Recently Funded Projects: Leveraging Integrated Models of Care to Improve Patient-Centered Outcomes

Leveraging Integrated Models of Care to Improve Patient-Centered Outcomes for Publicly-Insured Adults with Complex Health Care Needs


Funder: Patient-Centered Outcomes Research Institute (PCORI)

Summary: Improving the health of individuals with multiple chronic conditions (MCC) is widely recognized as the U.S. public health challenge of the 21st century. Physical and behavioral health conditions take a large toll on those suffering from multiple diseases, including many who are publicly insured, and on their caregivers and society. While evidence-based integrated care models can improve outcomes for individuals with MCC, such models have not yet been widely implemented. Health care systems have innovative features that can be used to deploy these models; however, we do not yet know which of these features can best help to improve outcomes for individuals with MCC in general or for high-need subgroups in particular. As a result, patients lack information to make important decisions about their health and health care needs, and system-level decision makers face ongoing challenges in effectively and efficiently supporting those who have MCC.

Individuals with MCC want and need to play an active, informed role in managing their own health and health care. To do so, they require trusted information for deciding among available options that meet their preferences. Our study interventions were designed with input from adult patients with MCC. High-Touch uses a personalized service design, including nurses and social workers to provide intensive, in-person support/resources for patients in homes and communities. High-Tech uses web-based technology and information sharing capabilities to support individual health care choices and the use of telehealth, remote monitoring, and web-based health tools. Usual Care involves system-level staff to facilitate routine hospital discharge planning processes.

In response to the documented needs of adults with MCC and other key stakeholders, this real-world study will provide useful and actionable information about available options for supporting the health of this population. Building on existing efforts, we will enroll 1,662 adults with MCC at risk for repeated hospitalizations and assess the impact of three system-level care models (High-Touch, High-Tech, Usual Care) on patient-centered outcomes, namely patient activation in health care, health status, and subsequent rehospitalization. We will also determine which option works best for whom under what circumstances by gathering information directly from individuals with MCC through self-report questionnaires, health care use data, and interviews.

Patient partners and other stakeholders have and will continue to contribute to all phases of our work. Our collaborative study team includes a Patient Partner Co-Investigator, a work group of patient partners with lived experience similar to that of our study population, and an advisory board comprising a wide range of organizations and individuals who are deeply committed to this work. Their combined oversight and contributions to research-related activities will be carried out through following PCORI engagement principles.

Learn more about this project here.


UPMC Center for
High-Value Health Care

UPMC is a global health enterprise and one of the nation's largest integrated health care delivery and financing systems. The UPMC Center for High-Value Health Care translates the work of this unique payer-provider laboratory into evidence-based practice and policy change for improving health care quality and efficiency. Many Center activities are supported through grants and contracts and conducted in partnership with community organizations and government agencies.



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