Medical care has improved greatly over the past 50 years. Treatments for most medical conditions can help people lead longer and healthier lives, but there are still problems. Many patients with two or more conditions see several different doctors and sometimes take more medications than needed. These patients can feel lost and confused. In addition, nonmedical issues involving housing, food, transportation, employment, income, support from others, and language barriers can have a large impact on individuals’ health. In Minnesota, many primary care clinics are using a method called care coordination to improve the health of patients who have multiple chronic diseases (e.g., diabetes, heart disease, asthma, and depression). With care coordination, a nurse in the clinic helps the various doctors, clinics, and specialists 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 such as housing, transportation, or employment. Care coordination can help reduce patient confusion. It also can improve patient health and lower patient burdens and costs of medical care. We are proposing a study to help determine what types of care coordination are most successful.
Our plan is to track the health of patients receiving care coordination and compare two types: care coordination performed by a nurse or other clinic staff and care coordination in which a licensed social worker also assists the patient. In this study, we will measure many outcomes, including the following:
- control of chronic conditions, such as diabetes, heart disease, asthma, and depression;
- reduction in unnecessary hospitalizations;
- reduction in emergency department visits;
- reduction in unnecessary medications and duplicate tests;
- reduction in specialty care while increasing the use of necessary care and preventive services;
- improvement in health Improvement and patient satisfaction and access to care;
- increased shared decision making (in which the doctor and the patient make treatment decisions together);
- reduction of patient burden (i.e., how much time and effort the patient spends trying to get healthy);
- and reduction in 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. Four patient partners will help conduct the study and interpret and broadly share the results.
The project was developed with input from patients, clinic leaders, members of 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 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.
Other Health Services Interventions
Training and Education Interventions
Individuals with Multiple Chronic/co-morbid Conditions
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.