Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial

Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and commu...

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Published in:Current controlled trials in cardiovascular medicine Vol. 21; no. 1; pp. 517 - 14
Main Authors: Krist, Alex H., O’Loughlin, Kristen, Woolf, Steven H., Sabo, Roy T., Hinesley, Jennifer, Kuzel, Anton J., Rybarczyk, Bruce D., Kashiri, Paulette Lail, Brooks, E. Marshall, Glasgow, Russel E., Huebschmann, Amy G., Liaw, Winston R.
Format: Journal Article
Language:English
Published: London BioMed Central 11.06.2020
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ISSN:1745-6215, 1745-6215
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Abstract Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems. Methods We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR) , to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. Discussion This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. Trial registration ClinicalTrials.gov: NCT03885401 . Registered on 19 September 2019.
AbstractList Abstract Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems. Methods We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. Discussion This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. Trial registration ClinicalTrials.gov: NCT03885401 . Registered on 19 September 2019.
Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.
Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems. Methods We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR) , to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. Discussion This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. Trial registration ClinicalTrials.gov: NCT03885401 . Registered on 19 September 2019.
Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.
BackgroundMany patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems.MethodsWe are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR.DiscussionThis study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.Trial registrationClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.
Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems.BACKGROUNDMany patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems.We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR.METHODSWe are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR.This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.DISCUSSIONThis study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.TRIAL REGISTRATIONClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.
Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. Methods We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. Discussion This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. Trial registration ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019. Keywords: Primary care, Health behaviors, Mental health, Social determinants of health, Health risk assessment, Goal setting, Health promotion
ArticleNumber 517
Audience Academic
Author Woolf, Steven H.
O’Loughlin, Kristen
Glasgow, Russel E.
Huebschmann, Amy G.
Krist, Alex H.
Liaw, Winston R.
Sabo, Roy T.
Hinesley, Jennifer
Kuzel, Anton J.
Rybarczyk, Bruce D.
Kashiri, Paulette Lail
Brooks, E. Marshall
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  fullname: Liaw, Winston R.
  organization: Department of Health Systems and Population Health Sciences, University of Houston College of Medicine
