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Preventing tipping points in high comorbidity patients: a lifeline from health coaches
Investigator (PI): Tobin, Jonathan
Performing Organization (PO): (Current): Clinical Directors Network / (212) 382-0699
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2019
Final Year: 2024
Record Source/Award ID: PCORI/IHS-2017C3-8923
Funding: Total Award Amount: $7,864,001
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Abstract: This research project is in progress. PCORI will post the research findings on the PCORI website within 90 days after the results are final. What is the research about? Poorly managed chronic conditions can lead to disability, unplanned hospital visits, and decreased quality of life. But managing multiple chronic conditions can be hard. Many patients take several medicines each day and have many doctor's appointments. Patients need help figuring out how to manage their health conditions. In this study, the research team is adding health coaches to patients' health care teams to help patients set life and health goals and manage their chronic conditions. The team wants to know how well medical teams with a health coach help patients manage their conditions and avoid unplanned hospital visits compared with medical teams that don't have a health coach. Who can this research help? Primary care practices may use these results when considering ways to help patients manage multiple chronic conditions. What is the research team doing? The research team is working with 16 federally qualified health centers, or FQHCs, in New York City and Chicago. These health centers serve mostly black and Latino patients with low incomes. The health centers are patient-centered medical homes, or PCMHs. In PCMHs, center staff get to know each patient and work to make sure they get the right care at the right time. With the help of health center staff, the research team is enrolling 1,920 patients with multiple chronic conditions to take part in the study. The team is then assigning the health centers by chance to provide either regular PCMH care or PCMH care with a health coach. Regular PCMH care includes team-based preventive, wellness, acute, and chronic care as needed. The health coach helps patients identify what is important to them, set goals, and choose self-care activities to help them reach their goals. Coaches are also leading a program that teaches patients to have a positive attitude about self-care. Finally, coaches help patients identify and access social services in their communities to address needs such as housing, employment, and transportation. The research team is reviewing electronic health records and data on patients' use of health care to see how often and why patients go to the emergency room, or ER, or hospital. The team is also asking patients about the effect of their illnesses on their life. The team is comparing outcomes in health centers with a health coach versus centers without a coach. FQHCs, patients, clinicians, and clinical data networks help with every stage of this project. Research methods. Design; The study design is a cluster randomized controlled trial. Population: The study population is 1,920 adult patients with multiple chronic conditions (Charlson comorbidity index e4) who are primary care patients at 16 FQHCs in New York City and Chicago. Interventions/comparators are PCMH and PCMH with a health coach. Outcomes: Outcomes are (1) primary: unplanned hospitalizations and disability; and (2) secondary: ER visits, patient activation, patient education, and self-management. The timeframe is 2-year follow-up for primary outcomes.
Abstract Archived: We plan to identify and work with 1,920 predominantly low-income, black and Latino adult patients who have several different chronic diseases ("multiple comorbidity") that require them to have many medical appointments and take several different medications every day. These people will be patients who receive their medical care at 12 federally qualified health centers (FQHCs) in New York City (NYC) (6 FQHCs) and Chicago (6 FQHCs), which serve predominantly low-income, black and Latino patients. These FQHCs are called "Patient Centered Medical Homes (PCMH)," which means that they take responsibility for making sure that all necessary medical care is provided to their patients. Patients who helped plan this study have told us that they need more help in planning to do things that will help to keep them more healthy, and that this type of help, which is not available from their primary care providers, may help them to better deal with the many social and health-related challenges they face. Patients often need help talking with their doctors and finding their way around the complicated medical system and we propose to add health coaches to the PCMH health care team. We want to understand if adding health coaches will help patients to better manage their sources of stress, and if this improves how people can take better care of themselves, and avoid having to go to the hospital more often. This study will use a lottery to offer patients in half of the 12 FQHC clinical sites a new program, which will include in addition to their regular medical care, a health coaching program that uses practices to help people to set their own life goals, and in doing this, become more motivated to do the things they need to do to help them manage their different conditions. We believe that this method may prevent the build-up of stress that often leads to "tipping points" or overwhelming situations that may lead to unplanned hospitalization, increased emergency department visits, and increased disability. We will compare what happens to the patients in the 6 FQHCs that receive the program to the patients in the 6 FQHCs that do not receive the program, by comparing information about hospitalizations and emergency room visits from their electronic health records and medical claims, as well as by asking them to answer questions about their quality of life and disability. The proposed study will have many partners in NYC and Chicago, including the PCORnet Clinical Data Research Networks (CDRNs: NYC-CDRN and CAPriCORN), which have information from patients' complete electronic health records (EHRs), which will be used to help find patients for the study and to learn about whether they have gone to the hospital or emergency room during the study. In addition, patients will answer questions about their quality of life and disability to learn who gets better from the program. Patient partners as well as other members of the health care system, including clinicians and those who provide health insurance, from NYC and Chicago will continue to be involved in every stage of the project, and will help us share the results of the study with their communities when it is completed.

MeSH Terms:
  • Access to Health Care
  • African Americans
  • Chicago
  • Chronic Disease /*ethnology
  • /*therapy
  • Disabled Persons
  • Health Promotion /*methods
  • Hispanic Americans
  • Humans
  • New York City
  • Patient-Centered Care
  • Poverty
  • Primary Care
  • Quality of Life
Country: United States
State: New York
Zip Code: 10018
UI: 20193253
CTgovId: NCT04176510
Project Status: Ongoing
Record History: ('2020: Archived abstract to Abstract Archived 1 field and added new abstract. Alternate Title: What is the effect of adding a health coach to patient-centered medical homes for managing multiple chronic conditions?',)