Trial tests integrated chronic care

Care managers can help people with several chronic illnesses after a hospital stay, but a randomized trial found the biggest measurable gain was in how confident patients felt managing their own care. (ajmc.com) The study, published by *The American Journal of Managed Care* on December 3, 2025, followed 1,387 Medicaid or Medicare-Medicaid adults with multiple chronic conditions for 12 months after discharge from an inpatient hospitalization. Participants were assigned in a 2:2:1 ratio to high-touch in-person care management, high-tech remote monitoring, or telephonic optimal discharge planning. (ajmc.com) Researchers reported no statistically significant difference between the three groups on 90-day readmissions, and health status improved over time across the study without a significant difference by intervention. Patient activation, a measure of how ready and able a person is to manage care, improved more in the high-touch group than in the telephonic group, with an adjusted difference of 2.69 points at 12 months. (ajmc.com) The trial enrolled publicly insured adults age 21 and older in Pennsylvania who had at least one physical condition plus another physical or behavioral health condition and had been discharged within the previous 30 days. ClinicalTrials.gov lists actual enrollment at 1,400, with recruitment running from September 4, 2018, to November 4, 2021. (clinicaltrials.gov) Multiple chronic conditions are common enough that care often breaks across clinics, hospitals, and insurers. The Centers for Disease Control and Prevention said in 2025 that more than half of U.S. adults have two or more chronic conditions, and 78.8% of adults 65 and older reported that level in 2023 survey data. (cdc.gov; cdc.gov) That helps explain why this trial tested delivery methods rather than a new drug. The interventions compared face-to-face support, digital tools with remote care management, and a lighter-touch discharge-planning model run through UPMC Health Plan and community-based care workflows. (ajmc.com; clinicaltrials.gov) The project was backed in part by the Patient-Centered Outcomes Research Institute with $3.79 million in funding and ran from January 1, 2018, through November 30, 2024, according to UPMC’s project page. UPMC said the work was designed to test in-home and digitally driven care management for adults covered by Medicaid or Medicare-Medicaid. (upmchighvaluehealthcare.com) The paper’s results point to a narrower claim than many care-management pitches make. The authors wrote that health systems can use several person-centered approaches “without compromising patient outcomes,” while the clearest advantage in this trial came from in-person support on patient activation rather than from lower readmission rates. (ajmc.com) That leaves a practical opening for consumer health apps that can export records into clinical workflows: if the care model depends on coordination, the useful tool is the one a patient can carry from home to hospital to insurer. The trial did not test those apps directly, but it did test the kind of handoff-heavy care process those records are meant to support. (ajmc.com; clinicaltrials.gov)