Article Figures & Data
Figures
- Figure 1.
Care coordinator survey participant flow diagram. Abbreviations: HCH, Health Care Home.
Tables
- Table 1.
Descriptive Characteristics of the 213 Responding Care Coordinators – N (%) Unless Stated Otherwise
Overall Only Work in Medical/Nursing Clinics Only Work in Integrated Social Worker Clinics Work in Both Clinic Models P N 213 117 88 8 Degree* <0.001 RN 88 (41.3) 51 (43.6) 35 (39.8) 2 (25.0) MSN or RN + BSN 75 (35.2) 48 (41.0) 25 (28.4) 2 (25.0) MSW or BSW 14 (6.6) 0 (0.0) 11 (12.5) 3 (37.5) LPN or CMA 20 (9.4) 9 (7.7) 10 (11.4) 1 (12.5) Other or None 16 (7.5) 9 (7.7) 7 (8.0) 0 (0.0) Certified in care coordination, yes 33 (15.8) 13 (11.4) 19 (21.8) 1 (12.5) 0.128 Years practicing as a care coordinator mean (SD) 4.8 (4.4) 4.2 (3.9) 5.7 (5.0) 5.2 (2.1) 0.053 Practicing in multiple clinics, yes 61 (28.6) 27 (23.1) 26 (29.5) 8 (100.0) <0.001 Years worked as care coordinator in study clinic/s mean (SD) 3.5 (3.4) 3.1 (3.3) 3.9 (3.5) 4.5 (2.8) 0.13 Hours/week as care coordinator in study clinic/s (SD) 31.6 (21.2) 27.2 (19.4) 37.4 (23.0) 32.2 (7.9) 0.003 Work onsite at study clinic/s, usually or always mean (SD) 32 (15.4) 5 (4.4) 22 (25.6) 5 (62.5) <0.001 Abbreviations: RN, registered nurse; MSN, master’s in nursing; BSN, bachelor of science in nursing; MSW, master’s in social work; BSW, bachelor of science in social work; LPN, licensed practical nurse; CMA, certified medical assistant; SD, standard deviation.
*Respondents could report multiple degrees (“Check all that apply”).
Total Medical/Nursing Model Integrated Social Worker Model n = 317 n = 178 n = 139 1. A social worker is on the care coordination team 160 (50.5) 21 (11.8) 139 (100) 2. The social worker is responsible for assessing and coordinating social services for care coordination patients 140 (44.2) 1 (0.6) 139 (100) 3. The social worker interacts regularly with care coordination patients 143 (45.1) 4 (2.2) 139 (100) 4. The social worker interacts regularly with the clinicians of those patients 144 (45.4) 5 (2.8) 139 (100) Fits all 4 requirements 139 (43.8) 0 (0) 139 (100) - Table 3.
Care Coordination (CC) Activities Used by Clinic Care Model (All # below Double Line Are in %)
Characteristic Total Medical/Nursing Model Integrated Social Worker Model P N 317 178 139 Hours/week devoted to CC per care coordinator – Mean (SD) 21.7 (14.8) 18.8 (14.7) 25.3 (14.1) <0.001 Number of clinicians/FTE care coordinator – Mean (SD) 12.4 (14.1) 9.3 (9.2) 16.3 (17.9) <0.001 Patient panel size/care coordinator – Mean (SD) 48.5 (72.8) 45.3 (85.7) 52.5 (52.7) 0.38 Patient panel seems: <0.001 - about right 61 61 61 - too many 19 12 26 - too few 20 26 12 At least one care coordinator always on-site 55 63 44 <0.001 Communication with CC patients (always/mostly): In-person meeting 24 23 25 0.4 Telephone 89 84 95 0.008 EMR 14 6 24 <0.001 Video visits 1 1 0 0.2 Who initiates communications: 0.007 Care coordinator 81 84 78 Patient 2 3 1 Equal 17 14 21 Regularly/often engage with the family and/or caregivers 47 42 53 0.053 Communication between CC & clinician: Before talking with patients (reg/often) 48 54 40 0.017 After talking with patients (reg/often) 63 63 63 >0.9 In person meeting (always/mostly) 39 46 29 0.007 In person ad hoc (always/mostly 31 31 31 0.62 Telephone (always/mostly) 22 15 30 <0.001 EMR (always/mostly) 70 69 70 0.4 Video 0 0 1 0.41 Services provided: Disease management 91 89 93 0.25 Facilitating services by PC clinicians 87 82 94 0.001 Patient education and counseling 87 85 91 0.13 Mental health