Improving the Management of Multiple Chronic Conditions with mPROVE (California)

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As the US population ages, the number of patients with multiple chronic conditions (MCCs) treated in primary care settings is increasing. Defined as having two or more chronic conditions, patients with MCC account for 71 percent of all US healthcare costs. The personal behaviors of patients, such as poor nutrition, lack of exercise, and substance use, may cause and further influence these chronic conditions. The patient’s ability to manage these conditions and their personal behaviors is crucial to their care. However, management of these conditions is often complicated by complex medication regimes, unclear care goals, and differences in patient and provider expectations.

Recording patient-reported outcomes (PROs) in real time between visits, versus by patient recall during visits, allows patients to monitor and self-manage their health and capture a more comprehensive picture of their health status and overall health experience. Because of this increased understanding of the patient’s experience, PROs allow patients and providers to co-manage MCC and engage in meaningful shared clinical decision making. Despite the importance of this clinical information, PRO use in primary care is limited by challenges in PRO collection, patient engagement, and clinical workflow integration.

The Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE) project aims to improve MCC outcomes by engaging a diverse population of patients in self-monitoring, offering PRO feedback, and improving patient self-management while informing providers of patients' health experiences and enabling patient-centered shared clinical decision making.

The specific aims of the research are as follows:

  1. Develop the mPROVE system in multiple languages for patient self-care and shared decision making. 
  2. Integrate mPROVE into the University of California San Francisco’s (UCSF) electronic health record (EHR) and into the clinical workflow of three internal medicine clinics. 
  3. Study the effectiveness of mPROVE in a multilingual primary care population of 120 internal medicine patients with MCC. 

The mPROVE project will demonstrate an original, replicable, accessible, and effective information technology and implementation strategy for bringing PROs to settings caring for diverse patients with MCC. Researchers will test patient-facing iOS and Android apps collecting information using traditional-format PRO surveys and novel visual PROs. A provider-facing dashboard will be developed and tested for provider actions and shared decision making. Once mPROVE is developed, tested, and integrated into UCSF’s EHR, workflows and policies for patient self-care and for shared decision making will be optimized. Finally, researchers will evaluate quality of care and implementation outcomes, and identify and address barriers and facilitators to implementation.

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