Chronic Care Management for Adults at FQHCs

With a growing aging population, the number of persons with chronic conditions continues to
escalate and challenges related to chronic care quality, effectiveness and cost remain
unresolved.Federally Qualified Health Centers (FQHC) have experienced increasing numbers of
patient visits for chronic conditions, and FQHC patients are more likely to have serious
chronic conditions when compared to patients being cared for by non-FQHC providers.
Effectively managing multiple chronic conditions is particularly challenging for both
patients and health professionals, and costs of care rise as the number of co-morbid
conditions increases.FQHCs primarily serve patients with public insurance or those who are
uninsured. Consequently, simultaneously controlling costs and improving chronic care is a
critical issue for the FQHC system. Two approaches that have been used to improve health
status and reduce health care utilization are preventive home visiting and patient
activation counseling. Preventive home visiting allows for multidimensional assessment and
individualized, patient-centered care, and there is wide agreement that engaging patients to
be an active part of the care process is an essential element of the quality of care. This
concept is known as "health activation".

The Chronic Care Intervention (CCI) combines home visiting with health activation coaching
and has resulted in improved health status and reduced expenditures (Preliminary Studies).
However, the model has only been tested with persons with chronic conditions who were
receiving Medicaid in-home care services who did not have a single or consistent health
home. By implementing the CCI for aging adults with multimorbidity (2 or more chronic
conditions) and high baseline acute care utilization, the investigators will test and expand
the efficacy, external validity and cost effectiveness of the proposed intervention model.
The investigators seek to improve patients' and FQHCs' abilities to effectively manage
chronic conditions and reduce acute care use. This contribution is significant because it
potentially extends our knowledge about effective community partnerships and best practices
that can enhance the effectiveness of health homes in providing patient-centered team-based
care for patients with multimorbidity and high baseline health care utilization.
Specifically, this study will advance knowledge about self-management support and patient
activation. It will also create opportunities for further study by contributing knowledge
about the effects of the CCI on key outcomes such as patient-level health status and acute
care utilization. In addition, the clinical partnerships proposed in this translational
study give it a high level of external validity that will contribute to advancing knowledge
about effective care coordination and integration of community resource networks--a goal
that is even more critical as implementation of the Accountable Care Act begins.