Improving care management for chronic diseases in community health centers

DEDICATE: aDvancing carE management aDoption In Community heAlTh cEnters

['FUNDING_R01'] · OCHIN, INC. · NIH-10834669

This study is all about finding better ways to help low-income and minority patients with chronic diseases by connecting them with local organizations that can support their health needs, using technology to make these connections easier and more effective.

Quick facts

Phase['FUNDING_R01']
Study typeNih_funding
SexAll
SponsorOCHIN, INC. (nih funded)
Locations1 site (PORTLAND, UNITED STATES)
Trial IDNIH-10834669 on ClinicalTrials.gov

What this research studies

This research focuses on enhancing care management for low-income and racial/ethnic minority populations suffering from chronic diseases. It aims to improve the connection between patients and community-based organizations (CBOs) to address social risks that affect health outcomes. By utilizing electronic health records (EHR) to facilitate these connections, the project seeks to identify best practices for community health centers (CHCs) to better serve their patients. The approach includes systematic implementation of technology and workflow redesign to operationalize care management effectively.

Who could benefit from this research

Good fit: Ideal candidates for this research are low-income individuals and racial/ethnic minorities with chronic diseases who receive care at community health centers.

Not a fit: Patients who do not have chronic diseases or who are not receiving care at community health centers may not benefit from this research.

Why it matters

Potential benefit: If successful, this research could lead to improved health outcomes and reduced health disparities for patients with chronic diseases.

How similar studies have performed: Previous research has shown that linking patients with community resources can improve health outcomes, indicating a promising approach in this area.

Where this research is happening

PORTLAND, UNITED STATES

Researchers

About this research

  1. This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
  2. Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
  3. For full project details, budget, and progress reports, visit the official NIH RePORTER page below.

View on NIH RePORTER →

Conditions: Chronic Disease, chronic disorder, Diabetes Mellitus, diabetes

Last reviewed 2026-05-15 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.