MNCARES: Frequently Asked Questions (Primary Cohort)

A: The study is intended to include patients who were enrolled in care coordination and engaged for a meaningful period of time, using whatever criteria make the most sense in your care system. Please do not include patients who were temporarily or “partially” enrolled. For example, some medical groups may apply an inclusion criterion to their query such as: include only patients who were enrolled for at least 2 months with at least 3 care coordination encounters within the care system. You may also use other ways to narrow the list to those enrolled patients intended for the study, depending on what parameters are used to define a “fully enrolled” care coordination patient in your system.

A: Please include patients whose first-ever care coordination enrollment started in your care system between 01/01/2021-12/31/2021. Please exclude patients whose care coordination began within your care system before 01/01/2021. 

A: Please include patients that are deceased or inactive. If you confirm that a patient is deceased, please submit "0" for patient status in column O or enter the date of death in column N in the Demographic File. If you confirm that a patient is no longer active in your care coordination program please indicate this by submitting both the most recent care coordination encounter date in column AI. If you confirm that a patient is no longer an active patient within your care system, please indicate this by including the most recent encounter date in column AK. Including as much situational data as possible will help with the analysis of the data and ultimately lead to better outcomes for this study.  

A: Column AM (Count of Care Coordination encounters) should include all care coordination encounters that occurred at any time up until the date that the data is pulled. This includes the start/enrollment encounter and the most recent encounter.

A: Yes. Please enter the most recent encounter dates as of the day that the data is pulled. We expect the majority of these dates will occur after 12/31/2021. 

A: Please enter the care coordination start/enrollment date if the patient did not have any additional encounters. 

A: If a HCH clinic closed since 01/01/2021, please enter the original MNCM-assigned clinic ID associated with the start of the patient’s care coordination enrollment, even if the clinic ID is inactive. Please contact support@mncm.org if you have questions or if you need to confirm the MNCM Clinic ID for a closed clinic. 

A: There is not standard way that organizations track Care Coordination, rather, individual methods are used. We recommend connecting with staff in your organization familiar with how Care Coordination is tracked which may provide guidance in how to extract this information from your system. Additional information can be found here.