Transforming health care to improve quality and outcomes while reducing costs demands both innovation and collaboration. It takes individuals and communities working side-by-side to creatively propose solutions that reach across the healthcare system. The Accelerating Data Value Across a Community Health Center Network (“ADVANCE”) Clinical Data Research Network (CDRN) conducts patient-centered outcomes research (PCOR) that builds knowledge about the vulnerable patient populations served by our nation’s healthcare safety net. These patients are often left out of healthcare research, and it is important that we understand the best way to care for them. Because they have not been included in research, many interventions, healthcare systems, and policies do not adequately account for the complexities, challenges, and needs of patients who are low-income, racial/ethnic minorities, and/or adversely impacted by social determinants of health (SDH). For this observational study, ADVANCE will partner with the OneFlorida CDRN whose stakeholders have prioritized high healthcare utilizers and more effectively analyzing risk, with a particular emphasis on patients experiencing co-occurring physical and mental health disorders.
This study looks at how factors like where a patient lives, how much money they have, and whether or not they graduated high school have an effect on how patients use healthcare services and how healthy they are. It explores whether being diagnosed with multiple conditions like physical and mental health issues means that patients and health systems have poorer outcomes. The proposed project also looks at a variety of data resources such as Medicaid insurance claims data, patient record data, and data about the communities where patients live. The study also aims to teach us about how patients, doctors, and others can use this information.
This topic of research was identified by health systems leaders in an earlier PCORnet health systems demonstration project as being a key area of study. One of our key mechanisms for engaging health systems leaders, clinicians, patients, and subject-matter experts is through the Advisory Team. This team is composed of one health systems leader, one clinician, and one patient from each of our CDRNs, as well as subject matter experts in social determinants of health data and comorbidity risk data. The Advisory Team will be integrally involved in the prioritization exercises detailed in Aim 1 and in the interpretation and dissemination of results detailed in Aim 3. We will also work with patients, physicians, and other stakeholders through our governance structure (the Clinic and Patient Engagement Group, the Patient Engagement Panel, the Clinical Oversight Review Committee, the Citizens Scientist Program, and the Physician Champions Program).
Individuals with Multiple Chronic/co-morbid Conditions
^The original principal investigator for this project was Scott Fields, MD, MHA.