Results Summary

PCORI funded the Pilot Projects to explore how to conduct and use patient-centered outcomes research in ways that can better serve patients and the healthcare community. Learn more.


Older adults with long-term illnesses may find it hard to cope or to access the health care they need, especially in low-income and minority communities.

One solution might be the patient-centered medical home, which is a way of providing care in which clinic staff get to know each patient to make sure each patient gets the right care at the right time. Researchers wanted to see if there was a way to set up a similar structure in patients’ communities, specifically in low-income neighborhoods and focusing on older adults. Researchers thought the structure could help older adults participate in the wellness services they need. The researchers call this potential solution a person-centered wellness home.

Project Purpose

The team had three goals. The team tested whether getting wellness coaching after completing a disease self-management course could help older patients with two or more diseases take care of their long-term illnesses.

The researchers also wanted to create a personal health record that patients could use to share their self-care and wellness goals with doctors, nurses, and wellness coaches.

The team also wanted to create an organizational structure for a person-centered wellness home.


The study had three parts.

Part 1: Researchers recruited 121 patients who had completed a six-week disease self-management course, were age 55 or older, and had two or more long-term illnesses. To join the study, participants also needed to speak English or Spanish, be able to walk on their own, and not have problems with thinking or memory. All of the participants lived in low-income public housing communities in the South Bronx in New York City.

Researchers divided the patients at random into two groups. One group of 61 patients worked with certified wellness coaches. The coaches split this group into three classes. Patients in each class participated in 24 weekly one-hour group phone sessions.

The second group of 60 people didn’t get any wellness coaching.

The researchers then looked at whether people who had a wellness coach and participants who did not have a coach differed in

  • Exercise
  • Waist size
  • Smoking habits
  • Physical functioning
  • The number of times they had fallen in the past month
  • Confidence that they could improve their health

All participants also answered a set of questions at the beginning of the study, after three months, and then again after six months. These questions helped researchers see whether any changes occurred in participants’ physical health, depression levels, energy levels, pain, and sleep. The researchers also studied how much participants socialized with their wellness coaches or other people who had been part of their disease self-management program.

Part 2: Researchers created a draft of the personal health record and interviewed doctors in New York City to get feedback on it. They asked doctors whether the information in the record might help with both wellness and medical care and whether the visual display of these records could be improved.

Part 3: The researchers held a workshop for doctors, community health planners, and policy experts to discuss the important elements of a person-centered wellness home for people in underserved communities. Based on information gathered at the workshop, the researchers created a list of important elements that should be part of a person-centered wellness home.


Part 1: Compared with patients who didn’t get coaching, patients who received coaching

  • Improved more in physical functioning
  • Were slightly more confident in their ability to improve their health

There was no difference between groups in

  • Exercise
  • How many and what types of social interactions participants had with other people from their disease management program
  • Waist size
  • Smoking habits
  • Falls
  • Depression
  • Pain
  • Sleep

Part 2: Doctors provided ideas for improving the personal health records’ content (for example, adding space to include reasons why a patient is unable to reach their wellness goals) and format. Doctors also suggested how best to use them. The doctors suggested sharing the record with nurses.

Part 3: According to workshop participants, a person-centered wellness home would

  • Listen to the community’s wellness needs and then come up with a strategy to promote wellness
  • Work with experts who can help patients get health insurance or connect them to a patient-centered medical home
  • Create a directory of community health programs that have been shown to work
  • Use community health workers—public health workers with a close connection and clear understanding of the community—to help patients get the wellness care they need
  • Use community health workers to find out what each patient already knows—or doesn’t know—about wellness care
  • Provide programs led by community health workers that make patients more confident that they can improve their health
  • Offer ongoing, effective community programs run by community health workers
  • Develop a wellness record that patients can share with their doctors and community health workers


Most participants were Hispanic women with low levels of education. The results might be different for other groups of people. The researchers originally planned to provide 24 coaching sessions spread over one year but had to provide the 24 sessions over six months. Participants attended on average almost half of the coaching sessions. Results might be different for people who attended more sessions or had the 24 coaching sessions spread over a year.


Getting wellness coaching after attending a wellness course seemed to help patients improve their physical functioning and their confidence in their ability to improve their health.

Eight components of the person-centered wellness home were identified as important, especially in underserved communities. Older adults living in low-income, minority communities could use trained community health workers to help put many of these components into action. 

Sharing the Results

The researchers will write reports about their findings and share them with South Bronx residents.

Project Information

Thelma J. Mielenz, PhD
Columbia University Medical Center
Creation of the Person-Centered Wellness Home Across the Life Course

Key Dates

June 2012
May 2015

Study Registration Information


Has Results
Award Type
Funding Type
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: March 14, 2024