Term of Award

Fall 2022

Degree Name

Doctor of Public Health in Public Health Leadership (Dr.P.H.)

Document Type and Release Option

Dissertation (open access)

Copyright Statement / License for Reuse

Digital Commons@Georgia Southern License


Jiann-Ping Hsu College of Public Health

Committee Chair

William Mase

Committee Member 1

Linda Kimsey

Committee Member 2

Samuel Opoku


Background: Healthcare cost in the U.S. has been increasing at an unsustainable rate due to the growing population diagnosed with multiple chronic conditions and a fragmented healthcare system. The high-risk patient population includes persons who over utilize the healthcare system with frequent avoidable hospitalizations, emergency room visits, and exacerbations of their chronic conditions. This high-risk population makes up five percent of the U.S. but accounts for over fifty percent of all healthcare spending. Care coordination models have emerged to focus proactive health interventions for the highest-risk patient populations to reduce overutilization and empower patients to improve long-term health. Evidence has shown care coordination models are essential for achieving quality and safety outcomes for patients and their families, but first, the patient must agree to enroll in the care coordination program to receive the support provided by the care coordination services.

Methods: A retrospective secondary data study design was used from Emory Healthcare Ambulatory Care Coordination Department. Multivariate logistic regressions were conducted to examine whether race, age, sex, and primary insurance type significantly predicted enrollment and achievement of the program care plan goals. A multivariate logistic regression was also conducted to examine if the average communication time significantly affected the patient’s achievement of their care plan goals.

Results: The overall models demonstrated that race, age, sex, and primary insurance type were significant predictors of patient enrollment and achievement of care plan goals (p < .001). The average communication between the care coordinator and the patient also significantly predicted the patient achieving care plan goals (p < .001), but there was no significance for average talk times over 90 minutes.

Conclusion: The study results will serve as a benchmark for the Emory Healthcare Care Coordination Department and create a foundation for further research to inform effective strategies to utilize proactive outreach and promote the enrollment of a diverse patient population. It will be essential to continue longitudinal studies of the enrolled patient population further to inform the long-term cost savings effects of the program.

OCLC Number


Research Data and Supplementary Material