As the number of patients living with multiple chronic conditions increases across the country, researchers from the Camden Coalition and the University of Massachusetts at Amherst have published a new study in the Journal of Interprofessional Education & Practice that lays important groundwork for designing effective staffing models for care coordination programs.

The Camden Coalition’s Director of Analytics Aaron Truchil and former Data Analytics Manager Zachary Martinez, with Ekin Koker and Hari Balasubramanian of the University of Massachusetts at Amherst, analyzed how the Camden Coalition’s care team spends their time over the course of the Camden Core Model intervention. The Camden Core Model — staffed by an interprofessional team of nurses, social workers, and community health workers — aims to empower individuals with complex health and social needs in the Camden area with the skills and support they need to avoid preventable hospital use and improve their wellbeing.

“Care coordination for patients with multiple chronic conditions is a strategy for focusing resources to achieve better outcomes for this segment of the population, yet little has been published on how care coordination programs should or do allocate effort within their patient panels,” write the study’s authors. “To our knowledge, no study has described staff efforts of an interprofessional team delivering a care coordination program.”

The researchers analyzed care coordination encounter records for 531 patients who were enrolled in the program over a three-year period from 2012 to 2015. The care coordination encounters, recorded by Camden Core Model team members, amounted to a combined total of 24,249 hours of staff effort. The range of activities included patient accompaniment on visits to providers and hospitals, home visits and phone conversations with patients, and coordination with clinical and social services providers and patients’ families.

The study revealed three key findings:

  • More than 20% of staff effort occurs within the first two weeks of patient enrollment in the program. Concentrated staff effort at the beginning of the intervention reflected the care team’s prioritization of several key post-discharge milestones, including a home visit and primary care visit within five and seven days of hospital discharge. Success on these measures has shown promise at reducing the possibility of subsequent hospital readmissions.
  • 70% of care coordination effort occurs face-to-face. Home visits accounted for the largest share of staff effort, with 31% of total time effort.
  • Patient characteristics like housing instability and behavioral health needs were associated with staff spending more time with patients. This is consistent with the understanding among care team members that some of the longest program enrollments eventually center around patients with more social complexity who require advanced social coordination, such as assistance in obtaining housing.

We see more work ahead in this space, in terms of understanding how to provide high quality care coordination work at scale, including being able to identify the types and amount of effort necessary to support clients as early as possible.

— Aaron Truchil, Director of Strategy and Analystics, Camden Coalition

As care coordination becomes more widely adopted by organizations to improve care for people with complex health and social needs, we hope that the study can both serve as a helpful reference point for those beginning to construct staffing and intervention models, as well as encourage the build-out of data platforms that enable high quality data about care team interactions with clients.

Read the study in Journal of Interprofessional Education & Practice

Stay Informed

Join our mailing list to get the latest updates sent right to your inbox from the Camden Coalition.

Sign Up