ORIGINAL RESEARCH
Jennifer L. Gilbert, PsyD; E. Marshall Brooks, PhD; Adam J. Funk, PhD; Benjamin Webel, BA; Paulette Lail Kashiri, MPH; Jacqueline B. Britz, MD, MSPH; Jong Hyung Lee, PhD, MS; Roy T. Sabo, PhD; Kristen M. O’Loughlin, PhD; Russell E. Glasgow, PhD; Amy G. Huebschmann, MD, MSc; Alex H. Krist, MD, MPH
Corresponding Author: Jennifer L. Gilbert, PsyD; Department of Family Medicine, Virginia Commonwealth University.
Email: jennifer.gilbert2@vcuhealth.org
DOI: 10.3122/jabfm.2026.260215R1
Keywords: Chronic Disease, Electronic Health Records, Family Medicine, Mental Health, Multiple Chronic Conditions, Patient Care Planning, Primary Health Care, Risk Assessment, Social Determinants of Health
Dates: Submitted: 5/29/2026; Revised: 8/14/2026; Accepted: 9/8/2026
Status: In Press.
PURPOSE: Patients with uncontrolled multiple chronic conditions (MCC) often have co-occurring unhealthy behaviors, mental health challenges, and unmet social needs. Addressing these upstream drivers may improve outcomes beyond traditional biomedical care. We evaluated whether an enhanced care planning (ECP) approach improved MCC control better than usual care.
METHODS: We conducted a clinician-level cluster randomized trial. Clinicians were randomized to usual care or ECP. Using electronic health record (EHR) data and surveys, we identified all patients aged 18-75 years with ≥2 chronic conditions (cardiovascular disease or risks, diabetes, obesity, or depression) and ≥1 uncontrolled condition. Ten respondents per clinician could participate. Intervention patients completed an online health risk assessment and worked with patient navigators to prioritize risks, develop SMART goals, and connect with community resources. Outcomes were assessed via EHR, surveys, and risk assessment database. Mixed effects models accounted for clustering and repeated measures.
RESULTS: Among 457 enrolled patients (mean of 3.1 MCCs, 2.0 uncontrolled) there was no significant difference in chronic condition control between groups at 6 or 12 months. Intervention patients versus usual care demonstrated significantly greater improvements in overall risks at 6 months (RR=0.45; 95% CI: 0.04-0.87; p=0.031) and 12 months (RR=0.42; 95% CI: 0.03-0.83; p=0.034), and greater resolution of social risks at 12 months (RR=1.45; 95% CI: 1.01-2.05; p=0.039).
CONCLUSIONS: ECP meaningfully improved upstream drivers of health, without a change in biomedical control. These changes may matter more to patients and have a greater impact on quality of life than traditional measures of chronic disease control.