This study tests an innovative model for including primary care clinicians in systems to connect patients with multiple chronic conditions to needed community resources.
Study Overview
Problem: Medical care to manage multiple chronic conditions (MCC) is unlikely to be effective for patients who are struggling to meet their basic needs, such as having stable housing and enough to eat.
Main Objective: To examine how primary care clinicians can participate in new models for connecting patients with needed community services, and measure whether doing so improves patient outcomes.
Approach: In this clinician-level randomized controlled trial, 60 clinicians from the Virginia Ambulatory Care Outcomes Research Network (ACORN) were randomized to provide either usual care (the control group) or enhanced care planning with clinical-community linkage support (the intervention group) for 600 patients with uncontrolled MCC. In the intervention group, patients were first screened for health behavior, mental health, and social needs using an enhanced care planning tool. Then, clinical navigators helped patients prioritize their needs and create care plans to help guide the care team. Next, clinical navigators and community health workers worked to connect patients with needed resources in the community. Six months and two years after enrollment, the research team assessed MCC health outcomes and patient-reported physical health, mental health, and social wellbeing outcomes.
The research team also conducted medical record reviews, patient surveys, field observations, and semi-structured interviews with patients, clinicians, and community stakeholders to understand how contextual influences impacted the implementation and effectiveness of the intervention.
Results: The research team has learned that patient navigation services do not require a large time commitment or intensive training. However, due to current demands on primary care teams, most practices require additional staff or resources to be able to provide these services.1 Patients report being less comfortable discussing social needs that are not health-related with their primary care team, such as finances, housing, and transportation. Yet, they are willing to discuss their needs when a strong relationship with the clinician already exists, there is adequate time provided for this discussion, and the practice ensures referrals to helpful community services.2
Additional results from this study are forthcoming. Publications from this grant will be posted here.
Primary Care Relevance
This study helps to inform efforts to include primary care clinicians in the growing number of Accountable Health Care-like systems as a strategy to address mental health and social needs.
AHRQ Primary Care Priority Area
Research to improve primary care, including regarding quality, access and affordability, the workforce, care delivery models, financing, digital healthcare, person-centeredness, and health equity.
Notes
1. Hinesley JLG, Brooks EM, O'Loughlin K, Webel B, Britz J, Kashiri PL, Scheer J, Richards A, Lavallee M, Sabo RT, Huebschmann AG, Krist AH. Feasibility of Patient Navigation for Care Planning in Primary Care J Prim Care Community Health 2022 Jan-Dec;13:21501319221134754. doi: 10.1177/21501319221134754. PMID: 36348571; PMCID: PMC9647277.
2. O'Loughlin K, Shadowen HM, Haley AD, Gilbert J, Lail Kashiri P, Webel B, Huebschmann AG, Krist AH. Patient Preferences for Discussing and Acting on Health-Related Needs in Primary Care. J Prim Care Community Health 2022 Jan-Dec; 13:21501319221115946. doi: 10.1177/21501319221115946. PMID: 35920033; PMCID: PMC9358340
