Enhancing Complex Care Through an Integrated Care Coordination Information System

Ambulatory Safety and Quality Program: Improving Management of Individuals With Complex Healthcare Needs Through Health It

Cluster randomized controlled trial comparing care coordination incentives to pay for performance (quality measure) incentives in clinics on utilization, cost, quality, and patient experience.

Inclusion Criteria:

• Six Clinics participating whom Care Management Plus team has worked with before
• Patients belonging to one of these six clinics
• Picked based on an algorithm designed to identify high risk patients.
• Clinic will review potential patients list and issue a survey with consent form

Exclusion Criteria:

• Younger than 18
• Older than 90