Alternative payment models lead to strategic care coordination workforce investments


      • Value-based payment is leading to enhanced care coordination staffing.
      • Sites are task shifting low-complexity care coordination to unlicensed staff.
      • Important care coordination education gaps necessitate in-depth on-the-job training.
      • Demonstrating the return on investment of care coordination staffing remains a challenge.



      Care coordination is generally viewed as a key to success for health systems seeking to adapt to a range of new value-based payment policies.


      This study explores care coordination staffing in four health systems participating in new payment models, including Medicaid payment reform and Accountable Care Organizations.


      Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff at four health systems engaged in value-based contracts.


      Each of the sites engaged in significant task shifting of low-complexity care coordination activities to licensed practical nurses, medical assistants, and other unlicensed personnel freeing up registered nurses and social workers for more complex patients. Few have care coordination experience, requiring a significant investment in on-the-job training.


      Payment reform is leading to a greater investment in the care coordination workforce. However, demonstrating the return on investment remains a challenge.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Nursing Outlook
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Agency for Healthcare Research and Quality. (2008). Section 4: Selecting care management interventions [AHRQ Web site]. Content last reviewed October 2014. Retrieved from

      2. Agency for Healthcare Research and Quality. (2010). Chapter 2. What is care coordination? [AHRQ Web site]. Content last reviewed June 2014. Retrieved from

        • Berenson R.
        • Burtona R.
        • McGrath M.
        Do accountable care organizations (ACOs) help or hinder primary care physicians' ability to deliver high-quality care?.
        Healthcare. 2016; 4: 155-159
        • Berwick D.
        • Noan T.
        • Whittington J.
        The triple aim: Care, health, and cost.
        Health Affairs. 2008; 27: 759-769
        • Blumenthal D.
        • Anderson G.
        • Burke S.
        • Fulmer T.
        • Jha A.
        • Long P.
        Tailoring complex-care management, coordination, and integration for high-need, high-cost patients: A vital direction for health and health care.
        ([National Academy of Sciences Web site])2016 (Retrieved from)
        • Blumenthal D.
        • Chernof B.
        • Fulmer T.
        • Lumpkin J.
        • Selberg S.
        Caring for high-need, high-cost patients—An urgent priority.
        The New England Journal of Medicine. 2016; 375: 909-911
        • Chen C.
        • Ackerly D.
        Beyond ACOs and bundled payments: Medicare's shift toward accountability in fee-for-service.
        Journal of the American Medical Association. 2014; 311: 673-674
        • Craig C.
        • Eby D.
        • Whittington J.
        Care coordination model: Better care at lower cost for people with multiple health and social needs.
        ([IHI Web site])2011 (Retrieved from)
        • Dale S.
        • Ghosh A.
        • Peikes D.
        • Day T.
        • Yoon F.
        • Taylor E.
        • Brown R.
        Two-year costs and quality in the comprehensive primary care initiative.
        The New England Journal of Medicine. 2016; 374: 2345-2356
        • Davis K.
        Paying for care episodes and care coordination.
        The New England Journal of Medicine. 2007; 356: 1166-1168
        • Evans M.
        Demand grows for care coordinators.
        ([Modern Healthcare Web site])2015 (Retrieved from)
        • Fraher E.
        • Ricketts T.
        • Lefebvre A.
        • Newton W.P.
        The role of academic health centers and their partners in reconfiguring and retooling the existing workforce to practice in a transformed health system.
        Academic Medicine. 2013; 88: 1812-1816
        • Fraze T.
        • Lewis V.
        • Rodriguez H.
        • Fisher E.
        Housing, transportation, and food: How ACOs seek to improve population health by addressing nonmedical needs of patients.
        Health Affairs. 2016; 35: 2109-2115
        • Institute of Medicine. Committee on Identifying Priority Areas for Quality Improvement
        Priority areas for national action: Transforming health care quality.
        ([National Academy Press Web site])2003 (Retrieved from)
        • Institute of Medicine. Committee on Quality of Health Care in America
        Crossing the quality chasm: A new health system for the 21st century.
        ([National Academy Press Web site])2001 (Retrieved from)
        • Ladden M.D.
        • Bodenheimer T.
        • Fishman N.W.
        • Flinter M.
        • Hsu C.
        • Parchman M.
        • Wagner E.H.
        The emerging primary care workforce: Preliminary observations from the primary care team: Learning from effective ambulatory practices project.
        Academic Medicine. 2013; 88: 1830-1834
        • Lamb G.
        Overview and summary: Care coordination: Benefits of interprofessional collaboration.
        Online Journal of Issues in Nursing. 2015; 20 (Overview and Summary)
        • McDonald K.
        • Sundaram V.
        • Bravata D.
        • Lewis R.
        • Lin N.
        • Kraft S.
        Closing the quality gap: A critical analysis of quality improvement strategies.
        in: Care coordination. Vol. 7. Agency for Healthcare Research and Quality, Rockville, MD2007
        • McWilliams J.M.
        • Hatfield L.A.
        • Chernew M.E.
        • Landon B.
        • Schwartz A.
        Early performance of accountable care organizations in Medicare.
        The New England Journal of Medicine. 2016; 374: 2357-2366
      3. Peikes D., Anglin G., Taylor E., Dale S., O’Malley A., Ghosh A., …, Brown R. (2015). Evaluation of the comprehensive primary care initiative: First annual report, [ web site]. Retrieved from

