Time and Effort in Care Coordination for Patients with Complex Health and Social Needs: Lessons From a Community-Based Intervention

Zachary Martinez
Ekin Koker
Aaron Truchil
Hari Balasubramanian
Peer-Reviewed Article
June 2019

Care coordination programs for individuals with multiple chronic conditions and unmet social needs can be operationally complex, but little research has been done on staff effort within these programs. This study, conducted over three years at the Camden Coalition in New Jersey, identified time spent by non-physician staff in an interprofessional team on care coordination functions, and what patient characteristics were associated with higher intensity of staff effort.

Among the findings of this study are that staff time effort was most intensive in the initial weeks after enrollment in the intervention. 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, 70 percent 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.

This research fills an important gap on time requirement estimates of care coordination teams for complex patients, and details the variability of time spent by team members across the duration of an intervention as well as across program enrollees. It also provides a template for other programs to use for data collection and analysis of staff allocations.  

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