Benefits of Care Coordination Tick Up with Patient Activation

When it comes to care coordination and social determinants of health interventions, patient engagement and activation are key, according to new data in JAMA Network Open.

The study, published by researchers from the New Jersey-based Camden Coalition and California’s Kaiser Permanente, gives credence to key value-based care principles. Particularly, it showed that when hospitals coordinate post-discharge access to social services and manage care for socially complex patients—and patients engage in those interventions—the organization can see better outcomes, such as hospital readmission rates.

This study is a follow-up of a 2020 report that countered the traditional value proposition for value-based care—that care coordination and SDOH work would improve outcomes for socially complex patients. The 2020 study was published in the New England Journal of Medicine and featured the Camden Coalition’s Camden Core Model in which the organization flags high-risk patients for post-discharge care coordination.

The Camden Core Model hypothesized that coordinating interventions for patients’ social and clinical needs would have downstream impacts, like better readmission rates, but the 2020 study did not find such. At the study’s end, readmission rates were about the same for the intervention group and the control group receiving usual care.

This latest study takes a closer look at how the Camden Core Model performed among different subgroups of patients within the intervention group. Using intervention participation data, the researchers grouped patients by engagement or activation level. From there, the team looked at readmission rates by different subgroup.

According to the researchers, segmenting the intervention group this way made a big difference in understanding the efficacy of care coordination and the Camden Model of Care.

“By applying the distillation method to the data, we were able to see significant differences between intervention and control group patients in readmission rates and readmission counts,” study author Dawn Wiest said in a press release. “We found that the people who were more likely to be engaged had significantly better outcomes.”

The patients whom the researchers pegged as more engaged saw better outcomes. The relative 30-day hospital readmission risk among the more engaged subgroups was 48 percent lower than for the less engaged subgroups. Meanwhile, the relative 90-day readmission risk was 52 percent lower.

These findings may not be surprising, but still, this is a novel finding considering the nuance it adds to the overall value proposition for value-based care.

“We now have data supporting the effectiveness of the Camden Model, which is benefiting individuals with complex medical and social needs not only in our community, but around the country,” Camden Coalition CEO Kathleen Noonan said in the press release. “By demonstrating the association between our care management model, the frequency of engagement, and hospital readmissions, we can build a better roadmap for how to improve our overall complex care ecosystem – so that we can provide resources that keep patients engaged and on the path toward a better life.”

This data isn’t just a win for the Camden Coalition or care coordination efforts nationwide. The researchers were also able to peg which patients were the most likely to engage in care coordination and SDOH interventions. This could provide a roadmap for other organizations doing similar work.

Particularly, the researchers found that patients experiencing housing instability or with a history of criminal justice involvement were less likely to engage with the Camden Model of Care. This is potentially because it is more difficult to maintain contact with these patients, the team said.

Healthcare organizations may consider changing program inclusion criteria to target populations more likely to engage with and benefit from care coordination interventions, the researchers advised. It may be fruitful to look into certain social services partnerships, like those tailored for housing insecure or those with histories with the criminal justice system, to manage this base level of need, they added.