How do other Minnesota care systems provide care coordination?

September 20, 2023

MNCARES Study Enters Final Year – Release of Study Findings Begins and Continues through 2024

The Minnesota Care Coordination Effectiveness Study (MNCARES) is focused on learning which approaches to care coordination for patients with complex health care needs and/or high health care costs produce the best outcomes for patients. As the study enters its final year, the study team will be analyzing study data and writing papers that highlight learnings that have emerged regarding how care systems and care coordinators can produce the best care quality, utilization, and patient-centered outcomes. 

This post showcases the first paper.  Please watch for additional publications to be highlighted in the newsletter and blog in 2023 and 2024.

Highlighted Learnings from MNCARES Series:

How do other Minnesota care systems provide care coordination?

The majority of primary care clinics in Minnesota provide care coordination services for their patients with complex medical or social needs, but there is some variety in how they do that. We surveyed leaders in 42 care systems of various sizes and locations around the state to learn about how their approaches differ. Some of what we learned was:

  • 82% of large care systems, 40% of medium, and 25% of small ones had a social worker on their care teams, but nearly all reported addressing both medical and social needs.
  • Size of care system was not related to either the type of patients targeted for care coordination or the type of services provided.
  • Care coordination teams across care systems included: registered nurses (86%), practical nurse/medical assistants (55%), social workers (45%), nonclinical staff (40%), and community health workers (24%).
  • The majority (79%) of care systems bill payment sources for care coordination services.

Key takeaway: Though large and small care systems differ in resources and capabilities; different sized organizations were generally more similar to each other than different in their approach to care coordination.

Access to the full article is available here:


Posted in Blog

Recent Posts

By Jessica Donovan April 29, 2026
MN Community Measurement (MNCM) has released two new reports highlighting the state’s health care performance: Health Care in Minnesota: Summary Report on Quality, Disparities, and Cost and Health Care in Minnesota: Health Care Quality Leaders . Together, these reports provide a comprehensive analysis of 2024 data, examining trends in health care quality, disparities, and costs, while also recognizing medical group quality leaders and those demonstrating meaningful improvement. These reports, based on data submitted to MNCM in 2025 and reflecting care delivered in 2024, work in tandem with MNCM’s Performance Hub —an interactive platform providing statewide analyses of health care quality and cost measures. Collectively, these tools equip community partners, including medical groups, payers, policymakers, public health agencies, researchers, and community-based organizations, with actionable insights to drive improvements in care and advance health equity across Minnesota. Report highlights include: Health Care Quality Significant gaps remain in asthma control, with thousands of patients needing improved care to meet statewide benchmarks. Colorectal cancer screening rates for the newly eligible 45-49 age group continues to improve. While the 2024 rate for all age groups has significantly increased compared to 2023, it remains significantly lower than 2021. Childhood immunization continues to show a decrease in statewide rate from year to year. This measure has not shown improvement in rates following the COVID-19 pandemic. There were modest improvements in breast cancer screening, cervical cancer screening, controlling high blood pressure, diabetes eye exams, and immunizations for adolescents. Health Care Disparities Black, Indigenous, Multi-Race, and Hispanic/Latinx patients experienced the most disparities across multiple measures, particularly in Colorectal Cancer Screening. Patients speaking Somali and Spanish, as well as those from Laos, Mexico, and Somalia, had lower rates of preventive care and chronic disease management compared to statewide averages. Cost and Utilization The total cost of care increased by 7.3% in 2024, primarily driven by an 8.9% rise in pharmacy costs and an 8.3% rise in professional fees. All categories of medical services saw increased use, except for inpatient admissions. Women aged 36-64 had the highest number of claims, while men aged 18-35 had the lowest number of claims. Quality Leaders In 2024, 31 medical groups were recognized as quality leaders across the measures reported by medical groups. In 2024, 58 medical groups were recognized as quality leaders across the measures reported by payers. 
By Elizabeth Cinqueonce March 5, 2026
Aligning for Impact: Minnesota's Health Data Evolution A 2026 Leadership Series from the MNCM Board Chair & President
By Jessica Donovan January 21, 2026
CONNECTED THROUGH DATA: Uncovering Disparities in Cervical Cancer
By Jess Donovan, MPH, BSN October 21, 2025
This October marks the 40th anniversary of Breast Cancer Awareness Month. According to the American Cancer Society, about 1 in 8 women will be diagnosed with invasive breast cancer in their lifetime. Fortunately, however, early detection through screening and advances in treatment have decreased mortality by 44% since 1989. Screening can catch cancer early, when it is… The post Empowered by Data: Uncovering Screening Disparities and Reducing Breast Cancer Risk appeared first on MN Community Measurement.
By Jess Donovan, MPH, BSN September 30, 2025
September is Sexual Health Awareness Month. As we close out September, we’re highlighting two of the measures we report on – Cervical Cancer Screening and Chlamydia Screening in Women.   Cervical cancer, once one of the most common cancers affecting women in the United States, has significantly decreased since the 1970s. The reason for the decline… The post Empowered by Data: Spotlight on Screening for Sexual Health appeared first on MN Community Measurement.

Recent Comments

Archives

Categories