Project Summary

This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

Patients with multiple health problems may receive care from several doctors. Trying to follow all of the medical advice they receive and take medicines correctly may be overwhelming. Some patients may also need help finding resources for social needs, such as housing, food, or a job. In care coordination, health providers, clinics, and specialists work together to support the patient. Some clinics also have a nurse or social worker who coordinates care and helps patients find resources.

In this study, the research team is comparing two ways to coordinate care for patients with multiple health problems and social needs.

Who can this research help?

Results from this study may help clinics when considering ways to coordinate care for patients with multiple health problems and social needs.

What is the research team doing?

The research team is recruiting 300–400 primary care clinics in Minnesota that have been certified as healthcare homes. A healthcare home is an approach to primary care where clinics and providers work together to coordinate care for patients with multiple health needs. Patients in the study receive care at one of the study clinics.

Clinics in the study offer care coordination in two different ways:

  • Nurse only. A nurse coordinates care, including teaching patients about and helping patients manage their health problems.
  • Nurse plus social worker. A nurse coordinates care as in the nurse-only clinics. A social worker also helps patients identify resources for social needs.

In the year before and after starting care coordination, the research team is looking at patient data on clinical measures such as blood pressure, diabetes, and asthma to learn about the quality of care. The team is also using data from health insurance claims to learn about emergency room, or ER, visits and hospital stays. Also, the team is surveying patients about their health and social needs, medicines they take, healthcare costs, and how satisfied they are with their health care. The team is comparing these outcomes between the two approaches to care coordination.

Patients that receive care coordination are part of the research team. They are helping to choose outcomes that are important to patients and to plan and conduct the study.

Research methods at a glance

Design Element Description
Design Observational: cohort study
Population 5,000–10,000 adults with complex health needs at 300–400 primary care clinics
  • Nurse only
  • Nurse plus social worker support 

Primary: healthcare quality, healthcare utilization, ER visits, hospitalizations, patient-reported health status, satisfaction with care

Secondary: healthcare access, healthcare coordination, personal goal attainment, shared decision making, medicine and care burden, change in insurance coverage, going without care due to cost, out-of-pocket medical costs, changes in social needs

Timeframe 1-month follow-up for primary outcomes

Project Information

Leif I. Solberg, MD
HealthPartners Institute
Comparing Two Approaches to Care Coordination for High-Cost/High-Need Patients in Primary Care

Key Dates

November 2019
May 2024

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: March 14, 2024