Care coordination to target patient complexity and reduce disparities in primary care

Abstract

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.

Definition of patient complexity in adults: A narrative review

“… 22 Miller et al developed the Activation and Coordination Team (ACT) framework, which integrates patient complexity (demographic characteristics, mental and physical health, social environment, and health literacy) with intervention strategies (e.g., patient support), proximal outcomes (patient activation and self-care management) and distal outcomes (e.g., quality of life, utilization, and cost). 79 This framework further uses medical and social complexity criteria to classify patients into four quadrants (wellness care, medically complex, socially complex, and medically and socially complex).…”

Resource Brokering: Efforts to Assist Patients With Housing, Transportation, and Economic Needs in Primary Care Settings

“…It is not surprising that one-half of the organizations delivered social care as part of their effort to improve health outcomes for complex patients since delivering comprehensive, coordinated care for these patients is a cornerstone of primary care. 43,44 Similarly, federal policymakers have focused on improving the social conditions of clinically complex patients, 32,[45][46][47] which is not unexpected as the links between health care outcomes, costs, and social conditions are likely strongest for these patients. 48,49 For example, as part of the CHRONIC Care Act, the CMS granted Medicare Advantage plans greater flexibility in supplemental benefits.…”

Patient complexity assessment tools containing inquiry domains important for Indigenous patient care: A scoping review

“…Generally agreed to be a separate entity from comorbidity or multi-morbidity [1], patient complexity [2][3][4] is deemed to arise from the social and contextual factors that impact health outcomes [1,5,6]. The complex interplay between the various determinants of health and their presentation within patients can be difficult to address for healthcare providers (HCPs) [2,7].…”