Care Coordination: How Is It Implemented and Is It Different If a Social Worker Is on the Team?

References

1. 1.↵
   1. Brown DM,
   2. Hernandez EA,
   3. Levin S,
   4. et al

   . Effect of social needs case management on hospital use among adult Medicaid beneficiaries: a randomized study. Ann Intern Med 2022;175:1109–17.

   OpenUrlPubMed
2. 2.↵
   1. Magnan S

   , HealthPartners Institute. Social determinants of health 101 for health care: five plus five. NAM Perspectives 2017;7: October 9, 2017:9. Available at: https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/.
3. 3.↵
   1. Wray CM,
   2. Tang J,
   3. Lopez L,
   4. Hoggatt K,
   5. Keyhani S

   . Association of social determinants of health and their cumulative impact on hospitalization among a national sample of community-dwelling US adults. J Gen Intern Med 2022;37:1935–42.

   OpenUrlCrossRefPubMed
4. 4.↵
   National Academies of Sciences E, and Medicine. Integrating social care into the delivery of health care: moving upstream to improve the nation's health. Washington DC: the National Academies Press; 2019.
5. 5.↵
   1. Albertson EM,
   2. Chuang E,
   3. O'Masta B,
   4. Miake-Lye I,
   5. Haley LA,
   6. Pourat N

   . Systematic review of care coordination interventions linking health and social services for high-utilizing patient populations. Popul Health Manag 2022;25:73–85.

   OpenUrlCrossRefPubMed
6. 6.↵
   1. Pourat N,
   2. Lu C,
   3. Huerta DM,
   4. Hair BY,
   5. Hoang H,
   6. Sripipatana A

   . A systematic literature review of health center efforts to address social determinants of health. Med Care Res Rev 2022;80:255–65.

   OpenUrlPubMed
7. 7.↵
   1. Escobar ER,
   2. Pathak S,
   3. Blanchard CM

   . Screening and referral care delivery services and unmet health-related social needs: a systematic review. Prev Chronic Dis 2021;18:E78–22.

   OpenUrlPubMed
8. 8.↵
   ClinicalTrials.gov. Minnesota Care Coordination Effectiveness Study (MNCARES). 2023; Available at: https://clinicaltrials.gov/study/NCT04957979. Accessed 9/17/23.
9. 9.↵
   PCORI. Comparing two approaches to care coordination for patients with multiple health needs. 2023; Available at: https://www.pcori.org/research-results/2019/comparing-two-approaches-care-coordination-patients-multiple-health-needs. Accessed 9/17/23.
10. 10.↵
    1. Solberg LI,
    2. Bergdall A,
    3. Ziegenfuss JY,
    4. et al

    . Care coordination in primary care: mapping the territory. Am J Manag Care 2023;29:294–301.

    OpenUrl
11. 11.↵
    1. McDonald KM,
    2. Schultz E,
    3. Albin L,
    4. et al

    . Care Coordination Measures Atlas Version 4. Rockville, MD: AHRQ; 2014.
12. 12.↵
    1. JaKa MM,
    2. Beran MS,
    3. Andersen JA,
    4. et al

    . The role of care coordination: a qualitative study of care coordinator perceptions. J Nurs Care Qual 2024 Jan-Mar 01;39:44–50.

    OpenUrlPubMed
13. 13.↵
    1. Dillman DA,
    2. Smyth JD,
    3. Christian LM

    . Internet, Phone, Mail, and Mixed-Mode Surveys: The Tailored Design Method. 4th ed: Wiley Publishing; 2014.
14. 14.↵
    1. Harris PA,
    2. Taylor R,
    3. Thielke R,
    4. Payne J,
    5. Gonzalez N,
    6. Conde JG

    . Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81.

    OpenUrlCrossRefPubMedWeb of Science
15. 15.↵
    Team RC. R: a language and environment for statistical computing. 2022; Available at: https://www.R-project.org/.
16. 16.↵
    1. Hernán M,
    2. Robins J

    . Causal Inference. Boca Raton: Chapman & Hall/CRC, forthcoming; 2019.
17. 17.↵
    1. Kahlert J,
    2. Gribsholt SB,
    3. Gammelager H,
    4. Dekkers OM,
    5. Luta G

    . Control of confounding in the analysis phase - an overview for clinicians. Clin Epidemiol 2017;9:195–204.

    OpenUrlCrossRefPubMed
18. 18.↵
    Hub RHI. Rural-Urban Commuting Area (RUCA) codes. 2023; Available at: https://www.ruralhealthinfo.org/resources/769. Accessed 9/4/2023.
19. 19.↵
    Minnesota Department of Health. Rural health care in Minnesota: data highlights. 2022; Available at: https://www.health.state.mn.us/facilities/ruralhealth/docs/summaries/ruralhealthcb2022.pdf. Accessed Mar 21, 2024.
20. 20.↵
    1. Bibbins-Domingo K

    . Integrating social care into the delivery of health care. JAMA 2019;322:1763–4.

    OpenUrlPubMed
21. 21.↵
    1. Duan-Porter W,
    2. Ullman K,
    3. Majeski B,
    4. Miake-Lye I,
    5. Diem S,
    6. Wilt TJ

    . Care coordination models and tools-systematic review and key informant interviews. J Gen Intern Med 2022;37:1367–79.

    OpenUrlCrossRefPubMed
22. 22.↵
    1. Hudon C,
    2. Chouinard MC,
    3. Pluye P,
    4. et al

    . Characteristics of case management in primary care associated with positive outcomes for frequent users of health care: a systematic review. Ann Fam Med 2019;17:448–58.

    OpenUrlAbstract/FREE Full Text
23. 23.↵
    1. Savitz LA,
    2. Bayliss EA

    . Emerging models of care for individuals with multiple chronic conditions. Health Serv Res 2021;56 Suppl 1:980–9.

    OpenUrl
24. 24.↵
    1. Smith SM,
    2. Wallace E,
    3. Clyne B,
    4. Boland F,
    5. Fortin M

    . Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review. Syst Rev 2021;10:271.

    OpenUrlCrossRefPubMed
25. 25.↵
    1. Fichtenberg CM,
    2. Alley DE,
    3. Mistry KB

    . Improving social needs intervention research: key questions for advancing the field. Am J Prev Med 2019;57:S47–S54.

    OpenUrlCrossRefPubMed
26. 26.↵
    1. Glied S,
    2. D'Aunno T

    . Health systems and social services - a bridge too far? JAMA Health Forum 2023;4:e233445.

    OpenUrlPubMed