Care coordination engagement patterns in long-term patients

Health care networks are increasingly turning to programs that provide office-based care coordination to high-cost, high-need patients to control preventable health care costs. Although care coordination programs have been shown to result in shorter-term cost benefits, little is known about patients who remain in such programs beyond 2 years. This study sought to assess the amount of care coordination engagement over time in patients enrolled for more than 2 years in an office-based care coordination program.

Cohort study with 9 years of follow-up data.

The study population was adult patients enrolled for 2 or more years as of November 2023 in an office-based care coordination program at a major academic medical center in Boston, Massachusetts. The association between patient length of enrollment in an outpatient care coordination program and amount of care coordination engagement was assessed using linear regression, with differences between cohorts compared by t test and analysis of variance. Engagement patterns in 5 sequential study cohorts based on date of enrollment were compared.

Among all 2258 patients enrolled, care coordination engagement increased linearly over time, with a mean increase of 0.2 care coordination encounters per patient per year. Similar increasing engagement patterns over time were observed across all study cohorts.

Length of time enrolled in an office-based care coordination program predicted care coordination engagement, with care coordination services increasing the longer patients remained in the program.