How do other Minnesota care systems provide care coordination?

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.

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.

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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.