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Bethesda, Maryland�June 2-3, 2022

�

2022

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No disclosures�No conflicts of interest

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Evaluating the Feasibility of Enhanced Care Planning for Primary Care Teams to Better Address Multiple Chronic Conditions

Jennifer Gilbert Hinesley PsyD, Jonathan Scheer, Kristen O’Loughlin, Jacqueline Britz MD MSPH, Paulette Lail Kashiri MPH, Ben Webel, Alicia Richards, Martin Lavallee, Roy Sabo PhD, Alex Krist MD MPH

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Overview

  • Five-year R01 funded by the Agency for Healthcare Research and Quality (AHRQ), award # 1R01HS02622-01A1
  • Intervention to test whether care planning (including patient navigation and access to community health worker / resources) helps patients to manage multiple chronic conditions
  • This presentation/analysis focuses on feasibility of patient navigation as part of care planning for primary care

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Multiple chronic conditions

Traditional medical care

Behavioral needs

Mental health needs

Social needs

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Approach

Patient navigator

Care planning tool

Community health worker

Linkage to community resource

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Population

12 practices

45 clinicians

87 intervention patients

109 control patients

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Methods

Navigator recruitment for practices and clinicians

Number of navigator phone contacts for patients

Length of contacts

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Practice as navigator

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The navigation stats

29 patients

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35 weeks of support

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8 minutes per session

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158 minutes total or 4.5 minutes per week

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Discussion

  • What does 4.5 mins per patient per week mean? How might these numbers impact peoples’ perception of care planning?
  • Patients really seem to value this service which, in reality, doesn’t require a great deal of time
  • Disconnect between what practices do and what they could do vs. patient perception of how helpful navigation is to them

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What’s next

Short-term navigation may have long-term benefits

Team-based care model not currently feasible for many practices

Need increased health system and community support to make model viable

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Thank you!�Now it’s Q&A time

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Please feel free to get in touch!

Ben Webel

benjamin.webel@vcuhealth.org