Skip to main content
Patient-Centered Outcomes Research Institute
Patient-Centered Outcomes Research Institute
  • Blog
  • Newsroom
  • Find It Fast
  • Help Center
  • Subscribe
  • Careers
  • Contact Us

PCORI

Patient-Centered Outcomes Research Institute

Search form

  • About Us
    Close mega-menu

    About Us

    • Our Programs
    • Governance
    • Financials and Reports
    • Procurement Opportunities
    • Our Staff
    • Our Vision & Mission
    • Contact Us

    Fact Sheets: Learn More About PCORI

    Download fact sheets about out work, the research we fund, and our programs and initiatives.

    Find It Fast

    Browse through an alphabetical list of frequently accessed and searched terms for information and resources.

    Subscribe to PCORI Email Alerts

    Sign up for weekly emails to stay current on the latest results of our funded projects, and more.

  • Research & Results
    Close mega-menu

    Research & Results

    • Explore Our Portfolio
    • Evaluating Our Work
    • Research Results Highlights
    • Putting Evidence to Work
    • Peer Review
    • Evidence Synthesis
    • About Our Research

    Evidence Updates from PCORI-Funded Studies

    These updates capture highlights of findings from systematic reviews and our funded research studies.

    Journal Articles About Our Funded Research

    Browse through a collection of journal publications that provides insights into PCORI-funded work.

    Explore Our Portfolio of Funded Projects

    Find out about projects based on the health conditions they focus on, the state they are in, and if they have results.

  • Topics
    Close mega-menu

    Topics

    • Addressing Disparities
    • Arthritis
    • Asthma
    • Cancer
    • Cardiovascular Disease
    • Children's Health
    • Community Health Workers
    • COVID-19
    • Dementia and Cognitive Impairment
    • Diabetes
    • Intellectual and/or Developmental Disabilities
    • Kidney Disease
    • Maternal Morbidity and Mortality
    • Medicaid
    • Men's Health
    • Mental and Behavioral Health
    • Minority Mental Health
    • Multiple Chronic Conditions
    • Multiple Sclerosis
    • Obesity
    • Older Adults' Health
    • Pain Care and Opioids
    • Rare Diseases
    • Rural Health
    • Shared Decision Making
    • Telehealth
    • Transitional Care
    • Veterans Health
    • Women's Health

    Featured Topic: Women's Health

    Learn more about the projects we support on conditions that specifically or more often affect women.

  • Engagement
    Close mega-menu

    Engagement

    • The Value of Engagement
    • Engagement in Health Research Literature Explorer
    • Influencing the Culture of Research
    • Engagement Awards
    • Engagement Resources
    • Engage with Us

    Engagement Tools and Resources for Research

    This searchable peer-to-peer repository includes resources that can inform future work in patient-centered outcomes research.

    Engagement Awards

    Learn about our Engagement Awards program and view the announcements of all our open funding opportunities.

    Research Fundamentals: A New On-Demand Training

    It enables those new to health research or patient-centered research to learn more about the research process.

  • Funding Opportunities
    Close mega-menu

    Funding Opportunities

    • What & Who We Fund
    • What You Need to Know to Apply
    • Applicant Training
    • Merit Review
    • Awardee Resources
    • Help Center

    PCORI Funding Opportunities

    View and learn about the newly opened funding announcements and the upcoming PFAs in 2021.

    Tips for Submitting a Responsive LOI

    Find out what PCORI looks for in a letter of intent (LOI) along with other helpful tips.

    PCORI Awardee Resources

    These resources can help awardees in complying with the terms and conditions of their contract.

  • Meetings & Events
    Close mega-menu

    Meetings & Events

    • Upcoming
    • Past Events

    PCORI 2021 and Beyond

    During this webinar, PCORI leaders shared ways to get involved in PCOR, improvements to our funding opportunities, and more.

    2020 PCORI Annual Meeting

    Watch recordings of sessions and view titles and descriptions of posters presented at the virtual meeting.

    Board Approves Future PFA Topics at April Meeting

    The more than a dozen high-priority research topics will be considered for PCORI Funding Announcements (PFAs) that will be released this fall and in 2022.

You are here

  • Research & Results
  • Explore Our Portfolio
  • Comparing Three Ways to Help Patients...

Comparing Three Ways to Help Patients Manage Multiple Chronic Conditions

Sign Up for Updates to This Study  

Project Summary  

This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

In the United States, about 25 percent of adults have two or more chronic health conditions, such as high blood pressure, diabetes, and depression. Managing multiple chronic conditions can be hard. Many patients have frequent visits with different doctors and take multiple medicines. Patients with multiple chronic conditions are also more likely to need help with everyday tasks, spend time in the hospital, or die at an earlier age compared with patients who do not have these complex conditions.

Healthcare systems offer help for patients with multiple conditions, such as nurse support in the home or technology to help patients track medicine use. But researchers don’t know which types of help work best for which patients.

In this study, the research team is comparing three ways to help patients who have two or more chronic conditions manage their health and health care after a hospital stay. In the first, called High-Touch, care managers give intensive, in-person support in patients’ homes and communities. The second, called High-Tech, helps patients manage their health and health care using technology. It includes virtual visits with a care manager. The third option is usual care, where care managers carry out routine discharge planning to help patients transition home after a hospital stay. Patients in the usual care group also have access to community-based services.

