Health Care Homes - Minnesota Care Coordination Effectiveness Study

Health Care Homes Minnesota Care
Coordination Effectiveness Study (MNCARES)

Research reported in this website was funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (IHS-2019C1-15625).

HealthPartners Institute, in collaboration with the Minnesota Department of Health and MN Community Measurement, has been awarded $4 Million of funding from the Patient Centered Outcomes Research Institute (PCORI) to study the effect of care coordination on patient outcomes. The partners are pleased to introduce the new Minnesota Care Coordination Effectiveness Study (MNCARES) and outline the important questions it will help the community answer – and encourage you to bookmark the MNCARES web page hosted by MDH for ongoing updates.

MNCARES was developed with input from patients, clinic leaders, state government officials and additional experts in health and quality care. The study aligns with PCORI’s priority area of patient’s access to care, high quality of care, support of self-care and coordination of care across healthcare settings. Leif I. Solberg, MD, a Senior Advisor from HealthPartners Institute, leads the project along with Steve Dehmer, PhD, Health Economist.

Calendar of key activities, compensation milestones, and available findings for care systems in MNCARES can be found on the detailed timeline here: Calendar of MNCARES Key Activities (PDF). If you have questions please contact health care homes at:

Thank you to all clinics who have agreed to participate in the Minnesota Care Coordination Effectiveness Study (MNCARES). MNCARES is funded by PCORI and is a collaboration among HealthPartners Institute, Minnesota Department of Health, Minnesota Community Measurement, four payors (MN Department of Human Services, Blue Cross Blue Shield of Minnesota, Ucare, and HealthPartners), and the participating care systems. The goal of this study is to learn what approaches to care coordination in primary care settings produce the best care quality, utilization, and patient-centered outcomes.

We have had a great response from eligible clinics and care systems, with 45 care systems and 319 clinics agreeing to participate (84% of those eligible). This response rate is terrific. Thank you!

Minnesota Care Coordination Effectiveness Study (MNCARES) is moving forward with a recent approval of the study’s adaptation plan by Patient Centered Outcomes Research Institute (PCORI). The submission period opened June 14th and closes August 15th, 2021.

To get started, below are the preparations and next steps to submitting data for the Historical Cohort:

  1. Please download and review the data field specifications and file templates from the MNCARES Information Page for Clinics. The specifications provide details about all data elements that will be submitted for the clinic demographic and problem list data files.
  2. Please also complete the pre-submission questionnaire to provide additional information about your clinic's/care system's ability to identify patients meeting criteria for the Historical Cohort. This will help the study team understand any challenges your clinic(s) may have in identifying this group of patients in your data system(s) for historical patient records.
  3. Login credentials for the MNCARES data portal will be sent to your organization’s data submission contact for this project on the day that the portal opens. Once logged in, you will have access to upload data files for the study. Until then, we encourage you to view the recorded instructional video.

Also in June, MN Community Measurement will host a live session for clinics to ask technical questions about preparing the files and uploading data. Please stay tuned for more information! Please contact with questions.

The "Welcome to MNCARES! A Study to Inform Care Coordination Strategies" was presented on Wednesday, April 14, 2021 at 9:00 a.m. to provide more detail on the study activities and timeline and an opportunity for questions and suggestions. The webinar was recorded for those who are unable to attend. Please visit the MN Community Measurement website to view the webinar and slides.

View slides: "Welcome to MNCARES! A Study to Inform Care Coordination Strategies" (PPT).

Review Webinar Q & A: Answers to questions raised during the MNCARES Study Clinic Webinar (PPT).

Highlighted progress made in preparation for the official launch of the study activities this spring:

  • Shared how Minnesota Health Care Home Clinics, health plans, and patients will be engaged with the study.
  • Outlined the key questions the study will help us to answer to inform improvement efforts.
  • Provided an opportunity for questions and for input on what information you hope we can provide.
  • Provided information on how you can learn more and stay up to date with the study’s progress.

On behalf of the MNCARES partners, we greatly value and appreciate your participation in this study and look forward to working with you. Please email HCH with questions:

The purpose of MNCARES is to compare two approaches to care coordination for patients with high health care costs and multiple morbidities. The goal is to learn what approaches to care coordination in primary care settings produce the best care quality, utilization, and patient-centered outcomes. The first model includes care coordination performed by a nurse or other clinical staff. The second model includes a social worker as part of the care team.

Specifically, MNCARES will help to answer three important questions:

  1. How do health care quality, utilization, and patient-centered outcomes compare for those who receive care coordination services using a “nursing/medical” model, versus a “medical/social” model that includes a licensed social worker?
  2. What are the key components of the two models and what is each component’s impact on health care quality, utilization, and patient-centered outcomes?
  3. How do organizational, community, care process, and patient factors help explain differences in the outcomes?

