Advancing Patient-Centered Care for People Living With Multiple Chronic Conditions
AHRQ Vision
AHRQ envisions a sustainable healthcare system that delivers high-value, coordinated, integrated patient-centered care, based in primary care, that will optimize individual and population health by preventing and effectively managing multiple chronic conditions.
The Challenge
Although prevalence varies with definition, MCC is the most common chronic condition seen in clinical practice. Regardless of definition, MCCs are common, costly, and place a high burden on individuals, their caregivers, clinicians, healthcare teams, and health systems alike.
- One in three American adults, four in five Medicare beneficiaries, and a growing number of children have MCC.
- People living with MCC (PLWMCC) account for a disproportionate share of healthcare utilization and costs, 64% of all clinician visits, 70% of all inpatient stays, 83% of all prescriptions, 71% of all healthcare spending, and 93% of Medicare spending.
- Almost half of PLWMCC have functional impairments.
- Nearly all readmissions among Medicare beneficiaries occur among those with MCC.
- The prevalence of MCC is greater among low-income individuals and racial/ethnic minorities, who develop MCC at earlier ages.
- The prevalence of MCC will grow with our aging population.
- The need to improve the care of people living with MCC has been recognized nationally and internationally.
Above is one section of an infographic about the importance of investing in care for people with multiple chronic conditions. Select for the full infographic (PDF, 6.5 MB). (Select for an easily printable version [PDF, 12.5 MB].)
Our fragmented, disease-focused healthcare system is ill-designed to meet the needs of this growing population: Addressing the needs of people living with MCC is especially challenging due to the mismatch between the disease-specific organization and delivery of care and people's individualized medical needs, which requires a level of care coordination among clinicians and care settings. To better understand the challenges and impacts of navigating our fragmented healthcare system, view a short animated video about "A Day in the Life" of Mae, a woman living with multiple chronic conditions.
In a 2019 blog post, Learning While Caring: Advancing Patient-Centered Care for People With Multiple Chronic Conditions, AHRQ leadership further describes these challenges and the steps AHRQ is taking to help achieve its vision for care transformation for PLWMCC. One important recent step in framing the Agency's path to achieving its vision was development and publication in 2018 of the Care-and-Learn Model, developed by AHRQ researchers to help identify areas of unmet need and prioritize research questions with the most value for advancing the care of people with MCC. The Care-and-Learn Model starts by placing the patient at the center of care. It encourages learning about how best to care for patients by closely evaluating how well patients are doing and identifying which of their needs are not being met.
Seeking Solutions: Identifying and Filling Critical Research Gaps
2020 Summit on Transforming Care for People Living with MCC
In November 2020, AHRQ hosted a Research Summit on Transforming Care for PLWMCC to seek broad expert and stakeholder input on development of a research agenda to ensure that future AHRQ investments are strategically targeted for greatest impact. View these materials to learn more about this exciting 2-day event, or visit the Summit webpage:
- Summit Agenda containing links to slides and premeeting videos and other materials.
- Summit Proceedings containing links to slides and premeeting videos and other materials.
- Summit Participant Bios.
In a 2021 blog post, AHRQ Unveils Research Agenda to Transform Care for People With Multiple Chronic Conditions, Dr. Arlene Bierman describes the crisis the Nation is facing with the high and rising prevalence of MCC among people of all ages, and AHRQ's year-journey of gathering diverse views about the research that is needed to help achieve its vision of a transformed care delivery system that effectively meets the needs of people at risk for or living with MCC.
AHRQ-Sponsored Health Services Research Special Supplement: The Science of Care for People With Multiple Chronic Conditions
The Fall 2021 special issue of Health Services Research grew out of AHRQ's 2020 Research Summit and features an AHRQ Research Agenda for Transforming Care for People With Multiple Chronic Conditions, shaped by the invaluable wisdom and input of the Summit participants.
The issue also contains the following three evidence reviews commissioned by AHRQ for the Summit, as well as additional papers submitted in response to an open call:
- "Emerging Models of Care for Individuals With Multiple Chronic Conditions," by Elisabeth Bayliss and Lucy Savitz.
- "Health Information Technology to Improve Care for People With Multiple Chronic Conditions," by Lipika Samal and David Dorr.
- "A Scoping Review of Person and Family Engagement in the Context of Multiple Chronic Conditions," by Jennifer Wolfe and Judith Vick.
Finally, a commentary in the HSR Special Supplement by Victor Montori emphasizes the critical role of primary care in addressing the needs of people living with MCC and the pressing need for health services research to provide the evidence to optimize their care.
"Patients are often left to integrate and coordinate visits, tests, and treatments across siloed specialist services, to make sense of disparate information and recommendations, to complete administrative and medical errands, to figure out what to pay and who pays for what, and to take treatments and implement recommended behaviors with high fidelity."
—Victor Montori, M.D., M.Sc., Mayo Clinic
AHRQ-Funded MCC Research
Select to learn more about AHRQ-funded resources and research for improving the care of PLWMCC, and to view AHRQ Funding Opportunities for new MCC-related research.
