Improving health and healthcare systems for patients with multiple chronic conditions is critical in achieving population health. More than a quarter of Americans have been diagnosed with at least two major chronic conditions, and this number is much higher among vulnerable populations. Denver Health, an integrated safety-net delivery system serving predominantly uninsured and publicly insured patients, has conducted extensive descriptive analyses and patient interviews to better understand and improve services among high-risk super-utilizing patients (≥3 admissions within a year). This group of patients has high rates of multiple chronic medical conditions, mental health conditions, substance use disorders, and homelessness.
However, we have also identified subgroups of super-utilizers, and these chronic conditions and social characteristics are differentially experienced across these groups. This PCORI Pipeline project will focus on better understanding the unique needs of female super-utilizing patients with multiple chronic medical conditions including mental health and substance use. During this nine-month period, we will identify and establish an advisory committee that would include patients, caregivers, community stakeholders, clinicians, and researchers. The ultimate goal is to develop an engaged and structured partnership that will work collaboratively toward identifying and defining shared health priorities that would ultimately inform a comparative effectiveness research proposal for super-utilizing women.