VCU researcher leads study aimed at improving care for people with chronic conditions

The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality has awarded a $2 million grant to the Virginia Commonwealth University School of Medicine Department of Family Medicine and Population Health to test a model of care that aims to better connect primary care clinicians with community resources and health system services.

People who struggle with multiple chronic conditions often also have unmet social needs, unhealthy behaviors and other mental health challenges, said Alex Krist, M.D., a professor of family medicine in the School of Medicine who will lead the research funded by the grant.

“While primary care providers do their best to address the root causes of multiple chronic conditions, few medical practices can undertake a systematic approach without broader health system and coordinated community support,” Krist said.

The new care paradigm is intended to improve on conventional models, helping primary care providers better address the root causes of poor health.

“A sea change is occurring in which health systems and communities increasingly recognize the need to address underlying issues that contribute to multiple chronic conditions,” Krist said. “The health systems and community partners are experimenting with, and investing in, new models for connecting patients with needed services, but primary care clinicians, whose regular contact with patients make them more familiar with patients’ needs than large health systems and specialists, are often not included in the new systems.”

One in four Americans has multiple chronic conditions, such as high blood pressure, diabetes and depression. These conditions last for a year or more and require ongoing medical attention. That number rises to 3 in 4 Americans age 65 and older, according to the Centers for Disease Control and Prevention.

As a family medicine physician in Northern Virginia, Krist observes firsthand the impact that underlying issues such as unmet social needs, unhealthy behaviors and mental health challenges can have on managing chronic conditions. He is also keenly aware of the challenges primary care physicians face in helping their patients address those issues.

“As a clinician, these are the types of things I see every day with my patients,” Krist said. He added that doctors frequently rely on medications, diagnostic tests and specialty referrals to manage chronic conditions rather than working toward resolving the underlying issues.

“The current model of care is not set up to seamlessly connect physicians with resources that will help resolve their patients’ problems,” Krist said. He hopes the proposed care model will help bridge that gap.

Krist, who is the co-director of community-engaged research at the VCU C. Kenneth and Dianne Wright Center for Clinical and Translational Research, will lead a research team that includes VCU investigators along with community partners and colleagues at the University of Colorado and University of Texas Health Science Center. The research was informed by a pilot grant awarded to Krist by the Wright Center, through which he and colleagues tested a social needs screening tool that will be used for the study.

For five years, the researchers, clinicians and community partners will work with patients with multiple chronic conditions from 60 primary care practices in the Richmond metropolitan region on a randomized, controlled clinical trial. The clinical trial includes developing individually tailored care plans and fostering connections between primary care practices and community resources.

“We are trying to see if addressing the root causes of poor health will do a better job of improving health than traditional medical care models,” Krist said. “It goes back to the concept that we think these root causes are critical drivers of health. Trying to address them better has much stronger potential for improving health than traditional means.

“We believe this study can show doctors a new way to help their patients,” Krist said. “Instead of just giving patients more pills to control chronic disease, doctors can find the root causes of poor health. With the support of health system and community programs, doctors and patients can address these root causes to truly promote health and well-being.”