on a scale | Standard Deviation 32 |
| Primary Cohort: Medical/Nursing Model | Medication and Care Burden | 38 score on a scale | Standard Deviation 31 |
| Primary Cohort: Medical/Social Model | Medication and Care Burden | 45 score on a scale | Standard Deviation 31 |
p-value: <0.00195% CI: [-10, -5]t-test, 2 sided
p-value: 0.00795% CI: [-10, -2]t-test, 2 sided
Secondary
Out-of-pocket Medical Costs
Percent of patients reporting self reporting \>$500 out-of-pocket medical costs in the past 12 months (Medical expenditure panel survey)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Out-of-pocket Medical Costs | 168 Participants |
| Historical Cohort: Medical/Social Model | Out-of-pocket Medical Costs | 181 Participants |
| Primary Cohort: Medical/Nursing Model | Out-of-pocket Medical Costs | 373 Participants |
| Primary Cohort: Medical/Social Model | Out-of-pocket Medical Costs | 552 Participants |
p-value: <0.00195% CI: [6.8, 15]Chi-squared
p-value: 0.00195% CI: [4.7, 20]Chi-squared
Secondary
Perceived Care Integration
Self-reported experience of care integration as measured by IntegRATE scale - Ranges 0 to 3 lower scores represent more favorable rating of care integration
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Historical Cohort: Medical/Nursing Model | Perceived Care Integration | 0.59 score on a scale | Standard Deviation 0.54 |
| Historical Cohort: Medical/Social Model | Perceived Care Integration | 0.71 score on a scale | Standard Deviation 0.62 |
| Primary Cohort: Medical/Nursing Model | Perceived Care Integration | 0.64 score on a scale | Standard Deviation 0.59 |
| Primary Cohort: Medical/Social Model | Perceived Care Integration | 0.75 score on a scale | Standard Deviation 0.62 |
p-value: <0.00195% CI: [-0.16, -0.06]t-test, 2 sided
p-value: 0.00695% CI: [-0.2, -0.03]t-test, 2 sided
Secondary
Rating of Care Coordinator
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.
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Rating of Care Coordinator | 97 Participants |
| Historical Cohort: Medical/Social Model | Rating of Care Coordinator | 128 Participants |
| Primary Cohort: Medical/Nursing Model | Rating of Care Coordinator | 317 Participants |
| Primary Cohort: Medical/Social Model | Rating of Care Coordinator | 623 Participants |
p-value: 0.02395% CI: [0.86, 11]Chi-squared
p-value: 0.595% CI: [-14, 7]Chi-squared
Secondary
Shared Decision Making
Self-reported experience of shared decision making as measured by CollaboRATE scale - Ranges 0 to 4 higher scores represented more favorable rating of SDM
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Historical Cohort: Medical/Nursing Model | Shared Decision Making | 2.9 score on a scale | Standard Deviation 0.91 |
| Historical Cohort: Medical/Social Model | Shared Decision Making | 2.7 score on a scale | Standard Deviation 0.99 |
| Primary Cohort: Medical/Nursing Model | Shared Decision Making | 3.0 score on a scale | Standard Deviation 0.89 |
| Primary Cohort: Medical/Social Model | Shared Decision Making | 2.89 score on a scale | Standard Deviation 0.9 |
p-value: <0.00195% CI: [0.06, 0.19]t-test, 2 sided
p-value: <0.00195% CI: [0.06, 0.32]t-test, 2 sided
Secondary
Social Needs - Access to Dependable Transportation
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)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Social Needs - Access to Dependable Transportation | 32 Participants |
| Historical Cohort: Medical/Social Model | Social Needs - Access to Dependable Transportation | 82 Participants |
| Primary Cohort: Medical/Nursing Model | Social Needs - Access to Dependable Transportation | 123 Participants |
| Primary Cohort: Medical/Social Model | Social Needs - Access to Dependable Transportation | 373 Participants |
p-value: <0.00195% CI: [-10, -4.1]Chi-squared
p-value: 0.00295% CI: [-13, -3.2]Chi-squared
Secondary
Social Needs - Food Security
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)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Social Needs - Food Security | 51 Participants |
| Historical Cohort: Medical/Social Model | Social Needs - Food Security | 124 Participants |
| Primary Cohort: Medical/Nursing Model | Social Needs - Food Security | 165 Participants |
| Primary Cohort: Medical/Social Model | Social Needs - Food Security | 510 Participants |
p-value: <0.00195% CI: [-13, -6.8]Chi-squared
p-value: <0.00195% CI: [-17, -5.6]Chi-squared
Secondary
Social Needs - Housing Security
Percent of patients reporting No steady place to live when asked to describe they current living situation (modified from CMS HRSN Screening Tool)
Time frame: 6 to 18 months after start of care coordination
Population: 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.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Cohort: Medical/Nursing Model | Social Needs - Housing Security | 18 Participants |
| Historical Cohort: Medical/Social Model | Social Needs - Housing Security | 46 Participants |
| Primary Cohort: Medical/Nursing Model | Social Needs - Housing Security | 73 Participants |
| Primary Cohort: Medical/Social Model | Social Needs - Housing Security | 189 Participants |
p-value: 0.04695% CI: [-4.8, -0.14]Chi-squared
p-value: 0.03395% CI: [-8.4, -0.52]Chi-squared