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.