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Evaluation of Care Management and Team Roles in the ACT Model: Improving Population Health Outcomes for Medicaid Patients

Research Team

Kathryn Swartwout, Principal Investigator, Rush CON

Arlene Miller, Co-Investigator, Rush CON

Award Period

01/01/17 - 12/31/18

Funding Source

Building Healthy Urban Communities, Rush University Medical Center

Department of Health Systems Management


Activation and Coordination Team (ACT) Model was developed at Rush University Medical Center (RUMC) to guide efficient inter-professional care management for individuals in primary care and community settings. ACT is based on the Chronic Care Model which suggests that, influenced by community and health system factors, productive interactions between an informed, activated patient and a prepared, proactive practice team improves health outcomes. Unlike many care management models, the ACT Model considers social determinants of health to evaluate patient complexity and plan patient care. Teams (“Primary Care Triads”), composed of registered nurses, social workers and patient navigators, have the opportunity to provide robust care management targeted to a Medicaid primary care population using the ACT Model. purpose of this fellowship project is to 1) further work to better understand the relationships between patient complexity and patient-centered health outcomes in this Medicaid population and 2) describe, evaluate and improve the processes/activities performed by the ACT teams for the RUMC primary care practices.