Researchers will measure a wide variety of outcomes to identify actionable information that will allow clinics to improve their services to patients with complex needs. These outcomes include:

Category Outcomes to be Measured Data Source
Patient Care Quality Control of blood pressure, cardiovascular disease, diabetes, asthma, and depression MN Community Measurement
Patient Health Care Utilization Urgent care and emergency department visits, hospitalizations, primary care and specialty visits, substance use programs and duplicate diagnostic tests MN Health Care Payers
  • HealthPartners
  • MN Dept. of Human Services
  • UCare
  • BCBS of MN
Reported Outcomes
Health status, satisfaction with clinician, access, coordination, personal goal attainment, shared decision making, medication and care burden, change in insurance coverage, going without care due to cost, out-of-pocket medical costs and changes in social needs Patient Surveys

Care Coordination Publications:

    MNCARES provides an opportunity to provide information that clinics and care systems can implement to improve patient care quality, reduce utilization burden and improve patient-centered outcomes.

Invitations for Certified Health Care Home clinics to participate in the study will be distributed in the fall.

Participating care systems and clinics will be asked to complete a survey to provide information about the approach to care coordination at their organization, and to submit data for adult patients at their clinics who are receiving care coordination services. The patient lists will be used to secure necessary utilization data from participating health plans, add quality data from MNCM, and to disseminate surveys to collect patient-centered/reported outcomes.

One care coordinator from each clinic will be asked to complete a short survey about the details for care coordination for their clinic, and a few coordinators and clinic leaders will be asked to participate in a short interview about their perspectives on the care coordination process.

Participating clinics will have an opportunity to request some financial reimbursement for expenses, reports on overall study outcomes, participants will receive individual reports that can help understand how the clinic compares to its peers and will forego one recertification.

Invitations for Certified Health Care Home clinics to participate in the study could be distributed as soon as October 2020.

HealthPartners, the Minnesota Department of Human Services, BCBS of MN, and UCare have agreed to participate as MNCARES payer partners. Each of the payers will receive a data file from MNCM, identifying patients enrolled with their plan who are receiving care coordination services. They will use the patient list to extract the necessary utilization data from the payer’s administrative billing and claims data. These data will then be sent back to MNCM for final assembly, de-identification, and secure transfer to HealthPartners Institute for analysis.

HealthPartners InstituteHealthPartners Institute has more than 30 years of experience in research grant and contract administration and is the prime site for the MNCARES study. The Institute oversees all activities pertaining to governance, finance, legal, business, and technical operations to ensure contractual obligations are met for MNCARES.

The HealthPartners Institute leads and engages all stakeholders within the collaboration (including state government, health care payers, care systems, patient co-investigators and advisors, and other interested stakeholders and consultants) to inform study design and provides project management to ensure the aims of the study are achieved.

The Research Team will conduct all quantitative and qualitative analysis, produce the final research report, and lead efforts to disseminate study findings.

The HealthPartners Institute’s Center for Evaluation and Survey Research (CESR) is responsible for conducting patient surveys relevant to the study.

Co-Principal Investigators:
Leif I. Solberg, MD
Senior Investigator

Steven P. Dehmer, PhD
Research Investigator & Health Economist

Health Care HomesThe concept for MNCARES was originally conceived by the director of the Minnesota Department of Health (MDH) Health Care Homes (HCH) Program.

MDH is engaged in the ongoing planning, implementation, evaluation, and dissemination activities for MNCARES. They are a member of the Executive and Steering Committees for the study and play a leadership role in workgroups focused on recruitment and survey development.

MDH is the lead for recruiting clinics for the study, administering a clinic survey, and assisting with the recruitment of patients to participate in patient interviews in Years 1 and 3 of the study.

MDH HCH team members will use their existing connections with clinics to conduct semi-structured interviews with care coordinators and assist in the recruitment of clinician and clinic leaders and patients who will also be interviewed. These interviews will occur in Years 1 and 3.

Site Principal Investigator:
Bonnie LaPlante, RN
Health Care Homes Program Director

Health Care HomesMN Community Measurement (MNCM) is a member of the Executive and Steering Committees for the study and plays a leadership role in several workgroups defining the details for data collection.

MNCM is responsible for providing input into the study design and operational plan of data flow – and is responsible aggregating data from all sources relevant to the study. It will then produce the final data set for HealthPartners Institute to conduct the analysis.

As the data hub for MNCARES, MNCM will receive patient data from participating clinics, send selective data to and receive data back from payers and the survey center, add relevant MNCM data on quality measures for care coordination patients, and send aggregate deidentified data to the study team.

MNCM will leverage its established legal framework and relationships with medical groups and health plans across Minnesota for quality measurement purposes, to secure agreements necessary to integrate data needed for the study.

Site Principal Investigator:
Liz Cinqueonce
Chief Operating Officer

Return to Health Care Homes Main Page

Updated Wednesday, 20-Oct-2021 09:05:58 CDT