Enhanced Care Planning for Multiple Chronic Conditions

Overseen By Paulette Lail-Kashiri, MPH

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Virginia Commonwealth University

Disqualifiers: Richmond study, clinician excludes

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

457 Participants Needed

Trial Summary

What is the purpose of this trial?

Patients with multiple chronic conditions (MCC) have a range of needs that extend beyond traditional medical care, including behavioral, mental health, and social needs. While primary care does its best to address these needs, few practices can undertake a systematic approach without broader health system and coordinated community support. Fortunately, communities and health systems are investing in new models of care to address these needs. New tools are emerging that allow for enhanced care planning to identify and prioritize patients' needs based on their values, preferences, social, and clinical context. Additionally, support systems to promote partnerships between patients and clinical and community care teams are emerging. Building on work occurring as part of the Richmond Accountable Health Community, the investigators propose to (a) evaluate the implementation of an enhanced care planning approach, paired with community-clinical linkages support to address health behavior, mental health, and social needs; (b) determine within a randomized controlled trial the benefit of this approach compared to usual care; and (c) assess which person, family, community, and system contextual factors that influence MCC.

Research Team

Alex Krist, MD

Principal Investigator

Virginia Commonwealth University

Eligibility Criteria

This trial is for individuals with at least one uncontrolled condition and two or more chronic conditions who have completed a baseline survey. It's not open to those already in the Richmond Accountable Health Community study or excluded by their clinician.

Inclusion Criteria

I have a health condition that is not currently under control.

Completes baseline survey

You have two or more long-term health problems.

Exclusion Criteria

The doctor has determined that you are not eligible for the study.

You are currently involved in the Richmond Accountable Health Community study.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Baseline Assessment

A baseline assessment is mailed to 50 randomly selected patients to identify those with uncontrolled MCC

Within 6 months of enrollment

Intervention

Enhanced care planning and clinical-community linkages are implemented, including quarterly updates to care plans

2 years

Quarterly updates

Follow-up

Participants are monitored for improvements in MCC outcomes and quality of life measures

2 years

Treatment Details

Interventions

• Enhanced care planning

Trial Overview The trial tests an enhanced care planning approach that includes behavioral, mental health, and social support, comparing it to usual care in patients with multiple chronic conditions within a randomized controlled setting.

Participant Groups

Group I: Enhanced care planning Experimental Treatment 1 Intervention

The intervention consists of two components - enhanced care planning and clinical-community linkages. The enhanced care plan is created using MOHR (https://myownhealthreport.org). MOHR screens patients for unhealthy behaviors, mental health needs, and social needs. Patients identify the needs they would like to address and create a care plan, which they update quarterly. A clinical navigator and community health worker (CHW) help patients address their care plans using clinical-community linkages, which has four components. First, clinicians and clinical navigators have a resource registry identifying community programs and support - No Wrong Door (NWD) and https://navigator.aafp.org/. Second, MOHR shares information (care plans, patient narrative, and patient progress) across clinical and community team members. Third, MOHR supports messaging and video visits for team members and patients. Finally, MOHR sends care team members quarterly patient progress updates.

Group II: Usual medical care Active Control 1 Intervention

Clinicians randomized to the control condition will continue to provide "usual care." This includes current non-systematic assessment of health behaviors, mental health needs, and social needs. Neither clinicians nor patients will be eligible to receive CHW support or have access to NWD. Clinicians may refer some control patients to community programs as part of their current usual care. Control clinicians will be blinded as to which patients are included in the study. At the end of the study, the investigators will share with control clinicians our lessons learned, access to MOHR, and lists of useful community resources.

Who Is Running the Clinical Trial?

Virginia Commonwealth University

Lead Sponsor

Trials

732

Recruited

22,900,000+

Agency for Healthcare Research and Quality (AHRQ)

Collaborator

Trials

415

Recruited

6,777,000+