Chronic Care Management Model Translation to Multimorbid Aging Adults at FQHCs

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DESCRIPTION (provided by applicant): Despite high chronic care costs, patient care satisfaction, education, activation and outcomes are sub-optimal. Translational research to test innovative models that will empower high risk patients to manage chronic conditions in collaboration with their health homes while improving care outcomes is critically needed because of the growing prevalence of aging adults with multiple chronic conditions (i.e., multimorbidity), and the fiscal urgency for higher care quality without increased costs. The main objective of this application is to translate the Chronic Care Intervention (CCI) to aging adults with multimorbidity that have a high baseline rate of acute care utilization. To this end, the following specific aims will be achieved: 1) Evaluate the impact of the Chronic Care Intervention (CCI) on health activation among aging adults with multimorbidity and high baseline acute care use who have a Federally Qualified Health Center (FQHC) home; 2) Evaluate the impact of the CCI on acute care utilization among aging adults with multimorbidity and high baseline acute care use who have a FQHC home; and 3) Evaluate the cost-effectiveness of the CCI among aging adults with multimorbidity and high baseline acute care use who have a FQHC home. The CCI will be tested using a randomized, single- blind clinical trial design. Study entry criteria include FQHC home patients over 45 years of age (n = 300) who live in the community and have at least two chronic conditions. After IRB-approved written informed consent, participants will be placed into one of the two groups using a randomization software program that will stratify each participant across potential confounders. The intervention will be implemented by a RN and Social Worker team to provide intervention-arm participants with self-management support and care coordination such that participants are engaged as partners with their health team. Attention control intervention will be implemented by a Social Services Paraprofessional Aide who will provide control participants with information about available community resources for assistance in the home if they self-identify a need for such support. Participants and/or famil members/caregivers could then contact the community resource if they so desired. All participant will be assessed on pertinent outcomes (health activation scores, self-rated health status, and health-related quality of life) at baseline, 3, 6, 9, and 12 months. Acute care utilization data will be assessed at 3, 6, 9 and 12 months. The primary outcome for Specific Aim 1 will be participant activation stage. The main outcomes for Specific Aim 2 will be days to first ED visit or hospitalization and total number of ED visits and hospitalizations. The outcome for Specific Aim 3 will be health-related quality of life. To evaluate the aims, random-effects regression techniques will be performed to identify group differences on 1) patient activation over time, 2) ED visits and rehospitalizations, and 3) health-related quality of life over time. Th expected outcomes of the experimental intervention are that participant activation, health status ratings, and health-related quality of life will increase and that ED visits, hospital admissions, and costs will be reduced. This contribution is significant because it will advance knowledge about community partnerships and best practices to enhance the ability of health homes to provide patient-centered team-based care in a manner that engages activated and informed patients and results in more effective use of health care resources.