Health Care Homes
Minnesota Care Coordination Effectiveness Study (MNCARES)

Calendar of key activities, compensation milestones, and available findings for care systems in MNCARES can be found on the detailed timeline here: Calendar of MNCARES Key Activities (PDF). If you have questions please contact health care homes at: Health.HealthCareHomes@state.mn.us

Interim findings

Interim Findings from the MN Care Coordination Effectiveness Study 2023 (PDF)

Care coordination in clinics

View an updated definition of the care coordination models, the type of services provided by both models and the similarities and differences.

MNCARES Study Update December 2021 (PDF)

Participation

Thank you to all clinics who have agreed to participate in the Minnesota Care Coordination Effectiveness Study (MNCARES). MNCARES is funded by PCORI and is a collaboration among HealthPartners Institute, Minnesota Department of Health, Minnesota Community Measurement, four payors (MN Department of Human Services, Blue Cross Blue Shield of Minnesota, Ucare, and HealthPartners), and the participating care systems. The goal of this study is to learn what approaches to care coordination in primary care settings produce the best care quality, utilization, and patient-centered outcomes.

We have had a great response from eligible clinics and care systems, with 45 care systems and 319 clinics agreeing to participate (84% of those eligible). This response rate is terrific. Thank you!

The purpose of MNCARES is to compare two approaches to care coordination for patients with high health care costs and multiple morbidities. The goal is to learn what approaches to care coordination in primary care settings produce the best care quality, utilization, and patient-centered outcomes. The first model includes care coordination performed by a nurse or other clinical staff. The second model includes a social worker as part of the care team.

Specifically, MNCARES will help to answer three important questions:

1. How do health care quality, utilization, and patient-centered outcomes compare for those who receive care coordination services using a “nursing/medical” model, versus a “medical/social” model that includes a licensed social worker?
2. What are the key components of the two models and what is each component’s impact on health care quality, utilization, and patient-centered outcomes?
3. How do organizational, community, care process, and patient factors help explain differences in the outcomes?

Researchers measured a wide variety of outcomes to identify actionable information that will allow clinics to improve their services to patients with complex needs. These outcomes include:

These papers describe characteristics of care coordination programs across the state and highlight themes and lessons from interviews with patients and care coordinators. Questions? Email the study team at mncares@healthpartners.com.

Announcement of Study

WHAT MAKES CARE COORDINATION WORK BEST? 2021 (PDF)
MNCARES provides an opportunity to provide information that clinics and care systems can implement to improve patient care quality, reduce utilization burden and improve patient-centered outcomes.

Care Coordination in Primary Care: Mapping the Territory

Solberg LI, Bergdall A, Ziegenfuss JY, JaKa MM, Whitebird RR, Chrenka EA, Beran MS, McDonald K, LaPlante B, Dehmer SP. Care Coordination in Primary Care: Mapping the Territory. The American Journal of Managed Care. 2023;29(10). Published online July 12, 2023.

Leaders in 42 care systems of various sizes and locations around Minnesota were surveyed about the variety in care coordination services. Findings include:

• 82% of large care systems, 40% of medium, and 25% of small had a social worker on their care teams; nearly all reported addressing both medical and social needs.
• Size of care system was not related to the type of patients targeted for care coordination or the services provided.
• Care coordination teams across care systems included: registered nurses (86%), practical nurse/medical assistants (55%), social workers (45%), nonclinical staff (40%), and community health workers (24%).

Though resources and capabilities differ, organizations were generally alike in their approach to care coordination.

The Impact of COVID-19 on Patients Receiving Care Coordination in Primary Care: A Qualitative Study

Whitebird RR, Solberg LI, JaKa MM, Kindt JM, Bergdall AR, LaPlante B, Dehmer SP. The Impact of COVID-19 on Patients Receiving Care Coordination in Primary Care: A Qualitative Study. Journal of the American Board of Family Medicine. Published online June 15, 2023.

19 patients from 19 different care systems were interviewed. These patients were potentially high risk for being seriously affected by health care and social disruptions during the early COVID pandemic. The interviews revealed:

• There was little or no impact on these patients’ physical health or medical services.
• On the other hand, most reported major disconnections from family, friends, and community. With anxiety about their health, this seriously impacted mental health and wellbeing.
• Nearly all reported that their care coordinators were very helpful in providing support.

Patients with complex medical and/or social needs found their relationship with their care coordinator to be especially important during the COVID-19 pandemic.

Patient experiences and perceptions of care coordination in primary care

Whitebird RR, Solberg LI, JaKa MM, Kindt JM, Bergdall A, Beran MS, Winger M. Patient experiences and perceptions of care coordination in primary care. Journal of Nursing Care Quality. 2024 Jan 10.

This paper revealed that most patients greatly appreciate the support care coordination provides and report that care coordinators are an important touch point for facilitating access, medical care, and health self-sufficiency.

The Role of Care Coordination: A Qualitative Study of Care Coordinator Perceptions

JaKa MM, Beran MS, Andersen JA, Whitebird RR, Bergdall AR, Kindt JM, Dehmer SP, Winger M, Solberg LI. The Role of Care Coordination: A Qualitative Study of Care Coordinator Perceptions. Journal of Nursing Care Quality. Published online May 9, 2023.

19 care coordinators from various care systems were interviewed about what was important for helping the complex patients they served. Interviews showed:

• Identifying and helping patients with social needs that interfere with self-care actions is a priority.
• Strong support from clinicians and care system leaders helps care coordination programs be successful.
• The key skill needed for this work is the ability to build and maintain strong relationships with patients and their clinicians.

