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

Public Health Nurs. 2019 Jul;36(4):451-460. doi: 10.1111/phn.12606. Epub 2019 Mar 20.


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.

Keywords: care coordination; care management; interprofessional teams; population health; primary care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Cross-Sectional Studies
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Healthcare Disparities / statistics & numerical data*
  • Humans
  • Male
  • Medicaid / statistics & numerical data
  • Middle Aged
  • Primary Health Care / methods*
  • Risk Assessment / methods
  • Surveys and Questionnaires
  • United States
  • Young Adult