Journal article

Time and effort in care coordination for patients with complex health and social needs: Lessons from a community-based intervention

Care management & redesign Data analysis & integration Quality improvement Workforce development

In a study published in the Journal of Interprofessional Education and Practice, our data team joined forces with researchers at the University of Massachusetts—Amherst to map out the time that our care team staff spent on care coordination and determine what patient characteristics were associated with higher intensity of staff effort.

This study is part of a larger effort to use data to design effective staffing models for care coordination programs.

We found that that staff time effort was most intensive in the initial weeks after enrollment in the intervention, with more than 20% of staff effort occurring in the first two weeks of enrollment. Nurses spent more time at the beginning of the intervention, and other staff who focus on addressing social needs, such as community health workers, comprised a higher percentage of overall staff effort in the later stages of the intervention.

Additionally, we found that 70% of all care coordination efforts involved in-person interactions between care coordinators and patients. Patient characteristics associated with the most time-intensive program enrollments included social vulnerability and behavioral health conditions.