Project Summary

The health of communities and health disparities are influenced both by the healthcare system and by the social context in which people live. Accordingly, interventions that seek to meaningfully reduce disparities should consider patients’ medical and social needs. The fragmentation of medical care is one aspect of the healthcare system that adversely affects health, perhaps particularly for socioeconomically disadvantaged individuals with more limited resources. Indeed, while many care coordination programs have been developed, evidence supporting their effectiveness is quite limited, especially for vulnerable populations. This study will fill important gaps in evidence concerning the effects of three diverse care coordination models on hospitalization rates for a socioeconomically disadvantaged population at increased risk of hospitalization that is served by the University of Chicago Medicine (UCM). Secondary outcomes include patient activation and engagement with care, satisfaction with care, general health and mental health, and personal goal attainment. The first model is a commonly implemented care coordination model developed and studied by Partners HealthCare, which we call the Partners HealthCare Care Management Program (PHCMP). In PHCMP, high-risk patients have access to nurse care coordinators who seek to manage these patients’ care. UCM has recently implemented a model based on PHCMP that it calls the Ambulatory Care Coordination Team (ACCT). In ACCT, nurses and social workers provide proactive care coordination to high-risk patients. Both programs are representative of common care coordination models implemented nationally in that they involve additional hiring and increased hand-offs. The second model is a novel care delivery program called the Comprehensive Care Physician (CCP) program.

The CCP model seeks to more effectively integrate inpatient and outpatient care for patients at increased risk of hospitalization, by offering them care from the same physician in the inpatient and the outpatient settings so that they can benefit from the advantages of continuity in the doctor–patient relationship. Since 2012, we have developed and tested this model at UCM in a socioeconomically disadvantaged population of patients at increased risk of hospitalization, through a randomized controlled trial funded by the Center for Medicare and Medicaid Innovation that compares CCP with standard care (SC) at UCM in which patients receive care inpatient and outpatient care from different doctors and do not have access to care coordinators. Our findings to date indicate that CCP significantly improves patient satisfaction and outcomes and decreases resource use. We think that these improved outcomes stem from the greater continuity of care our CCP team is able to provide patients, as team members care for them in and out of the hospital.

The third model, the Comprehensive Care, Community and Culture Program (C4P), was motivated by the finding that roughly 30 percent of patients who enrolled in the CCP program did not engage with it, despite having expressed interest in the program, and that a wide range of social factors might be barriers to their engagement. To better address social determinants of health, C4P builds on CCP by adding

  1. systematic screening of 17 domains of unmet social needs,
  2. access to a community health worker, and
  3. access to community-based arts and culture programming.

Preliminary findings from a pilot of C4P indicate that the program increases patient activation and engagement in care compared with SC. While we have rigorously compared CCP with SC and performed a pilot study of C4P, CCP, and SC at UCM, we have not compared CCP or C4P with the more commonly used CC model, nor have we rigorously compared CCP and C4P. The findings comparing these models that we propose to generate are sorely needed by patients and health systems to inform choices about care coordination models. In this study, we aim to determine primarily whether socioeconomically disadvantaged Medicare patients at increased risk of hospitalization experience fewer hospitalization if they are offered care in

  1. ACCT, in which patients receive care from different physicians in the hospital and the clinic settings and have access to nurse and social worker care coordination services;
  2. CCP, in which patients receive care from one physician in the inpatient and outpatient settings; or
  3. C4P, which adds screening of unmet social needs, community health worker support, and arts and culture programming to CCP. We also will determine how these programs affect patient activation and engagement in care, satisfaction with care, general physical and mental health, and goal attainment.

Project Information

David O. Meltzer, MD, PhD
The University of Chicago

Key Dates

November 2019
February 2026

Study Registration Information


Award Type
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: September 26, 2023