Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic
Needs of Patients with Multiple Chronic Conditions
PROJECT SUMMARY
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, we 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 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), we 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
oversampling 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). We 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. We 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.
