Optimizing Care for People Living with Multiple Chronic Conditions through the Development of Enhanced Care Planning

Notice Number: NOT-HS-16-013

Key Dates
Release Date: April 18, 2016

Related Announcements

March 16, 2022 - AHRQ Announces Interest in Primary Care Research. See Notice NOT-HS-22-011

February 17, 2022 - AHRQ Announces Interest in Health Services Research on Health System and Healthcare Professional Responsiveness to COVID-19. See Notice NOT-HS-22-010

Issued by
Agency for Healthcare Research and Quality (AHRQ)


More than one in four Americans, and two out of three older Americans, are estimated to have at least two chronic physical or behavioral health problems. Treatment for people living with these multiple chronic conditions (MCC) currently accounts for an estimated 66% of the Nation's health care costs. As the U.S. population ages, and as chronic conditions accumulate in the lives of younger Americans, the number of patients with MCC continues to grow. The Agency for Healthcare Research and Quality (AHRQ) has a long-standing interest in increasing our understanding of how to optimize care for people living with multiple chronic conditions.

AHRQ has a multi-year plan to study and implement new approaches for caring for patients with MCC. These approaches aim to promote health and function, reduce the burden of illness, minimize the burden of treatment on patients and caregivers, and support patient goals. One such approach is to help patient care teams develop and use more effective care plans. Effective care planning requires a partnership between health professionals and patients, and must incorporate information about patients circumstances and life contexts so that choices about care can be prioritized to meet the needs, values and preferences of the patient. This contextual information could include patient characteristics such as health literacy level and language preferences, access to transportation, gender, socioeconomic status, other demands on the patient's time and energy, amount of practical assistance at home, and preference for decision-making authority, as well as community characteristics and resources (See Bayliss et. al. 2014 http://www.annfammed.org/content/12/3/260.long).

With this Special Emphasis Notice AHRQ is indicating a specific interest in generating knowledge about how clinical teams will use a patient’s values, preferences and personal, social, and clinical context to formulate and use plans of care in partnership with patients, caregivers, and families. Preferences, values and context may be specific to the situation and also can change over time. Therefore, proposals that address how the process of care planning and the care plans themselves will identify and respond to the specific and dynamic nature of patients circumstances are of interest. Examples of research projects that would be of interest include:

The development, implementation and evaluation of tools for clinicians and teams to use in partnership with patients and their families to improve care planning that integrate new contextual information with clinical diagnosis (based on physical and behavioral health). The tools could include guidance about how to use shared decision making to develop and implement the integrated care plan, and training materials to help teams develop the skills and process capacity to use contextual information to improve care;

The development, implementation and evaluation of enhanced care plans that can be used in diverse settings for diverse populations, including AHRQ priority populations (see https://grants.nih.gov/grants/guide/notice-files/NOT-HS-03-010.html). Questions to be investigated could include what user-centered design features and modalities optimize the use of enhanced care plans by clinical teams and patients, caregivers, and their families, taking into consideration the capacity and resources of the clinical setting and patients;

Evaluation of the effects of care plans that incorporate patient and family values, preferences, and context on patient burden of treatment, burden of illness, patient, family, and clinician satisfaction, patient adherence to the treatment plan, and health outcomes. Studies that examine whether and how these outcomes differ across diverse populations are also of interest;

The development, implementation, and evaluation of strategies to share and use contextual data in order to promote care coordination and integration across multiple providers.

AHRQ recognizes that this SEN does not address all aspects needed to develop and implement enhanced care planning for people with MCC. Prior work of AHRQ and others has focused on identifying contextual information to collect, and other AHRQ initiatives are focusing on how to collect these data. For the purpose of this announcement, AHRQ is interested in research on how clinical teams can use this information and the effects of the use of this information on outcomes.

AHRQ will use standing program announcements for the R01, R03, and R18 funding mechanisms to support this research. The funding opportunity announcements for the referenced funding mechanisms can be found at: https://grants.nih.gov/grants/guide/pa-files/PA-14-291.html; https://grants.nih.gov/grants/guide/pa-files/PA-15-147.html; https://grants.nih.gov/grants/guide/pa-files/PA-14-290.html. Applicants should clearly state in their cover letter, Project Summary (abstract), and the Specific Aims sections of the grant application that they are responding to this Notice. Applications responsive to this SEN should be submitted on regular research grant receipt dates and will be reviewed by AHRQ’s standing study sections.


Please direct all inquiries to:

Geralyn Goins, MSM
Agency for Healthcare Research and Quality (AHRQ)
Center for Evidence and Practice Improvement
Email: Geralyn.Goins@ahrq.hhs.gov