Chronic Care Management for Adults at FQHCs

Summary

With a growing aging population, the number of persons with chronic conditions continues to escalate and challenges related to chronic care quality, effectiveness and cost remain unresolved.Federally Qualified Health Centers (FQHC) have experienced increasing numbers of patient visits for chronic conditions, and FQHC patients are more likely to have serious chronic conditions when compared to patients being cared for by non-FQHC providers.

The Chronic Care Intervention (CCI) combines home visiting with health activation coaching and has resulted in improved health status and reduced expenditures (Preliminary Studies). Implementing the CCI for aging adults with multimorbidity (2 or more chronic conditions) and high baseline acute care utilization, allows us to test and expand the efficacy, external validity and cost effectiveness of the proposed intervention model. The investigators seek to improve patients' and FQHCs' abilities to effectively manage chronic conditions and reduce acute care use. This contribution is significant because it potentially extends our knowledge about effective community partnerships and best practices that can enhance the effectiveness of health homes in providing patient-centered team-based care for patients with multimorbidity and high baseline health care utilization.

Conditions

• Any Condition in N73.0 Specified as Chronic

Interventions

OTHER

Active self-management intervention

Participants will set health goals at baseline. They will then receive, at minimum, a visit or a phone call to assess how progress and coaching toward meeting goals on a monthly basis from a nurse and/or social worker. The frequency and exact activities associated with the intervention are dependent on each participant's unique health goals.

OTHER

Attention control phone calls

Participants will be called by a social service aide at 2, 4, 6, 8, 10, and 12 months.

Sponsors & Collaborators

• Community Health Association of Spokane

  collaborator UNKNOWN

• Aging and Long Term Care of Eastern Washington

  collaborator UNKNOWN

• Washington State University

  lead OTHER

Principal Investigators

• Cynthia Corbett, Ph.D. · Washington State University College of Nursing

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

SINGLE

Model

PARALLEL

Eligibility

Min Age

45 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2013-10-31

Primary Completion

2017-06-30

Completion

2017-06-30

Countries

• United States

Study Locations