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? 

Poorly managed chronic conditions can lead to disability, unplanned hospital visits, and decreased quality of life. But managing multiple chronic conditions can be hard. Many patients take several medicines each day and have many doctor’s appointments. Patients need help figuring out how to manage their health conditions.

In this study, the research team is adding health coaches to patients’ healthcare teams to help patients set life and health goals and manage their chronic conditions. The team wants to know how well medical teams with a health coach help patients manage their conditions and avoid unplanned hospital visits compared with medical teams that don’t have a health coach.

Who can this research help?

Primary care practices may use these results when considering ways to help patients manage multiple chronic conditions.

What is the research team doing?

The research team is working with 16 Federally Qualified Health Centers, or FQHCs, in New York City and Chicago. These health centers serve mostly black and Latino patients with low incomes. The health centers are Patient-Centered Medical Homes, or PCMHs. In PCMHs, center staff get to know each patient and work to make sure they get the right care at the right time.

With the help of health center staff, the research team is enrolling 1,920 patients with multiple chronic conditions to take part in the study. The team is then assigning the health centers by chance to provide either regular PCMH care or PCMH care with a health coach. Regular PCMH care includes team-based preventive, wellness, acute, and chronic care as needed.

The health coach helps patients identify what is important to them, set goals, and choose self-care activities to help them reach their goals. Coaches are also leading a program that teaches patients to have a positive attitude about self-care. Finally, coaches help patients identify and access social services in their communities to address needs such as housing, employment, and transportation.

The research team is reviewing electronic health records and data on patients’ use of healthcare to see how often and why patients go to the emergency room, or ER, or hospital. The team is also asking patients about the effect of their illnesses on their life. The team is comparing outcomes in health centers with a health coach versus centers without a coach.

FQHCs, patients, clinicians, and clinical data networks help with every stage of this project. 

Research methods at a glance

Design Element Description
Design Cluster randomized controlled trial
Population 1,920 adult patients with multiple chronic conditions (Charlson comorbidity index ≥4) who are primary care patients at 16 FQHCs in New York City and Chicago
  • PCMH
  • PCMH with health coach

Primary: unplanned hospitalizations, disability

Secondary: ER visits, patient activation, patient education and self-management 

Timeframe 2-year follow-up for primary outcomes

Project Information

Jonathan Tobin, PhD
Clinical Directors Network
Preventing Tipping Points in High-Comorbidity Patients: A Lifeline from Health Coaches

Key Dates

August 2018
December 2024

Study Registration Information


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
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: January 24, 2024