The research project will involve community health workers (CHWs) that will help participants to better understand their medical conditions and to responsibly manage their medical needs. The project will focus on participants with the greatest medical needs and those that have many different illnesses at the same time. CHWs will help guide participants in focusing on improving their knowledge and confidence to manage their health conditions and to improve their ability to understand how the healthcare system works. This will give participants the opportunity to take charge of their illnesses and possibly improve their health conditions over time. The CHWs will work together with participants to develop a health plan focused on their specific health needs.
18 years and older,
Able to speak and understand English
Have been told by a health care provider that they have two or more, chronic health conditions
Are classified as medically underserved or socially vulnerable person
None
Parallel
Intervention
BehavioralPersons assigned to the intervention group will receive strategic and intentional outreach and support from a CHW for 9 months to carry out the patient activation intervention. CHWs will work with persons in the intervention group to develop an Individual Patient Health Activation Plan (IHAP) that is informed by the participants individual health conditions. The IHAP will address priorities and barriers to obtaining optimal health, access to care, and adherence to a health care plan. CHWs will actively outreach the study participant a minimum of monthly to see how they are doing and to update or modify the IHAP, as needed. They will assist the participant in understanding medical advice, developing chronic disease self-management skills, accessing health care, making appointments, and addressing challenges arising from SDoH. CHWs will also utilize motivational interviewing to assist participants in making
Control Group
BehavioralPersons in the comparator group will receive support to complete an IHAP and access to an interactive community resource website. CHWs will remain available to comparator group participants in response to communicated need and interest but will not provide active outreach to participants.
Patient Activation Measure
Scored from 0 to 100 with higher scores denoting higher levels of patient activation, it measures participant knowledge, skills, and confidence to manage their own health and healthcare, navigate the healthcare system, and address social barriers that create challenges in their ability to achieve optimal health.
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Meharry Medical College
Lead sponsor
Baptist Memorial Health Care Corporation
Collaborator
National Heart, Lung, and Blood Institute (NHLBI)
Collaborator
Cherokee Health Systems
Collaborator
This trial is not recruiting at the moment. You can still explore other options:
