ECP Study Description
Randomized control trial
The Enhanced Care Planning study is a randomized controlled trial. Patients were randomized to the intervention or control group.
Intervention group: Patients were linked with enhanced care planning, where they received weekly phone calls from a patient navigator and were linked with a community health worker and additional resources as needed, in addition to continuing with routine follow up with their primary care doctor.
Control group: Patients in the control group had routine care from their primary care provider and did not have care planning.
Outcomes are compared at 6 and 12 months based on repeat Health Risk Assessments, data from MyOwnHealthReport, EHR data, as well as qualitative interviews.
4 key components of intervention
Patient Navigator is assigned at patient enrollment and provides weekly calls to help patient reach goals and address barriers.
A Community Health Worker is available to refer patients to community resources.
MyOwnHealthReport
MyOwnHealthReport (MOHR) is an online enhanced care planning tool.
Patients are referred to a variety of community resources that address mental health needs, social needs, and behavioral health needs.
MyOwnHealthReport (MOHR) is an enhanced care planning online tool that helps identify patients to create personal care plans.
Health Risk Assessment
Through MOHR, patients can complete a Health Risk Assessment (HRA), which can help inform care plans.
An HRA is completed upon enrollment, and repeated at 6 and 12 months after enrollment.
Creating a care plan
Patient Navigators help patients to use their Health Risk Assessment results to create a care plan based on their unique behavioral health, mental health, and social needs.
Patients are followed every 1 to 2 weeks by phone and connected to a Community Health Worker and additional community resources when needed. A navigator continues to follow the patient until they have completed their care plan.
