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| ID | Type | Description | Link |
|---|---|---|---|
| IHS-2019C1-15625 | Other Identifier | Patient Centered Outcomes Research Institute |
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| Name | Class |
|---|---|
| Patient-Centered Outcomes Research Institute | OTHER |
| Minnesota Department of Health | OTHER_GOV |
| MN Community Measurement | UNKNOWN |
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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:
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.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| 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. |
| |
| 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. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Nursing/Medical Model of Care Coordination | Other | No social worker on the clinic's care coordination team. Services provided:
|
| Measure | Description | Time Frame |
|---|---|---|
| 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 |
| Measure | Description | Time Frame |
|---|---|---|
| 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. |
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Inclusion Criteria:
Exclusion Criteria:
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Study participants are patients receiving care coordination in Minnesota's Health Care Homes certified adult primary care clinics, starting during the specified date ranges.
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| Name | Affiliation | Role |
|---|---|---|
| Leif I Solberg, MD | HealthPartners Institute | Principal Investigator |
| Steven P Dehmer, PhD | HealthPartners Institute | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| MN Community Measurement | Minneapolis | Minnesota | 55413 | United States | ||
| HealthPartners Institute |
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.
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).
| ID | Title | Description |
|---|---|---|
| FG000 | 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:
|
| FG001 | 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.
Services provided:
|
| FG002 | Primary Cohort: Medical/Nursing Model | Patients starting care coordination in participating clinics between January and 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:
|
| FG003 | 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.
Services provided:
|
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
Baseline population is the population of patients identified by care systems meeting study eligibility criteria.
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| ID | Title | Description |
|---|---|---|
| BG000 | 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:
|
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | As documented in the EHR, at start of care coordination |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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. | 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. | Posted | Mean | Standard Deviation | Change in percent | 12 months pre- and post- initiation of care coordination |
|
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All-cause mortality, Serious and other Adverse Events were not collected as part of this work given the observational and retrospective nature of this study. Clinics made no changes in their care practices as a result of study participation and outcomes were observed as reported in the results section. Therefore there were no patients/units considered "at-risk" for adverse event reporting.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | 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:
|
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Steven P. Dehmer, PhD | HealthPartners Institute | 952-967-5216 | steven.p.dehmer@healthpartners.com |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Jan 29, 2024 | Mar 8, 2024 | Prot_SAP_002.pdf |
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| ID | Term |
|---|---|
| D002908 | Chronic Disease |
| D010342 | Patient Acceptance of Health Care |
| ID | Term |
|---|---|
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D000074822 | Treatment Adherence and Compliance |
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| ID | Term |
|---|---|
| D009729 | Nursing |
| ID | Term |
|---|---|
| D011364 | Professional Practice |
| D009934 | Organization and Administration |
| D006298 | Health Services Administration |
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|
| Medical/Social Model of Care Coordination | Other | Social worker is part of the clinic's care coordination team.
Services provided:
|
|
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 |
| 12 months pre and post start of care coordination |
| Change in Percent of Patients Meeting Breast Cancer Screening Criteria | Screening criteria defined as mammogram within the last 2 years. | 12 months pre and post start of care coordination |
| 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. | 12 months pre and post start of care coordination |
| Change in Percent of Patients Meeting Chlamydia Screening (Up-to-date) | Screening criteria defined as a screening test for chlamydia within the last year. | 12 months pre and post start of care coordination |
| 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. | 12 months pre and post start of care coordination |
| Change in Percent of Patients Meeting A1c Control | Control criteria defined as Hemoglobin A1c < or = 7% | 12 months pre and post start of care coordination |
| Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | Recommendation is documented aspirin use in patients unless contraindication or exception | 12 months pre and post start of care coordination |
| Change in Percent of Patients Meeting Blood Pressure Control Criteria | Control defined at BP < 140/90 mm Hg (SBP/DBP) | 12 months pre and post start of care coordination |
| Change in Percent of Patients Meeting Statin Use Recommendations | Recommendation is documented statin use in patients unless contraindication or exception | 12 months pre and post start of care coordination |
| Change in Percent of Patients Reporting Current Tobacco Use | Current tobacco use (tobacco includes any number of cigarettes, cigars, pipes, or smokeless tobacco) | 12 months pre and post start of care coordination |
| 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) - | 6 to 18 months after start of care coordination |
| 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. | 6 to 18 months after start of care coordination |
| 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 | 6 to 18 months after start of care coordination |
| 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 | 6 to 18 months after start of care coordination |
| 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) | 6 to 18 months after start of care coordination |
| 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) | 6 to 18 months after start of care coordination |
| 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 | 6 to 18 months after start of care coordination |
| 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) | 6 to 18 months after start of care coordination |
| 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) | 6 to 18 months after start of care coordination |
| 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) | 6 to 18 months after start of care coordination |
| 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) | 6 to 18 months after start of care coordination |
| Minneapolis |
| Minnesota |
| 55425 |
| United States |
| Minnesota Department of Health (MDH) | Saint Paul | Minnesota | 55164 | United States |
| BG001 | 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.