BackLink https://www.ncbi.nlm.nih.gov/pubmed/32527322$$D View this record in MEDLINE/PubMed
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Cites_doi 10.5888/pcd10.120172
10.1370/afm.1139
10.1001/jama.2012.8227
10.1016/S0140-6736(08)61690-6
10.1093/fampra/cmt039
10.1093/ije/dyu047
10.1001/jama.2016.14058
10.1001/archinte.167.16.1720
10.1016/S0140-6736(08)60269-X
10.1016/j.jad.2008.05.025
10.1037/0022-3514.51.6.1173
10.3122/jabfm.2018.03.170421
10.1186/1471-2458-13-1170
10.1146/annurev.publhealth.031308.100310
10.1016/S0140-6736(84)92337-7
10.1046/j.1525-1497.2001.016009606.x
10.1186/1748-5908-8-73
10.1001/archinte.166.10.1092
10.3399/bjgp09X453990
10.1001/jama.2016.15450
10.1176/appi.ps.201100317
10.1377/hlthaff.21.2.78
10.1210/jc.2004-0288
10.1001/archinte.158.16.1789
10.1136/amiajnl-2011-000576
10.7326/0003-4819-138-1-200301070-00008
10.2307/2626958
10.1370/afm.1643
10.1136/bjsm.2010.083469
10.7326/M16-0577
10.1377/hlthaff.20.6.64
10.1056/NEJMoa021423
10.1136/ebm.11.6.184
10.1016/0306-4603(82)90005-3
10.1056/NEJMp1512532
10.1097/JOM.0b013e31828349c9
10.1001/jama.1989.03430070055030
10.7326/M15-2023
10.1136/bmj.324.7347.1183
10.2105/AJPH.2005.084848
10.7326/M14-1796
10.1001/jama.291.10.1238
10.1097/01.MLR.0000093487.78664.3C
10.1370/afm.1717
10.1001/jama.1993.03510180077038
10.15585/mmwr.mm6544a2
10.1370/afm.1710
10.7326/0003-4819-155-7-201110040-00006
10.1001/jamainternmed.2016.7691
10.1371/journal.pmed.1000058
10.1001/jama.289.2.187
10.1001/jama.2015.18392
10.2307/3350391
10.1001/jama.2017.0332
10.1001/jama.2017.7171
10.1186/1471-2458-9-88
10.3122/jabfm.2018.03.170419
10.1001/jama.2013.284427
10.1370/afm.1260
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Issue 1
Keywords Social determinants of health
Health promotion
Goal setting
Mental health
Health behaviors
Health risk assessment
Primary care
Language English
License Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
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References 4463_CR2
4463_CR59
4463_CR5
DA Dillman (4463_CR67) 1999
HJ Chang (4463_CR14) 2009; 113
G Jain (4463_CR17) 2013; 55
HA Skinner (4463_CR80) 1982; 7
AG Renehan (4463_CR11) 2008; 371
4463_CR19
AH Krist (4463_CR56) 2014; 12
4463_CR18
K Bibbins-Domingo (4463_CR84) 2016; 164
EE Calle (4463_CR12) 2003; 348
N Krieger (4463_CR32) 2014; 43
PA Estabrooks (4463_CR69) 2012; 19
EH Wagner (4463_CR47) 1998; 1
K Kroenke (4463_CR74) 2003; 41
RL Spitzer (4463_CR77) 2006; 166
K Kroenke (4463_CR75) 2001; 16
B Arroll (4463_CR86) 2010; 8
RM Baron (4463_CR87) 1986; 51
RA Krueger (4463_CR89) 1997
RP Swinson (4463_CR76) 2006; 11
W Liaw (4463_CR58) 2018; 31
KR Fontaine (4463_CR7) 2003; 289
BF Miller (4463_CR52) 2016
SR Machlin (4463_CR3) 2013; 10
BF Crabtree (4463_CR94) 1999
A Donner (4463_CR96) 2000
CJ Stein (4463_CR6) 2004; 89
4463_CR25
A Peeters (4463_CR8) 2003; 138
R Stromberg (4463_CR13) 2013; 30
4463_CR65
WHO Commission on Social Determinants of Health, World Health Organization (4463_CR35) 2008
RP Bogers (4463_CR9) 2007; 167
BE Landon (4463_CR43) 2012; 308
DP Guh (4463_CR10) 2009; 9
J O’Neil (4463_CR64) 2000; Feb
M Heron (4463_CR4) 2016; 65
SA Berkowitz (4463_CR53) 2017; 177
AL Siu (4463_CR29) 2016; 315
DM Murray (4463_CR95) 1998
AL Siu (4463_CR26) 2015; 163
M Marmot (4463_CR36) 2008; 372
DC Grossman (4463_CR24) 2017; 318
4463_CR62
L Richards (4463_CR93) 2007
4463_CR61
4463_CR20
MB Miles (4463_CR91) 1994
4463_CR60
PA James (4463_CR83) 2014; 311
ST Tong (4463_CR57) 2018; 31
