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

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.

Primary care NPs: Leaders in population health.

A 2012 Institute of Medicine report calls primary and public healthcare workers to action, tasking them with working together to improve population health outcomes. A Practical Playbook released in 2014 enables this public health/primary care integration. Primary care NPs are in an excellent position to lead the charge and make this integration happen.