        • Peiris D.
        • Phipps-Taylor M.
        • Stachowski C.
        • Kao L.
        • Shortell S.
        • Lewis V.
        • Colla C.
        ACOs holding commercial contracts are larger and more efficient than noncommercial ACOs.
        Health Affairs. 2016; 35: 1849-1856
        • Sandberg S.
        • Erikson C.
        • Owen R.
        • Vickery K.
        • Shimotsu S.
        • Linzer M.
        Hennepin health: A safety-net accountable care organization for the expanded Medicaid population.
        Health Affairs. 2014; 33: 1975-1984
        • Shane D.M.
        • Nguyen-Hoang P.
        • Bentler S.E.
        • Damiano P.C.
        • Momany E.T.
        Medicaid health home reducing costs and reliance on emergency department: Evidence from Iowa.
        Medical Care. 2016; 54: 752-757
        • Song Z.
        • Rose S.
        • Safran D.
        • Landon B.
        • Day M.
        • Chernew M.
        Changes in health care spending and quality 4 years into global payment.
        The New England Journal of Medicine. 2014; 371: 1704-1714
        • Taylor L.
        • Coyle C.
        • Ndumele C.
        • Rogan E.
        • Canavan M.
        • Curry L.
        • Bradley E.
        The social determinants of health: What works?.
        ([Blue Cross Foundation Web site])2015 (Retrieved from)
        • Taylor E.F.
        • Dale S.
        • Peikes D.
        • Brown R.
        • Ghosh A.
        • Crosson J.
        • Shapiro R.
        Evaluation of the comprehensive primary care initiative: First annual report.
        ([ Web site])2015 (Retrieved from)
        • The Centers for Disease Control and Prevention's National Center for Health Statistics
        National Ambulatory Medical Care Survey.
        ([CDC Web site])2015 (Retrieved from)
        • Tomoaia-Cotisel A.
        • Farrell T.
        • Solberg L.
        • Berry C.A.
        • Calman N.S.
        • Cronholm P.F.
        • Magill M.K.
        Implementation of care management: An analysis of recent AHRQ research.
        Medical Care Research and Review. 2016; (Retrieved from
      4. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2016). Accountable care organizations: What providers need to know [CMS Web site]. Retrieved from

        • Wagner E.H.
        • Sandhu N.
        • Coleman K.
        • Phillips K.E.
        • Sugarman J.R.
        Improving care coordination in primary care.
        Medical Care. 2014; 52: S33-S38
        • Werner R.M.
        • Duggan M.
        • Duey K.
        • Zhu J.
        • Stuart E.
        The patient-centered medical home: An evaluation of a single private payer demonstration in New Jersey.
        Medical Care. 2013; 51: 487-493
        • Xing J.
        • Goehring C.
        • Mancuso D.
        Care coordination program for Washington State Medicaid enrollees reduced inpatient hospital costs.
        Health Affairs. 2015; 34: 653-661
        • Yao N.
        • Ritchie C.
        • Camacho F.
        • Leff B.
        Geographic concentration of home-based medical care providers.
        Health Affairs. 2016; 35: 1404-1409