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

Project Information

Dan Swayze
UPMC Center for High-Value Health Care
$3,790,561
Leveraging Integrated Models of Care to Improve Patient-Centered Outcomes for Publicly-Insured Adults with Complex Health Care Needs

Key Dates

September 2017
August 2024
2017

Study Registration Information

Tags

Award Type
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Funding Opportunity Type
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: March 4, 2022