Services provided:
|
| BG002 | 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:
|
| BG003 | 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.
Services provided:
|
| BG004 | Total | Total of all reporting groups |
| Mean |
| Standard Deviation |
| years |
|
| Sex/Gender, Customized | Count of Participants | Participants |
|
| Ethnicity (NIH/OMB) | As documented in the EHR | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | As documented in the EHR | Count of Participants | Participants |
|
| Primary Language | As indicated in the EHR for patients requesting language interpreter services | Count of Participants | Participants |
|
| Country of Origin | As documented in the EHR | Count of Participants | Participants |
|
| Insurance coverage | As documented in EHR | Count of Participants | Participants |
|
| Number of chronic conditions | As documented in EHR problem list | Count of Participants | Participants |
|
| Prevalent chronic conditions | As documented in the EHR problem list, with at least 20% prevalence in a study subgroup | Count of Participants | Participants |
|
| OG000 | 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:
|
| OG001 | 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.
Services provided:
|
| OG002 | Primary Cohort: Medical/Nursing Model | Patients starting care coordination in participating clinics between January 2021 and 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:
|
| OG003 | Primary Cohort: Medical/Social Model | Patients starting care coordination in participating clinics between January 2021 and 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.
Services provided:
|
|
|
|
| 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. | Patients included in analytic comparison if they were covered by participating insurers in both the year pre- and post-care coordination initiation. | Posted | Mean | Standard Deviation | Change in encounters per 100 people per | 12 months pre and post start of care coordination |
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|
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| 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. | Patients included in analytic comparison if they were covered by participating insurers in both the year pre- and post-care coordination initiation. | Posted | Mean | Standard Deviation | Change in encounters per 100 people per | 12 months pre and post start of care coordination |
|
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|
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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| Primary | Rating of Primary Care Clinic - Top Box | Percentage of patients reporting 9 or 10 when asked to rate primary care clinic (CG-CAHPS) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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|
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| 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. | Patients included in analytic comparison if they have a diagnosis of asthma in both the year pre- and post-care coordination initiation. | Posted | Number | Change in percent | 12 months pre and post start of care coordination |
|
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| Secondary | Change in Percent of Patients Meeting Breast Cancer Screening Criteria | Screening criteria defined as mammogram within the last 2 years. | 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 | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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|
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| 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. | 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. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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| 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. | 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. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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|
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| 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. | Patients included in analytic comparison if they had at least one PHQ9 score in both the year pre- and post-care coordination initiation. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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| Secondary | Change in Percent of Patients Meeting A1c Control | Control criteria defined as Hemoglobin A1c < or = 7% | 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. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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| Secondary | Change in Percent of Patients Meeting Aspirin or Anti-Platelet Use Recommendations | Recommendation is documented aspirin use in patients unless contraindication or exception | Patients included in analytic comparison if they had vascular disease in the year pre- and post-care coordination initiation. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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| Secondary | Change in Percent of Patients Meeting Blood Pressure Control Criteria | Control defined at BP < 140/90 mm Hg (SBP/DBP) | 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. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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| Secondary | Change in Percent of Patients Meeting Statin Use Recommendations | Recommendation is documented statin use in patients unless contraindication or exception | Patients included in analytic comparison if they had vascular disease diagnosis the year pre- and post-care coordination initiation. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
|
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| Secondary | Change in Percent of Patients Reporting Current Tobacco Use | Current tobacco use (tobacco includes any number of cigarettes, cigars, pipes, or smokeless tobacco) | Patients included in analytic comparison if they had a diabetes and/or vascular disease diagnosis in the year pre- and post-care coordination initiation. | Posted | Number | percentage of patients | 12 months pre and post start of care coordination |
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| 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) - | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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| 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. | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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| 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 | 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. | Posted | Mean | Standard Deviation | score on a scale | 6 to 18 months after start of care coordination |
|
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| 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 | 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. | Posted | Mean | Standard Deviation | score on a scale | 6 to 18 months after start of care coordination |
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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|
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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|
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| 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 | 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. | Posted | Mean | Standard Deviation | score on a scale | 6 to 18 months after start of care coordination |
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
|
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
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| 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) | 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. | Posted | Count of Participants | Participants | 6 to 18 months after start of care coordination |
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| 0 |
| 0 |
| 0 |
| 0 |
| 0 |
| 0 |
| EG001 | 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.
Services provided:
| 0 | 0 | 0 | 0 | 0 | 0 |
| EG002 | Primary Cohort: Medical/Nursing Model | Patients starting care coordination in participating clinics between January and 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:
| 0 | 0 | 0 | 0 | 0 | 0 |
| EG003 | 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.
