This study will use advanced analytics to identify patients with multiple chronic conditions and socially determined barriers to care, and then develop and test an EHR-based dashboard to help clinical teams ensure these patients receive high-quality primary care.
What is the research about?
People living with multiple chronic conditions (MCC) often experience barriers to receiving the high-quality, evidence-based primary care they need due to the various social, behavioral, and economic factors they face. For this project, the research team is using advanced analytics to identify which patients with MCC are at highest risk for facing socially determined barriers to care. The team is then developing an electronic health record (EHR) based dashboard that can be used by clinical teams to prioritize their most vulnerable MCC patients and help manage their care.
The research team will evaluate the use of this dashboard in three Kaiser Permanente organizations providing care in lower income communities: Richmond, CA; Rainier Valley, WA; and Aurora, CO.
The team will use transparent analytics and design the dashboard in such a way that it can be adapted and used in different clinical settings.
Results from this study are forthcoming. Current and future publications from this grant will be posted here.
Primary Care Relevance
The dashboard created through this grant will be able to be adapted by various primary care health systems to reduce barriers to care for patients who are both socially and medically complex.
AHRQ Primary Care Priority Area
Research on management of clinical areas unique to primary care, such as multiple chronic conditions, preventive care, undifferentiated syndromes, or behavioral and mental healthcare that is integrated within primary care.