Institute of Medicine (U.S.), Board on Population Health and Public Health Practice (4463_CR82) 2015
NE Adler (4463_CR44) 2016; 316
EA Bayliss (4463_CR63) 2014; 12
D Dillman (4463_CR66) 1999
DE Alley (4463_CR45) 2016; 374
4463_CR34
ML LeFevre (4463_CR23) 2014; 161
MG Marmot (4463_CR37) 1984; 1
LF Berkman (4463_CR41) 2009; 30
ES Leblanc (4463_CR50) 2011; 155
JM McGinnis (4463_CR39) 2002; 21
EH Wagner (4463_CR48) 2001; 20
RA Krueger (4463_CR88) 2000
G Danaei (4463_CR31) 2009; 6
AL Stewart (4463_CR28) 1989; 262
K Bush (4463_CR78) 1998; 158
KJ Devers (4463_CR92) 1999; 34
AH Mokdad (4463_CR30) 2004; 291
4463_CR73
4463_CR72
AH Krist (4463_CR55) 2013; 8
EA O'Connor (4463_CR51) 2017; 317
SM Phillips (4463_CR54) 2014; 12
R Sallis (4463_CR70) 2011; 45
K Bibbins-Domingo (4463_CR85) 2016; 316
O Hammig (4463_CR33) 2013; 13
BG Link (4463_CR38) 1995; Spec No
P Edwards (4463_CR68) 2002; 324
A Jamal (4463_CR21) 2016; 65
A Beck (4463_CR16) 2011; 9
Institute of Medicine (U.S.), Board on Population Health and Public Health Practice (4463_CR81) 2014
K Zivin (4463_CR15) 2012; 63
MQ Patton (4463_CR90) 2001
JM McGinnis (4463_CR40) 1993; 270
VA Moyer (4463_CR27) 2013; 159
KA Bradley (4463_CR79) 1998; 22
BW Ward (4463_CR1) 2014; 11
EH Wagner (4463_CR49) 2001; 27
IT Heyworth (4463_CR71) 2009; 59
EH Wagner (4463_CR46) 1996; 74
D Kanny (4463_CR22) 2013; 62
SH Woolf (4463_CR42) 2007; 97
References_xml – volume: 10
  start-page: E63
  year: 2013
  ident: 4463_CR3
  publication-title: Prev Chronic Dis
  doi: 10.5888/pcd10.120172
– volume: 8
  start-page: 348
  issue: 4
  year: 2010
  ident: 4463_CR86
  publication-title: Ann Fam Med
  doi: 10.1370/afm.1139
– volume: 308
  start-page: 461
  issue: 5
  year: 2012
  ident: 4463_CR43
  publication-title: JAMA
  doi: 10.1001/jama.2012.8227
– ident: 4463_CR73
– volume: 372
  start-page: 1661
  issue: 9650
  year: 2008
  ident: 4463_CR36
  publication-title: Lancet
  doi: 10.1016/S0140-6736(08)61690-6
– ident: 4463_CR19
– ident: 4463_CR25
– volume: 30
  start-page: 514
  issue: 5
  year: 2013
  ident: 4463_CR13
  publication-title: Fam Pract
  doi: 10.1093/fampra/cmt039
– volume: 65
  start-page: 1
  issue: 5
  year: 2016
  ident: 4463_CR4
  publication-title: Natl Vital Stat Rep
– volume: Feb
  start-page: 46
  year: 2000
  ident: 4463_CR64
  publication-title: Educ Leadersh
– volume: 43
  start-page: 1294
  issue: 4
  year: 2014
  ident: 4463_CR32
  publication-title: Int J Epidemiol
  doi: 10.1093/ije/dyu047
– volume-title: Doing qualitative research
  year: 1999
  ident: 4463_CR94
– volume-title: Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report
  year: 2008
  ident: 4463_CR35
– volume-title: Mail and Internet surveys: the tailored design method
  year: 1999
  ident: 4463_CR67
– volume: 22
  start-page: 1842
  issue: 8
  year: 1998
  ident: 4463_CR79
  publication-title: Alcohol Clin Exp Res
– volume: 316
  start-page: 1641
  issue: 16
  year: 2016
  ident: 4463_CR44
  publication-title: JAMA
  doi: 10.1001/jama.2016.14058
– ident: 4463_CR60
– volume: 167
  start-page: 1720
  issue: 16
  year: 2007
  ident: 4463_CR9
  publication-title: Arch Intern Med
  doi: 10.1001/archinte.167.16.1720
– volume: 371
  start-page: 569
  issue: 9612
  year: 2008
  ident: 4463_CR11
  publication-title: Lancet
  doi: 10.1016/S0140-6736(08)60269-X
– volume: 113
  start-page: 255
  issue: 3
  year: 2009
  ident: 4463_CR14
  publication-title: J Affect Disord
  doi: 10.1016/j.jad.2008.05.025
– volume: 51
