Advancing Care Management in Community Health Centers
Official title: DEDICATE: aDvancing carE management aDoption In Community heAlTh cEnters
Funded at Ochin, INC. · NIH-11597896 · Data updated 2026-11-12
A study to help rural and low-income patients with chronic diseases get better care by linking clinics with community services using their electronic health records.
Quick facts
| Grant type | R01 grant |
|---|---|
| Study type | NIH-funded research |
| Funding institution | Ochin, INC. NIH-funded |
| Lab location | 1 site (Portland, United States) |
| Project start | September 21, 2023 |
| Project end | June 30, 2028 |
| Funding year | 2026 |
| Award (this year) | $697,847 |
| NIH project number | 4R01NR021115-02 |
| Project ID | NIH-11597896 on NIH RePORTER |
Who could benefit from this research
✓Could help
Patients receiving care at participating Community Health Centers who have chronic conditions and social needs that could be addressed through clinic–community connections.
✕Less likely to help
Patients at non-participating centers or without identified social needs relevant to care management may see no direct benefit.
What this research studies
This project focuses on CHCs that serve rural and low-income communities and tests how to better connect patients to community resources through care management. It uses a cluster-randomized design to compare different ways of implementing clinic-to-community linkages within EHR workflows. The aim is to identify practical, scalable practices that help patients receive the social and medical support they need to manage chronic illness. The study will work with real clinics and patients to understand what works in everyday care settings.
Why it matters
Potential benefit: If successful, it could improve access to necessary services and support, helping patients manage chronic diseases more effectively.
How similar studies have gone: Prior care-management approaches show promise, with systematic patient–community linkages improving care coordination in some settings.
Where this research is happening
-
Ochin, INC.
Portland, United States Active
Researchers
- Principal investigator: Cook, Nicole Jill — Ochin, INC.
- Study coordinator: Cook, Nicole Jill
About this research
- This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
- Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
- For full project details, budget, and progress reports, visit the official NIH RePORTER page.