Individuals with multiple chronic health conditions (MCCs) face challenges obtaining the healthcare services and resources they need for improving and maintaining their health. Integrated care improves the way information about a person’s health is shared with their care team and makes healthcare services and benefits more accessible. Beginning in 2018, the UPMC Center for High-Value Health Care collaborated with patients, caregivers, healthcare providers, researchers, and community members and organizations to study different ways of providing integrated care to people with MCCs. The study team wanted to know how these different ways of providing care impact the health of people living with MCCs.
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At UPMC we develop and test innovative ways for improving the quality and value of services provided to our patients and members. We understand the importance of providing integrated care options, and we wanted to learn more about which type of integrated care strategies work best for which members, and under what circumstances. The UPMC Health Plan Community Team collaborated with the UPMC Center for High-Value Health Care (CHVHC) to conduct the Integrated Care Study, which examined the impact of in-home and digitally-driven care management strategies for adults with multiple chronic conditions (MCCs) and Medicaid or Medicare/Medicaid primary insurance coverage. The CHVHC received funding from the Patient-Centered Outcomes Research Institute® (PCORI®) to support the evaluation of three different models for providing integrated care to a group of adults with MCCs who were recently discharged from an inpatient hospitalization.
How did we go about this important work?
We identified and reached out to the experts to guide our work.
You might ask, “Who are the experts who inform research?” PCORI explains it all here, but—in a nutshell—collaborators or partners in research can include anyone who has some expertise to add to a project and those who will be impacted by the results of a study or program.
We asked a variety of different experts for their input to guide the Integrated Care Study.
Patient and caregiver experts
Expertise can be professional or clinical skills and knowledge, or expertise can also be lived experience. The expertise provided by patients and caregivers makes them critical contributors to healthcare research, including our research study. Who knows the challenges faced by patients better than patients and the caregivers who support them? Healthcare providers, payers, and policy makers are also important collaborators in healthcare research. After all, these representatives can help shape decisions made around program expansion—ensuring that individuals who need care management the most can access it. A team of patient partners and a designated patient co-investigator worked alongside our research team to conduct patient interviews, review study materials, and interpret study results.
Community experts
Incorporating perspectives from collaborators, including individuals from the community, was a top priority in our research process because we wanted the patients who participated in the study to feel supported in their healthcare needs, and we wanted the care management staff to feel confident that they provided the very best, evidence-based care. An advisory board including representatives from community-based organizations provided key insights to our research, including how to make research participation more accessible to language-diverse patient-members or people with active substance use.
Care management and provider experts
For more than a decade the, UPMC Health Plan Community Care Management Team (Community Team), made up of social workers and nurse care managers, has been helping members of our community connect with services and learn how to manage multiple, complex health diagnoses at home. In 2018, the Community Team expanded their in-person services to include a way for patients to connect with their care manager remotely using a smartphone. During the Integrated Care Study, Community Team care managers implemented three different ways of delivering care management services for patient-members and supported the design of tools to help patient-member participants engage in care.
Interested in learning more about the Integrated Care Study? Our final study results will be published in late 2024 – until then, stay tuned for the next installment of our Integrated Care Study Blog Series.
Acknowledgement: Research reported in this blog series was partially funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (IHS-1609-36670). The views presented in this series are solely the responsibility of the author(s) and do not necessarily represent the views of the PCORI. PCORI is an independent, nonprofit organization authorized by federal law. Its mission is to fund research that will provide patients, their caregivers, and clinicians with the evidence-based information needed to make better-informed healthcare decisions. PCORI is committed to continually seeking input from a broad range of stakeholders to guide its work.