Table 3.

Care Coordination Program Elements Reported in Included Studies

Program element	N (%) of programs with dataa	Summary of resultsb
Care Coordination Processes
Needs Assessment		.
Systematic assessment of any patient needs	17 (89%)	17 programs had a systematic process for evaluating medical, social, or other patient needs. The remaining 2 programs did not have adequate detail on this element.
Systematic assessment of social needs	9 (47%)	9 programs had a systematic process for evaluating patient social needs. The remaining 10 programs did not have adequate detail on this element.
Care Planning
Development of an individualized plan	12 (63%)	12 programs developed individualized care plans for patients. The remaining 7 programs did not have adequate detail on this element.
Patient Engagement
Emphasis on patient-centered care, empowerment, or self-management	11 (58%)	11 programs emphasized patient-centered care, empowerment, or self-management. The remaining 8 programs did not have adequate detail on this element.
Emphasis on ongoing patient support	8 (42%)	8 programs emphasized ongoing patient support rather than episodic or time-limited support. The remaining 11 programs did not have adequate detail on this element.
Frequent communication with patient	6 (32%)	5 programs expected care coordinators to communicate frequently (at least once per month) with each patient, and 1 required contact every 3 months. This was not discussed in adequate detail to classify many programs.
Mode(s) of communication with patient	18 (95%)	On-site communication: used by 15 programs. Four relied only on on-site communication, and 11 relied on this along with other modes.
		Field- or community-based communication: used by 11 programs. Two relied only on field-based communication (through home visiting and community-based navigators), and 9 relied on this along with other modes.
		Telephonic communication (phone or text): used by 8 programs. One relied only on telephonic communication, and 7 relied on this along with other modes.
Referrals
Used “active” referrals	10 (53%)	9 programs used “active” referrals (eg, making appointments) rather than “passive” referrals (eg, only providing information about services). One program did not use active referrals because of reliance on large caseloads and infrequent telephonic communication. The remaining 9 programs did not have adequate detail on this element.
Accountability
Regular meetings of interdisciplinary team	11 (58%)	11 programs had regular meetings of an interdisciplinary team to coordinate care. The remaining 8 programs did not have adequate detail on this element.
Formal partnerships with other organizations to coordinate care	7 (37%)	7 programs had formal partnerships with other organizations to coordinate care (eg, Business Associate Agreements, Memoranda of Understanding, or shared governance structures). The remaining 12 programs did not have adequate detail on this element.
Co-location of medical and social services	7 (37%)	3 programs co-located medical (physical health) and social services at the same site, and 4 did not co-locate services. The remaining 12 programs did not have adequate detail on this element.
Emphasis on shared vision of addressing social determinants of health	10 (53%)	10 programs emphasized a shared vision or mission of addressing social determinants of health. The remaining 9 programs did not have adequate detail on this element.
Care Coordination Infrastructure
Staffing
Primary care coordination staff type	18 (95%)	Physician or mid-level provider: primary staff for 12 programs. Four relied only on physicians or mid-level providers, and 8 relied on them along with other types of care coordination staff.
		Community health worker or peer coach: primary staff for 9 programs. Four relied only on community health workers or peer coaches, and 5 relied on them along with other types of care coordination staff.
		Social worker: primary staff for 5 programs, all of which relied on social workers along with other types of care coordination staff.
		Nonpermanent volunteers: primary staff for 2 programs, both of which primarily relied on volunteers without other types of care coordination staff, but with oversight from clinical practitioners.
Specialized staff training	14 (74%)	14 programs provided specialized staff training related to care coordination. The remaining 5 programs did not have adequate detail on this element.
Care coordinator caseload	8 (42%)	Typical caseloads: 2 programs had caseloads up to 20 patients, 2 had caseloads up to 50 patients, and 2 had caseloads up to 100 or 125 patients. This was not discussed in adequate detail to classify many programs.
		Outlier caseloads: 2 programs had very large caseloads (800 to 20,000) that likely were calculated using a method not comparable to other programs (eg, number of potential patients in the region)
Information Sharing
Patient information shared across providers	8 (42%)	7 programs shared patient information across providers to support care coordination, and 1 did not because of regulatory limitations on linkage across data systems. The remaining 11 programs did not have adequate detail on this element.
Standard Protocols
Has specialized intervention protocols	15 (79%)	15 programs had specialized intervention protocols or workflows for care coordination. The remaining 4 programs did not have adequate detail on this element.
Financing
Specialized funding or reimbursement structure	10 (53%)	10 programs had a funding source or reimbursement structure specialized to support care coordination. The remaining 9 programs did not have adequate detail on this element.

Final results consisted of 25 publications documenting 19 care coordination programs.

^a Programs were coded as having unavailable data for a program element if included publications did not include adequate information to classify the program as “Yes” or “No” for the element.

^b Results include only the program elements that were reported in included publications, and may omit elements that were not reported.