assessment/referral 84 80 90 0.02 Referral for other community resources 82 77 89 0.005 Social needs assessment/referral 81 71 93 <0.001 Finding culturally appropriate resources 74 64 86 <0.001 Facilitating services by medical specialists 74 65 86 <0.001 Financial needs assessment/referral 73 60 89 <0.001 Care transition services 73 62 86 <0.001 Assisting to access health insurance 69 58 84 <0.001 Employment assistance/referral 41 29 56 <0.001 Spiritual needs assessment/referral 37 30 56 0.007 Do coordinators (most of the time): Refer to services outside your care system 29 24 36 0.002 Refer to services in your care system 49 45 53 0.2 Directly provide services 28 28 28 >0.9 How do you help connect patients? Give patient a name/phone number 97 96 98 0.36 Contact the resource with referral 81 75 90 <0.001 Call resource with the patient 78 70 90 <0.001 Very involved in facilitating care transitions 22 15 30 <0.001 Complexity of medical needs is assessed for all or most patients 68 67 68 0.9 Complexity of social needs is assessed for all or most patients 67 62 73 0.04 Abbreviations: CC, care coordination; SD, standard deviation; EMR, electronic medical record; PC, primary care.
Characteristic Total Medical/Nurse Model Integrated Social Worker Model P N 317 178 139 Clinic supports for CC: Dedicated space to see patients 73 77 68 0.07 EMR prompts for follow-up 96 96 95 0.38 Searchable list of CC patients 96 96 95 0.8 Assistants help contact patients 78 78 78 >0.9 Other resources at your clinic: Community Health Workers 30 18 46 <0.001 Pharmacists 67 59 78 <0.001 Behavioral health services 59 56 63 0.2 Other medical specialists 56 55 58 0.6 Other surgical specialists 35 35 35 >0.9 How familiar (very) are you with: Clinical resources in your org. 70 69 71 0.3 People in those clinical resources 34 33 35 0.9 Community resources 49 44 55 0.008 People in those community resources 19 17 23 0.2 What measures are used by your care system to evaluate effectiveness of CC? Types of patients seen 36 34 38 0.5 Types of services provided 38 36 40 0.6 Utilization rates of hospital or emergency use 58 50 69 <0.001 Volume of CC patients seen 62 54 73 <0.001 Change in hospital/emergency visits 53 44 64 <0.001 Changes in chronic condition control 51 46 58 0.5 CC patient satisfaction 32 34 31 0.6 None of the above 14 15 13 0.6 Specialty medical services are readily available for CC patients most of the time 47 52 41 0.13 Community services are readily available for CC patients most of the time 40 43 37 0.14 Ease of coordinating services with hospitals or nursing homes 0.8 Very difficult 4 4 4 Somewhat difficult 32 31 34 Somewhat easy 55 54 55 Very easy 10 11 8 Payment or coverage for CC services is required to provide care most of the time >0.9 Most of the time 19 19 20 Sometimes 10 11 10 Rarely/Never 70 70 70 Patient financial constraints limit their access to needed social and medical services 0.4 Most of the time 27 26 28 Some of the time 68 68 69 Rarely/Never 5 6 3 Most clinicians value the CC role 0.037 Strongly agree 60 64 56 Somewhat agree 32 27 39 Somewhat disagree 4 6 1 Strongly disagree 4 4 4 Clinic leaders value the CC role 0.051 Strongly agree 56 63 47 Somewhat agree 32 27 37 Somewhat disagree 9 7 12 Strongly disagree 4 3 4 Overall satisfaction with the time/resources to provide CC services 0.2 Very satisfied 25 24 27 Somewhat satisfied 57 54 61 Somewhat dissatisfied 16 20 11 Very dissatisfied 2 2 1 Abbreviations: CC, care coordination; EMR, electronic medical record. All numbers except N and P are in %.
