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Care Coordination for Patients with Multiple Chronic Conditions

NOMINATED TOPIC | May 25, 2022

1. What is the decision or change (e.g. clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

Specific strategies for care coordination in primary care and they types of patients who are most likely to benefit from those strategies.

2. Why are you struggling with this issue?

AHRQ sponsored systematic reviews of care coordination for patients with multiple chronic conditions in 2007 and 2014 which found that it is probably effective for some conditions but they were unable to identify any specific strategies that work best (e.g., coordinator background and characteristics, in person or phone, frequency and location of contacts, relationship between coordinator and clinicians, focus on individual vs. the family, assistance with non-medical social needs). Those reports also didn't identify whether there are specific patient characteristic s, including home and family context, that are more likely to benefit. Primary care systems want to know these answers so they can more efficiently provide these services, since for the most part they are not covered by insurance. An update on the previous summaries by AHRQ is needed.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

I want to help care systems learn how to provide this service in a way that is likely to be effective and to identify measures of those strategies for public reporting so patients and clinicians can learn who in their region is doing care coordination in the most effective ways.

4. When do you need the evidence report?

Sat, 07/01/2023

5. What will you do with the evidence report?

We will compare it with what we learn from a large observational study of care coordination and report it to care systems for their use.

Optional Information About You

What is your role or perspective? Researcher and Care system leader

May we contact you if we have questions about your nomination? Yes

Page last reviewed May 2022
Page originally created May 2022

Internet Citation: Care Coordination for Patients with Multiple Chronic Conditions. Content last reviewed May 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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