Who can this research help?

Healthcare systems can use results from this study when planning how to help patients manage multiple chronic conditions after a hospital stay.

What is the research team doing?

The research team is recruiting 1,927 patients with multiple chronic conditions. To be in the study, patients must be eligible for Medicaid and have had a hospital visit in the past 30 days. The team is assigning patients by chance to receive either High-Touch, High-Tech, or usual care alone.

Patients in all three groups receive usual care. Usual care consists of help returning home after a hospital stay. This help could include an in-person meeting to plan appointments, an easy-to-read discharge plan, and information to help caregivers support patients.

After getting usual care, patients in the High-Touch and High-Tech groups receive additional services for four months. Patients in the High-Touch group receive in-person support and resources from a nurse or social worker in the community. In the High-Tech group, patients use mobile devices, technology applications, and the internet to manage their health care and communicate with their care manager. Patients receive automatic reminders about appointments or when to take medicine.

The research team is surveying patients at the start of the study and again every three months for one year. Surveys ask patients how confident they feel about managing and improving their health. Also, surveys ask about patients’ physical function, quality of life, and satisfaction with care. The research team is looking at insurance claims data to learn about patients’ healthcare use and any gaps in care.

Patients, patient advocates, providers, health insurers, community leaders, and policy makers give feedback on the study. A patient serves as co-investigator.

Research methods at a glance

Design Elements Description
Design Randomized controlled trial
Population 1,927 adults ages 21 and older living in Pennsylvania who qualify for Medicaid or who are dual (Medicare-Medicaid) eligible; have been discharged from the hospital within 30 days; and who have multiple comorbidities, polypharmacy, and/or risk of high future healthcare utilization
Interventions/
Comparators
  • High-Touch care strategy
  • High-Tech care strategy
  • ​Usual care strategy
Outcomes

Primary: patient activation, health status, hospital readmissions

Secondary: functional status; quality of life; care satisfaction; emergency care use; engagement in primary, specialty, and mental health care; gaps in care

Timeframe 1-year follow-up for primary outcomes

Related Articles

JMIR mHealth and uHealth

Addressing Implementation Challenges to Digital Care Delivery for Adults With Multiple Chronic Conditions: Stakeholder Feedback in a Randomized Controlled Trial

Project Details

Principal Investigator
James M. Schuster, MD, MBA
Project Status
In progress; Recruiting
Project Title
Leveraging Integrated Models of Care to Improve Patient-Centered Outcomes for Publicly-Insured Adults with Complex Health Care Needs
Board Approval Date
September 2017
Project End Date
January 2023
Organization
UPMC Center for High-Value Health Care
Year Awarded
2017
State
Pennsylvania
Project Type
Research Project
Health Conditions  
Cardiovascular Diseases
Hypertension
Mental/Behavioral Health
Addiction/Substance Abuse
Serious Mental Illness
Depression
Nutritional and Metabolic Disorders
Diabetes
Respiratory Diseases
Chronic Obstructive Pulmonary Disease
Multiple/Comorbid Chronic Conditions
Intervention Strategies
Behavioral Interventions
Care Coordination
Other Health Services Interventions
Technology Interventions
Telemedicine
Training and Education Interventions
Populations
Racial/Ethnic Minorities
Low Income
Older Adults
Individuals with Multiple Chronic/co-morbid Conditions
Funding Announcement
Improving Healthcare Systems
Project Budget
$3,790,561
Study Registration Information
HSRP20181594
NCT03451630
Page Last Updated: 
February 20, 2020

Research & Results

  • Explore Our Portfolio
  • Evaluating Our Work
  • Research Results Highlights
  • Putting Evidence to Work
  • Peer Review
  • Evidence Synthesis
  • About Our Research

About Us

  • Our Programs
  • Governance
  • Financials and Reports
  • Procurement Opportunities
  • Our Staff
  • Our Vision & Mission
  • Contact Us

Research & Results

  • Explore Our Portfolio
  • Evaluating Our Work
  • Research Results Highlights
  • Putting Evidence to Work
  • Peer Review
  • Evidence Synthesis
  • About Our Research

Engagement

  • The Value of Engagement
  • Engagement in Health Research Literature Explorer
  • Influencing the Culture of Research
  • Engagement Awards
  • Engagement Resources
  • Engage with Us

Funding Opportunities

  • What & Who We Fund
  • What You Need to Know to Apply
  • Applicant Training
  • Merit Review
  • Awardee Resources
  • Help Center

Meetings & Events

April 27
Priorities on the Health Horizon: Informing PCORI's Strategic Plan (Webinar #2)
May 6
Advisory Panel on Healthcare Delivery and Disparities Research Spring 2021 Meeting
May 10
Cycle 2 2021 Nonsurgical Options for Women with Urinary Incontinence -- Applicant Town Hall

PCORI

Footer contact address

Patient-Centered Outcomes
Research Institute

1828 L Street, NW, Suite 900
Washington, DC 20036
Phone: (202) 827-7700 | Fax: (202) 355-9558
info@pcori.org

Subscribe to Newsletter

Twitter Facebook LinkedIn Vimeo

© 2011-2021 Patient-Centered Outcomes Research Institute. All Rights Reserved.

Privacy Policy | Terms of Use | Trademark Usage Guidelines | Credits | Help Center