  start-page: 1173
  issue: 6
  year: 1986
  ident: 4463_CR87
  publication-title: J Pers Soc Psychol
  doi: 10.1037/0022-3514.51.6.1173
– volume: 31
  start-page: 342
  year: 2018
  ident: 4463_CR58
  publication-title: J Am Board Fam Med
  doi: 10.3122/jabfm.2018.03.170421
– volume-title: Focus group: a practical guide for applied research
  year: 2000
  ident: 4463_CR88
– volume: 13
  start-page: 1170
  year: 2013
  ident: 4463_CR33
  publication-title: BMC Public Health
  doi: 10.1186/1471-2458-13-1170
– volume: 30
  start-page: 27
  year: 2009
  ident: 4463_CR41
  publication-title: Annu Rev Public Health
  doi: 10.1146/annurev.publhealth.031308.100310
– volume: 1
  start-page: 1003
  issue: 8384
  year: 1984
  ident: 4463_CR37
  publication-title: Lancet
  doi: 10.1016/S0140-6736(84)92337-7
– volume: 16
  start-page: 606
  issue: 9
  year: 2001
  ident: 4463_CR75
  publication-title: J Gen Intern Med
  doi: 10.1046/j.1525-1497.2001.016009606.x
– volume: 8
  start-page: 73
  year: 2013
  ident: 4463_CR55
  publication-title: Implement Sci
  doi: 10.1186/1748-5908-8-73
– volume: 166
  start-page: 1092
  issue: 10
  year: 2006
  ident: 4463_CR77
  publication-title: Arch Intern Med
  doi: 10.1001/archinte.166.10.1092
– volume: 59
  start-page: e353
  issue: 568
  year: 2009
  ident: 4463_CR71
  publication-title: Br J Gen Pract
  doi: 10.3399/bjgp09X453990
– ident: 4463_CR20
– ident: 4463_CR72
– volume: 316
  start-page: 1997
  issue: 19
  year: 2016
  ident: 4463_CR85
  publication-title: JAMA
  doi: 10.1001/jama.2016.15450
– volume: 63
  start-page: 823
  issue: 8
  year: 2012
  ident: 4463_CR15
  publication-title: Psychiatr Serv
  doi: 10.1176/appi.ps.201100317
– volume: 62
  start-page: 77
  issue: 3
  year: 2013
  ident: 4463_CR22
  publication-title: MMWR Suppl
– volume: 159
  start-page: 210
  issue: 3
  year: 2013
  ident: 4463_CR27
  publication-title: Ann Intern Med
– volume: 34
  start-page: 1153
  issue: 5 Pt 2
  year: 1999
  ident: 4463_CR92
  publication-title: Health Serv Res
– volume: 21
  start-page: 78
  issue: 2
  year: 2002
  ident: 4463_CR39
  publication-title: Health Aff (Millwood)
  doi: 10.1377/hlthaff.21.2.78
– volume: 89
  start-page: 2522
  issue: 6
  year: 2004
  ident: 4463_CR6
  publication-title: J Clin Endocrinol Metab
  doi: 10.1210/jc.2004-0288
– volume: 158
  start-page: 1789
  issue: 16
  year: 1998
  ident: 4463_CR78
  publication-title: Arch Intern Med
  doi: 10.1001/archinte.158.16.1789
– volume: 11
  start-page: E62
  year: 2014
  ident: 4463_CR1
  publication-title: Prev Chronic Dis
– ident: 4463_CR59
– volume: 19
  start-page: 575
  issue: 4
  year: 2012
  ident: 4463_CR69
  publication-title: J Am Med Inform Assoc
  doi: 10.1136/amiajnl-2011-000576
– volume: 138
  start-page: 24
  issue: 1
  year: 2003
  ident: 4463_CR8
  publication-title: Ann Intern Med
  doi: 10.7326/0003-4819-138-1-200301070-00008
– ident: 4463_CR61
– volume: Spec No
  start-page: 80
  year: 1995
  ident: 4463_CR38
  publication-title: J Health Soci Behav
  doi: 10.2307/2626958
– volume: 12
  start-page: 260
  issue: 3
  year: 2014
  ident: 4463_CR63
  publication-title: Ann Fam Med
  doi: 10.1370/afm.1643
– volume: 45
  start-page: 473
  issue: 6
  year: 2011
  ident: 4463_CR70
  publication-title: Br J Sports Med
  doi: 10.1136/bjsm.2010.083469
– volume: 164
  start-page: 836
  issue: 12
  year: 2016
  ident: 4463_CR84
  publication-title: Ann Intern Med
  doi: 10.7326/M16-0577
