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As our nation struggles to respond to the ever evolving COVID-19 pandemic, an equally devastating but stealthy health crisis is upon us: the high prevalence and increasing numbers of people of all ages living with multiple chronic conditions (MCC). The challenge of MCC—two or more chronic physical or mental health conditions—is a “wicked problem,” and one that poses a great threat to the capacity and sustainability of a health system ill-prepared to confront this escalating crisis.

The impacts of MCC are staggering. MCC afflict 80 percent of the Medicare population and a growing number of children. People living with MCC account for a 64 percent of clinician visits, 70 percent of hospital in-patient stays, 83 percent of prescriptions, and 71 percent of all healthcare spending. A disproportionate share of care for MCC is shouldered by public programs. Low-income individuals and racial and ethnic communities experience a higher burden of MCC and develop MCC at earlier ages.

The high population burden of MCC resulted in increased morbidity and mortality from COVID-19, and the prevalence of MCC will continue to rise due to COVID-19’s longterm aftereffects.

To help health systems, clinicians, researchers, and other key stakeholders design solutions  to best address the challenges of MCC, the journal Health Services Research (HSR) has published a special issue, “The Science of Care for People with Multiple Chronic Conditions.” This issue includes an written by me and co-authors that presents AHRQ’s research agenda developed to provide the needed evidence to transform MCC care.

The includes evidence reviews of models of care, patient and family engagement, and the use of health information technology to improve care for people living with MCC. Studies examining the needs of people living with MCC, the barriers they encounter in receiving effective care, and the impact of tested models of care on health outcomes are also included.

A by Victor Montori emphasizes the critical role of primary care in addressing the needs of people living with MCC and the pressing need for health services research to provide the evidence to optimize their care. Dr. Montori writes, “Patients are often left to integrate and coordinate visits, tests, and treatments across siloed specialist services; to make sense of disparate information and recommendations; to complete administrative and medical errands; to figure out what to pay and who pays for what; and to take treatments and implement recommended behaviors with high fidelity."

The good news is that MCC can be prevented and/or more effectively managed. AHRQ envisions a sustainable healthcare system that delivers high-value, coordinated, integrated, patient-centered care, based in primary care, which will optimize individual and population health by preventing and effectively managing multiple chronic conditions.

Achieving this vision will require significant changes to the ways in which we organize and deliver care.People living with MCC often have complex medical, social, and psychological needs and receive fragmented care leading to poor outcomes and higher costs.

We need to transition from our current disease-focused system to person-centered care that takes into account all of an individual’s risk factors and conditions in the context of their lives, and that is aligned with their values, goals, and preferences.  As in all our work, AHRQ’s search for solutions to these challenges includes a special emphasis on addressing issues of health equity and the impacts of MCC on people of color and underserved communities.

Starting in early 2019, the Agency launched a series of stakeholder consultations to develop a research agenda to guide future investments in improving MCC care. We sought diverse perspectives on the greatest challenges and the research needed to address them. The culminating event of our year-long journey was our November 2020 AHRQ Summit on Transforming Care for People Living with Chronic Conditions (PDF, 488 KB) attended by  over 100 researchers, clinicians, patients, health system leaders, Federal partners and potential funders of MCC. Participants identified and prioritized key areas for investigation and innovation that would have the highest likelihood of addressing the challenges faced by clinicians, persons living with MCC, and their caregivers.

The result was a research agenda ripe with questions for exploration and input on the innovative research methods needed to maximize impact. Among them: How can we redesign care to enhance patient centeredness? What steps are needed to advance the unrealized potential of the medical home? How can we best capture the evidence needed to understand the effectiveness and safety of telehealth and other information technologies? What models of care improve outcomes without widening pervasive inequities in the MCC population?

Our work to advance the research agenda is ongoing. AHRQ will soon launch an initiative to identify and implement effective approaches to transforming the care for people with MCC in partnership with our stakeholders. We are also that test digital healthcare interventions at the point of care.

The need to do better is urgent. We are poised to produce the evidence needed and implement practice improvements that will prioritize patient needs, ensure equity, and lead to more effective care. AHRQ’s research agenda provides a roadmap to guide future research investments to help address the “wicked problem” of MCC.

Arlene Bierman in director of AHRQ’s Center for Evidence and Practice Improvement.

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