Care Coordination: How Is It Implemented and Is It Different If a Social Worker Is on the Team?

To understand how primary care clinics coordinate services for complex patients and whether clinics with an integrated social worker do it differently.

Cross-sectional survey of the 213 most experienced care coordinators for each of the 317 participating clinics. The survey asks about staffing, communications, care model (nursing vs integrated social worker), resources, support, services, how services are available and delivered, payment approach, and satisfaction. Clinics using the integrated model include the social worker as part of the care team, responsible for assessing and coordinating services for social needs, and communicating directly with both patients and clinicians.

Out of 317 clinics from 42 diverse care systems, 139 had an integrated social worker and 178 did not. Care coordinators in the integrated social worker clinics had somewhat larger patient panels and worked with almost twice as many clinicians. These care coordinators were also less likely to be on site and more likely to communicate with patients and clinicians by telephone rather than in person. Care coordinators in the integrated social worker clinics were 10 to 30% more likely to assess patients' social needs, provide a broader range of services, and to be more engaged in the process of referral for community services.

Clinics with an integrated social worker seem to differ in the frequency and approach to care coordination as well as in how social needs are addressed from those that use a nursing model while providing most medical/nursing services at similar or higher rates.