Improving the Management of Multiple Chronic Conditions with mPROVE

https://digital.ahrq.gov/ahrq-funded-projects/improving-management-multiple-chronic-conditions-mprove#nav-research-story A project team will develop, test, and evaluate mPROVE, a digital health tool that aims to advance care for patients with MCCs through improved patient-centered, shared clinical decision making. Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions https://digital.ahrq.gov/ahrq-funded-projects/implementation-electronic-care-plan-people-multiple-chronic-conditions Researchers found that e-care plan applications that use interoperability standards have the potential to improve care management and care coordination for people with MCCs across different healthcare settings. Care Transitions App for Patients with Multiple Chronic Conditions https://digital.ahrq.gov/ahrq-funded-projects/care-transitions-app-patients-multiple-chronic-conditions A patient-facing mobile health application aims to improve patient transitions between the hospital, home, and primary care clinic by better engaging patients and families in their healthcare. Using Smart Devices to Implement an Evidence-based eHealth System for Older Adults https://digital.ahrq.gov/ahrq-funded-projects/using-smart-devices-implement-evidence-based-ehealth-system-older-adults#nav-research-story A research team has developed a voice-controlled digital health tool to serve as an accessible and encouraging way for primary care providers to deliver healthcare self-management tools to older adults with MCCs. An Evaluation of the Spread and Scale of PatientToc™ from Primary Care to Community Pharmacy Practice for the Collection of Patient-Reported Outcomes https://digital.ahrq.gov/ahrq-funded-projects/evaluation-spread-and-scale-patienttoc-primary-care-community-pharmacy A digital health tool that provides pharmacists with PRO data on patients’ medication adherence allows them to inform counseling of patients in the pharmacy— potentially improving the management of chronic conditions. Implementing Personalized Cross-Sector Transitional Care Management to Promote Care Continuity, Reduce Low-Value Utilization, and Reduce the Burden of Treatment for High-Need, High-Cost Patient https://digital.ahrq.gov/ahrq-funded-projects/implementing-personalized-cross-sector-transitional-care-management-promote Using health information exchange to identify patients with MCCs, functional disabilities, and/or social needs during care transitions can facilitate cross-sector communication, improve care continuity, and reduce rehospitalizations and other acute care Real-Time Symptom Monitoring Using ePROs to Prevent Adverse Events During Care Transitions https://digital.ahrq.gov/ahrq-funded-projects/real-time-symptom-monitoring-using-epros-prevent-adverse-events-during-care-transitions Researchers will develop and validate a predictive model to reduce post-discharge adverse events for hospitalized patients with MCCs using relevant ePRO questionnaires and EHR-derived data.