Chronic disease is a major contributor to health disparities. It is increasingly common for patients to have multiple chronic conditions requiring multiple specialists, posing significant challenges for primary care providers and patients to manage competing demands and make appropriate use of condition-specific guidelines that do not account for complications of multiple conditions. Challenges are compounded in underserved communities where resources are limited, chronic disease is common, and risk factors are elevated. This Community Based Participatory Research (CBPR) study will be conducted in inner-city Buffalo, NY, which was recently ranked by the U. S. Census Bureau as the third-poorest city in the nation. The population is predominantly minority (African American) and ethnically diverse (Hispanic and resettled refugees from over 70 counties). The Research team includes four Pi's from an existing partnership (one research PI, two practice site PIs and one patient PI representing Patient Voices, a network of Patient Action Teams from each of the sites).
The specific aims of this study, using a CBPR approach, are to: 1) Conduct a needs assessment of a cohort of patients with complex chronic disease at 2 safety net primary care sites in medically underserved areas, 2) Design a Pilot Self-Management Intervention to address identified needs based on patient-reported factors that enable or hinder chronic disease self-management among patients age 18 and older, and 3) Implement a Pilot Self-Management Intervention among a systematic sample of 120 patients with CCD, recruited from an existing registry. Feasibility and effectiveness of the pilot intervention will be assessed over an 18-month period. The primary outcome will be change in the chronic disease outcomes. Intermediate outcome measures related to patient empowerment (social support, patient activation, self-management skills, functional status, and quality of life) will also be assessed. This study brings together patients and providers to create a patient centered intervention that meets patients'needs and can be practically implemented in the primary care setting.
Patients with multiple chronic diseases are more common particularly in minority underserved communities. A research team (led by a research PI, two practice site PIs, and a patient PI) will develop and implement a patient-centered intervention, in partnership with both patients and providers, to improve self-management among patients with two or more chronic diseases. Using a participatory approach will ensure that the intervention meets patients'needs and is practical in the primary care setting