We plan to identify and work with 1,920 predominantly low-income, black, and Latino adult patients who have several different chronic diseases (i.e., multiple comorbidity) that require them to have many medical appointments and take several medications every day. These people will be patients who receive their medical care at 12 Federally Qualified Health Centers (FQHCs)—six in New York City and six in Chicago—that serve predominantly low-income, black, and Latino patients. These FQHCs are Patient-Centered Medical Homes (PCMH), which means that they take responsibility for ensuring all necessary medical care is provided to their patients.
Patients who helped plan this study said they need more help in planning to do things that will help to keep them healthier, and that this type of help, which is not available from their primary care providers, may help them to better deal with the many social- and health-related challenges they face. Because patients often need help talking with their doctors and finding their way around the complicated medical system, we propose to add health coaches to the PCMH healthcare team. We want to understand if this addition will help patients better manage their sources of stress and if it enables patients to take better care of themselves to avoid repeat hospital visits.
This study will use a lottery to offer patients in half of the 12 FQHC clinical sites a new program, which will include, in addition to their regular medical care, a health coaching program that uses practices to help people set their own life goals. We theorize that this practice will motivate patients to engage in the proper activities and habits to manage their medical conditions. We believe this method may prevent the build-up of stress that often leads to or overwhelming situations for patients that may lead to unplanned hospitalization, increased emergency department visits, and increased disability. We will compare the results of patients in the 6 FQHCs that receive the program with the patients in the 6 FQHCs that do not receive the program, by comparing information about hospitalizations and emergency room visits from their electronic health records and medical claims, as well as by asking them to answer questions about their quality of life and disability.
The proposed study will have many partners in New York City and Chicago, including the PCORnet Clinical Data Research Networks (CDRNs)—NYC-CDRN and CAPriCORN—which have information from patients’ complete electronic health records, which will be used to help find patients for the study and to learn whether they have visited the hospital or emergency room during the study. In addition, patients will answer questions about their quality of life and disability to help us determine who the program benefits. Patient partners as well as other members of the healthcare system, including clinicians and those who provide health insurance, from New York City and Chicago will continue to be involved in every stage of the project and will help us share the results of the study with their communities when it is completed.
Other Health Services Interventions
Training and Education Interventions
Individuals with Multiple Chronic/co-morbid Conditions