Services provided:
| 0 | 0 | 0 | 0 | 0 | 0 |
Not provided
Not provided
| D015438 | Health Behavior |
| D001519 | Behavior |
| Superiority |
| 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. | Mixed Models Analysis | Adjusted for patient demographics, comorbidities, clinic characteristics, and includes random effect for clustering within clinic. | 0.45 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Incidence Rate Ratio | 1.09 | 2-Sided | 95 | 0.868 | 1.38 | Values > 1.0 represents higher rates post-care coordination in Medical/Social clinics as compared to Medical/Nursing. | Superiority |
| Superiority |
| 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. | Mixed Models Analysis | Adjusted for patient demographics, comorbidities, clinic characteristics, and includes random effect for clustering within clinic. | 0.08 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Incidence Rate Ratio | 1.33 | 2-Sided | 95 | 0.969 | 1.81 | Values > 1.0 represents higher rates post-care coordination in Medical/Social clinics as compared to Medical/Nursing. | Superiority |
| Generalized Linear Mixed Models with Binomial link function. | Mixed Models Analysis | Adjusted for patient demographics, comorbidities, clinic characteristics, and includes random effect for clustering within clinic. | 0.32 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 1.2 | 2-Sided | 95 | 0.84 | 1.72 | Values > 1.0 represents higher likelihood of positive rating in Medical/Social clinics as compared to Medical/Nursing. | Superiority |
| Generalized Linear Mixed Models with Binomial link function. | Mixed Models Analysis | Adjusted for patient demographics, comorbidities, clinic characteristics, and includes random effect for clustering within clinic. | 0.12 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 0.74 | 2-Sided | 95 | 0.51 | 1.08 | Values > 1.0 represents higher likelihood of positive rating in Medical/Social clinics as compared to Medical/Nursing. | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.987 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 1.009 | 2-Sided | 95 | 0.327 | 3.114 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | 0.04 | Odds Ratio (OR) | 0.399 | 2-Sided | 95 | 0.166 | 0.958 | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.192 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 0.84 | 2-Sided | 95 | 0.647 | 1.092 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.421 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 1.793 | 2-Sided | 95 | 0.433 | 7.426 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.492 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 0.845 | 2-Sided | 95 | 0.523 | 1.366 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | 0.004 | Odds Ratio (OR) | 0.559 | 2-Sided | 95 | 0.374 | 0.834 | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.003 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Mean Difference (Net) | 0.023 | 2-Sided | 95 | 0.002 | 0.268 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.069 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Mean Difference (Net) | 0.624 | 2-Sided | 95 | 0.376 | 1.037 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.866 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 1.117 | 2-Sided | 95 | 0.308 | 4.047 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Mixed Models Analysis | Binomial link function. Estimation parameter is the interaction between Time (post vs pre) and Care Model (Medical/Social vs Medical Nursing). | 0.32 | No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori | Odds Ratio (OR) | 0.569 | 2-Sided | 95 | 0.187 | 1.729 | Values > 1.0 represents larger improvement pre to post-care coordination in likelihood of specific care quality outcome for patients in Medical/Social clinics as compared to those in Medical/Nursing. | Superiority |
| Chi-squared |
| 0.002 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| 11 |
| 2-Sided |
| 95 |
| 4.2 |
| 18 |
Positive values reflect higher proportion of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| Chi-squared |
| 0.5 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| -3.7 |
| 2-Sided |
| 95 |
| -14.0 |
| 7.0 |
Positive values reflect higher proportion of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| t-test, 2 sided |
| <0.001 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Mean Difference (Net) |
| 0.19 |
| 2-Sided |
| 95 |
| 0.06 |
| 0.32 |
Positive values reflect higher/better scores of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| t-test, 2 sided |
| 0.006 |
| Mean Difference (Net) |
| -0.11 |
| 2-Sided |
| 95 |
| -0.2 |
| -0.03 |
Negative values reflect lower/better scores of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| 0.014 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| -5.7 |
| 2-Sided |
| 95 |
| -10.0 |
| -1.3 |
Positive values reflect higher percentage of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| 0.001 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| 12.0 |
| 2-Sided |
| 95 |
| 4.7 |
| 20.0 |
Positive values reflect higher percentage of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| t-test, 2 sided |
| 0.007 |
| Mean Difference (Net) |
| -6 |
| 2-Sided |
| 95 |
| -10 |
| -2 |
Negative values reflect lower/better scores of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| Chi-squared |
| 0.033 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| -4.5 |
| 2-Sided |
| 95 |
| -8.4 |
| -0.52 |
Positive values reflect higher percentage of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| Chi-squared |
| <0.001 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| -11.0 |
| 2-Sided |
| 95 |
| -17.0 |
| -5.6 |
Positive values reflect higher percentage of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |
| Chi-squared |
| 0.002 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| -8.2 |
| 2-Sided |
| 95 |
| -13.0 |
| -3.2 |
Positive values reflect higher percentage of responders in Medical/Nursing clinics as compared to Medical/Social |
| Superiority |
| Chi-squared |
| 0.3 |
No adjustments for multiple comparisons. Two-sided alpha of 0.05 specified a-priori |
| Risk Difference (RD) |
| -2.4 |
| 2-Sided |
| 95 |
| -6.1 |
| 1.4 |
Positive values reflect higher percentage of responders in Medical/Nursing clinics as compared to Medical/Social. |
| Superiority |