Making connections and building trust with both patients and clinicians are the foundation of care coordination.

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

Leif I. Solberg, MD, Meghan M. JaKa, PhD, Gregory S. Knowlton, MS, Jeanette Y. Ziegenfuss, PhD, Anna R. Bergdall, MPH, Robin R. Whitebird, PhD, MSW, LISW, Joan M. Kindt, RN, PHN, MHP, and Steven P. Dehmer, PhD. Care Coordination: How Is It Implemented and Is It Different If a Social Worker Is on the Team? (PDF) Journal American Board of Family Medicine Published January 30, 2025.

One of the main objectives of MNCARES was to understand how primary care clinics coordinate services for complex patients and whether clinics with an integrated social worker do it differently. This publication addressed the many differences in care coordination care models and activities. It concludes that clinics with an integrated social worker seem to differ in the frequency and approach to care coordination as well as in how social needs are addressed from those that use a nursing model while providing most medical/nursing services at similar or higher rates.

Care Coordination in Primary Care: Views of Clinicians and Clinic Leaders

Whitebird, Robin R. PhD, MSW, LISW; Beran, Mary Sue MD, MPH; Solberg, Leif I. MD; JaKa, Meghan M. PhD; Kindt, Joan M. RN; Bergdall, Anna R. MPH; Dehmer, Steven P. PhD. Care Coordination in Primary Care: Views of Clinicians and Clinic Leaders. Journal of Nursing Care Quality. January/March 2025.

The Minnesota Care Coordination Effectiveness Study sought to better understand the perspectives and experiences of clinicians/clinic leaders regarding the value, barriers, and facilitators for care coordination in primary care. Care coordination received strong support from clinicians and clinic leaders who viewed it as a valuable component of successful care delivery.

Five themes arose in the interviews:

• Financial issues were perceived as a primary barrier to care coordination.
• Participants valued care coordination as an important asset.
• They employed significant variation in how care coordination was structured.
• They identified both medical and social needs of patients as important.
• Care coordinators’ background, experience, and integration were viewed as critical to program success.

Invitations for all qualifying Certified Health Care Home clinics to participate in the study were sent in 2020.

Participating care systems and clinics completed a survey to provide information about the approach to care coordination at their organization, and submitted data for adult patients at their clinics who are receiving care coordination services. The patient lists were used to secure necessary utilization data from participating health plans, add quality data from MNCM, and to disseminate surveys to collect patient-centered/reported outcomes.

One care coordinator from each clinic completed a short survey about the details for care coordination for their clinic, and a few coordinators and clinic leaders participated in a short interview about their perspectives on the care coordination process.

Participating clinics will receive reports on overall study outcomes, and individual reports that can help understand how the clinic compares to its peers.

HealthPartners, the Minnesota Department of Human Services, BCBS of MN, and UCare agreed to participate as MNCARES payer partners. Each of the payers received a data file from MNCM, identifying patients enrolled with their plan who are receiving care coordination services. They used the patient list to extract the necessary utilization data from the payer’s administrative billing and claims data. This data was sent back to MNCM for final assembly, de-identification, and secure transfer to HealthPartners Institute for analysis.

HealthPartners Institute

HealthPartners Institute has more than 30 years of experience in research grant and contract administration and is the prime site for the MNCARES study. The Institute oversees all activities pertaining to governance, finance, legal, business, and technical operations to ensure contractual obligations are met for MNCARES.

The HealthPartners Institute leads and engages all stakeholders within the collaboration (including state government, health care payers, care systems, patient co-investigators and advisors, and other interested stakeholders and consultants) to inform study design and provides project management to ensure the aims of the study are achieved.

The Research Team conducts all quantitative and qualitative analysis, produce the final research report, and lead efforts to disseminate study findings.

The HealthPartners Institute’s Center for Evaluation and Survey Research (CESR) is responsible for conducting patient surveys relevant to the study.

Co-Principal Investigators:
Leif I. Solberg, MD
Senior Investigator

Steven P. Dehmer, PhD
Research Investigator & Health Economist

Minnesota Department of Health

The concept for MNCARES was originally conceived by the director of the Minnesota Department of Health (MDH) Health Care Homes (HCH) Program.

MDH is engaged in the ongoing planning, implementation, evaluation, and dissemination activities for MNCARES. They are a member of the Executive and Steering Committees for the study and play a leadership role in workgroups focused on recruitment and survey development.

MDH was the lead for recruiting clinics for the study, administering a clinic survey, and assisted with the recruitment of patients to participate in patient interviews in Years 1 and 3 of the study.

MDH HCH team members used their existing connections with clinics to conduct semi-structured interviews with care coordinators and assist in the recruitment of clinician and clinic leaders and patients who will also be interviewed. These interviews occurred in Years 1 and 3.

MN Community Measurement

MN Community Measurement (MNCM) is a member of the Executive and Steering Committees for the study and plays a leadership role in several workgroups defining the details for data collection.

MNCM was responsible for providing input into the study design and operational plan of data flow – and aggregated data from all sources relevant to the study. It then produced the final data set for HealthPartners Institute to conduct the analysis.

As the data hub for MNCARES, MNCM received patient data from participating clinics, sent selective data to and receive data back from payers and the survey center, added relevant MNCM data on quality measures for care coordination patients, and sent aggregate deidentified data to the study team.

MNCM leveraged its established legal framework and relationships with medical groups and health plans across Minnesota for quality measurement purposes and secured agreements necessary to integrate data needed for the study.

Site Principal Investigator:
Liz Cinqueonce
Chief Operating Officer