The number of patients in the United States with multiple chronic conditions (MCC) is
growing. Many patients with poorly controlled MCC also have unhealthy behaviors, mental
health challenges, and unmet social needs. Medical management of MCC may have limited
benefit if patients are struggling to address these basic life needs. Health systems and
communities increasingly recognize the need to address these issues and are experimenting
with and investing in new models for connecting patients with needed services. Yet
primary care clinicians, whose regular contact with patients makes them more familiar
with patients' needs, are often not included in these systems. Responding to the Special
Emphasis Notice NOT-HS-16-013, Optimizing Care for People Living with MCC through the
Development of Enhanced Care Planning, the investigators propose a clinician-level
randomized controlled trial to study how primary care clinicians can participate in these
community and hospital solutions and whether doing so is effective in controlling MCC.
This study will build on the Centers for Medicare and Medicaid Services (CMS)-funded
Accountable Health Community (AHC) in Richmond, Virginia. Sixty clinicians in the
Virginia Ambulatory Care Outcomes Research Network (ACORN) will be matched by age and sex
and randomized to usual care (control condition) or enhanced care planning with
clinical-community linkage support (intervention). From the electronic health record
(EHR), clinicians will identify all patients with MCC, including cardiovascular disease
or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to 50
randomly selected patients; 10 respondents per clinician (600 patients total) with
uncontrolled MCC will be randomly selected, with over-sampling of minorities. The
intervention includes two components. First, an enhanced care planning tool called My Own
Health Report (MOHR) will screen patients for health behavior, mental health, and social
needs. Clinical navigator support will help patients prioritize needs, create care plans
based on preferences, and write a personal narrative to guide the care team. Patients
will update care plans quarterly. Second, community-clinical linkage support will include
community resource registries, personnel to span settings (clinical navigators, community
health workers), and care team coordination tools (sharing MOHR content, secure
messaging, and virtual visits). The investigators will compare patient-level intervention
and control outcomes to assess improvements in MCC outcomes (primary outcome) and
self-reported PROMIS-29 measures (physical health, mental health, social wellbeing) six
months and two years post-enrollment. the investigators will also conduct a
mixed-methods, multilevel assessment of person-, family-, community-, and system-level
contextual influences on implementation and effectiveness. Data sources will include EHR
and MOHR data, chart reviews, patient surveys, field notes, and semi-structured
interviews of patients, clinicians, and community stakeholders. If effective, this study
will help inform efforts by primary care clinicians to participate in the growing number
of AHC-like systems as a strategy to better control MCC.