– ident: 4463_CR34
– ident: 4463_CR2
– volume: 20
  start-page: 64
  issue: 6
  year: 2001
  ident: 4463_CR48
  publication-title: Health Aff (Millwood)
  doi: 10.1377/hlthaff.20.6.64
– ident: 4463_CR65
– volume: 348
  start-page: 1625
  issue: 17
  year: 2003
  ident: 4463_CR12
  publication-title: N Engl J Med
  doi: 10.1056/NEJMoa021423
– volume: 11
  start-page: 184
  issue: 6
  year: 2006
  ident: 4463_CR76
  publication-title: Evid Based Med
  doi: 10.1136/ebm.11.6.184
– volume: 7
  start-page: 363
  issue: 4
  year: 1982
  ident: 4463_CR80
  publication-title: Addict Behav
  doi: 10.1016/0306-4603(82)90005-3
– volume: 374
  start-page: 8
  issue: 1
  year: 2016
  ident: 4463_CR45
  publication-title: N Engl J Med
  doi: 10.1056/NEJMp1512532
– volume-title: Design and analysis of cluster randomization trials in health research
  year: 2000
  ident: 4463_CR96
– volume: 55
  start-page: 252
  issue: 3
  year: 2013
  ident: 4463_CR17
  publication-title: J Occup Environ Med
  doi: 10.1097/JOM.0b013e31828349c9
– volume: 262
  start-page: 907
  issue: 7
  year: 1989
  ident: 4463_CR28
  publication-title: JAMA
  doi: 10.1001/jama.1989.03430070055030
– volume: 163
  start-page: 622
  issue: 8
  year: 2015
  ident: 4463_CR26
  publication-title: Ann Intern Med
  doi: 10.7326/M15-2023
– volume-title: Mail and Internet surveys: the total design method
  year: 1999
  ident: 4463_CR66
– volume: 324
  start-page: 1183
  issue: 7347
  year: 2002
  ident: 4463_CR68
  publication-title: BMJ
  doi: 10.1136/bmj.324.7347.1183
– volume-title: README FIRST for a user’s guide to qualitative methods
  year: 2007
  ident: 4463_CR93
– volume: 97
  start-page: 679
  issue: 4
  year: 2007
  ident: 4463_CR42
  publication-title: Am J Public Health
  doi: 10.2105/AJPH.2005.084848
– volume: 161
  start-page: 587
  issue: 8
  year: 2014
  ident: 4463_CR23
  publication-title: Ann Intern Med
  doi: 10.7326/M14-1796
– volume: 291
  start-page: 1238
  issue: 10
  year: 2004
  ident: 4463_CR30
  publication-title: JAMA
  doi: 10.1001/jama.291.10.1238
– volume: 41
  start-page: 1284
  issue: 11
  year: 2003
  ident: 4463_CR74
  publication-title: Med Care
  doi: 10.1097/01.MLR.0000093487.78664.3C
– volume: 12
  start-page: 505
  issue: 6
  year: 2014
  ident: 4463_CR54
  publication-title: Ann Fam Med
  doi: 10.1370/afm.1717
– volume-title: Capturing social and behavioral domains in electronic health records: phase 1
  year: 2014
  ident: 4463_CR81
– volume: 270
  start-page: 2207
  issue: 18
  year: 1993
  ident: 4463_CR40
  publication-title: JAMA
  doi: 10.1001/jama.1993.03510180077038
– ident: 4463_CR62
– volume-title: Creating a culture of whole health: recommendations for integrating behavioral health and primary care
  year: 2016
  ident: 4463_CR52
– ident: 4463_CR5
– volume: 65
  start-page: 1205
  issue: 44
  year: 2016
  ident: 4463_CR21
  publication-title: MMWR Morb Mortal Wkly Rep
  doi: 10.15585/mmwr.mm6544a2
– volume: 12
  start-page: 525
  issue: 6
  year: 2014
  ident: 4463_CR56
  publication-title: Ann Fam Med
  doi: 10.1370/afm.1710
– volume: 155
  start-page: 434
  issue: 7
  year: 2011
  ident: 4463_CR50
  publication-title: Ann Intern Med
  doi: 10.7326/0003-4819-155-7-201110040-00006
– volume: 177
  start-page: 244
  issue: 2
  year: 2017
  ident: 4463_CR53
  publication-title: JAMA Intern Med
  doi: 10.1001/jamainternmed.2016.7691
– volume-title: Design and analysis of group-randomized trials
