Project Summary

Background: United States health systems struggle to manage patients who have a mix of complex health and social needs. Chronic disease burden along with socioeconomic barriers create challenges for effective interaction with existing systems of care. There is significant opportunity to increase understanding of and engagement with this patient population, which has not been traditionally included in patient-centered outcomes research (PCOR) and comparative effectiveness research (CER).

Proposed Solution to the Problem: The University of Pennsylvania and Lancaster General Health created a process of engagement to better understand the capacity and needs related to medically and psychosocially complex patients to inform policy and build knowledge around complex care management in the health system and within communities. Key stakeholder groups involved in the engagement process included: Patients with complex health and social needs and their caregivers; clinicians; insurance representatives; community-based organizations; and health system and community policy makers.


  • Build capacity to conduct PCOR related to medically and psychosocially complex patients
  • Establish a process for including stakeholders in health system and community policy development, PCOR, and comparative effectiveness research (CER)
  • Produce products that will build knowledge about the stakeholders’ perspectives regarding PCOR, interventions, and appropriate mechanisms of engagement
  • Develop methods to sustain the stakeholder relationships developed through the award


  • The project team conducted Nominal Groups and individual interviews with key stakeholders to understand perspectives on engagement preferences and identify and understand barriers to participation in PCOR and CER.
  • The project team also organized collaborative stakeholder meetings where members all the stakeholder groups came together to discuss and develop a shared understanding of the important health issues, barriers and potential solutions relevant to this patient population. Stakeholder meetings helped to develop and foster mutual commitment among stakeholders to a future research agenda to improve the care of medically and socially complex patients.

Engagement Resources

Project Information

Peter Cronholm, MD, MS
Wendell Kellum, MD
The Trustees of the University of Pennsylvania

Key Dates

24 months


Project Status
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: February 2, 2023