Minnesota Care Coordination Effectiveness Study

"No social worker on the clinic's care coordination team.~Services provided:~* Coordinated medical care for patients~* Patient education~* Assistance in developing care plan~* Support for patient self-management~* Referrals for continuing care~* Referral to community resources~* Referral to mental health services if needed or requested~* Referral to interventional counseling for behavioral health issues"

"Social worker is part of the clinic's care coordination team.~* Need not be licensed as a social worker~* Must have time dedicated to care coordination for a specific clinic or clinics~* Must interact with individual patients to provide them with services~* Must interact with individual clinicians about their individual patients in care coordination~Services provided:~* Coordinated medical care for patients~* Patient education~* Assistance in developing care plan~* Support for patient self-management~* Assistance with referrals for continuing care~* Assessment and plan to address social and resource needs including housing, transportation or financial needs; Assist patient in locating and obtaining needed community resources~* Assistance with identifying and addressing psychological/emotional issues and referrals as needed~* Interventional counseling for behavioral health issues or referrals to interventional counseling, depending on licensure"