  year: 1998
  ident: 4463_CR95
– volume: 6
  start-page: e1000058
  issue: 4
  year: 2009
  ident: 4463_CR31
  publication-title: PLOS Med
  doi: 10.1371/journal.pmed.1000058
– volume-title: Analyzing and reporting focus groups results (Focus group kit, Vol #6)
  year: 1997
  ident: 4463_CR89
– ident: 4463_CR18
– volume: 289
  start-page: 187
  issue: 2
  year: 2003
  ident: 4463_CR7
  publication-title: JAMA
  doi: 10.1001/jama.289.2.187
– volume-title: Capturing social and behavioral domains and measures in electronic health records: phase 2
  year: 2015
  ident: 4463_CR82
– volume: 315
  start-page: 380
  issue: 4
  year: 2016
  ident: 4463_CR29
  publication-title: JAMA
  doi: 10.1001/jama.2015.18392
– volume: 74
  start-page: 511
  issue: 4
  year: 1996
  ident: 4463_CR46
  publication-title: Milbank Q
  doi: 10.2307/3350391
– volume: 317
  start-page: 2427
  issue: 23
  year: 2017
  ident: 4463_CR51
  publication-title: JAMA
  doi: 10.1001/jama.2017.0332
– volume: 27
  start-page: 63
  issue: 2
  year: 2001
  ident: 4463_CR49
  publication-title: Jt Comm J Qual Improv
– volume-title: Qualitative research and evaluation methods
  year: 2001
  ident: 4463_CR90
– volume: 318
  start-page: 167
  issue: 2
  year: 2017
  ident: 4463_CR24
  publication-title: JAMA
  doi: 10.1001/jama.2017.7171
– volume: 9
  start-page: 88
  year: 2009
  ident: 4463_CR10
  publication-title: BMC Public Health
  doi: 10.1186/1471-2458-9-88
– volume-title: Qualitative data analysis: an expanded sourcebook
  year: 1994
  ident: 4463_CR91
– volume: 1
  start-page: 2
  issue: 1
  year: 1998
  ident: 4463_CR47
  publication-title: Eff Clin Pract
– volume: 31
  start-page: 351
  year: 2018
  ident: 4463_CR57
  publication-title: J Am Board Fam Med
  doi: 10.3122/jabfm.2018.03.170419
– volume: 311
  start-page: 507
  issue: 5
  year: 2014
  ident: 4463_CR83
  publication-title: JAMA
  doi: 10.1001/jama.2013.284427
– volume: 9
  start-page: 305
  issue: 4
  year: 2011
  ident: 4463_CR16
  publication-title: Ann Fam Med
  doi: 10.1370/afm.1260
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Snippet Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social...
Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical...
Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social...
BackgroundMany patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social...
Abstract Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet...
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SubjectTerms Biomedicine
Cardiovascular disease
Chronic illnesses
Community health aides
Community health care
Community Mental Health Services - economics
Community Mental Health Services - organization & administration
Counseling
Diabetes
Electronic records
Emergency medical care
Exercise
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Multiple Chronic Conditions - psychology
Multiple Chronic Conditions - therapy
Nutrition research
Patient Care Planning - organization & administration
Patients
Physical fitness
Planning
Primary care
Primary care nursing
Primary Health Care - organization & administration
Public health
Quality of life
Randomized Controlled Trials as Topic
Risk Assessment
Social Determinants of Health
Statistics for Life Sciences
Study Protocol
Transportation services
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Title Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial
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