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 |
|
| 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 |
 |
1-year follow-up for primary outcomes |
Project Details
Care Coordination
Other Health Services Interventions
Technology Interventions
Telemedicine
Training and Education Interventions
Low Income
Older Adults
Individuals with Multiple Chronic/co-morbid Conditions