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Care coordination to target patient complexity and reduce disparities in primary care
Author(s) -
Miller Arlene M.,
Swartwout Kathryn D.,
Schoeny Michael E.,
Vail Matthew,
McClenton Regina
Publication year - 2019
Publication title -
public health nursing
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.471
H-Index - 55
eISSN - 1525-1446
pISSN - 0737-1209
DOI - 10.1111/phn.12606
Subject(s) - medicaid , health care , medical record , medicine , population , family medicine , social determinants of health , categorization , social complexity , public health , nursing , psychology , environmental health , philosophy , epistemology , economics , radiology , economic growth , social science , sociology
Objective The purpose of this study was to describe our Activation and Coordination Team (ACT) model for interprofessional care coordination in primary care and examine feasibility of using ACT medical and social complexity criteria to categorize patients into Quadrants that determine resource utilization. Research questions were: (a) Are there significant differences in demographic, medical, and social characteristics by Quadrant; (b) Do patients with combined high medical and social complexity differ from those with either high medical or social complexity; and (c) Is there an association between initial screening risk level and ACT Complexity Quadrant placement? Design Cross‐sectional, descriptive. Sample Patients ( N = 167) aged 18–65 enrolled in an urban Medicaid managed care network. Measurements Screening and comprehensive health risk assessment questionnaires and clinical data collection from electronic health records. Results Patient characteristics differed significantly by Quadrant. Combined medical and social complexity produced greater impact than additive effects. Patients who initially screened low risk nevertheless met ACT criteria for medical and/or social complexity. Conclusions Greater effects for individuals with medical and social issues are due to interactions among factors. Traditional screening may miss patients with complex needs who need care coordination. Care coordination skills should be incorporated into population health curricula.