Health coaching to prevent hospitalizations in patients with multiple chronic conditions

Preventing Tipping Points in High Comorbidity Patients: A Lifeline From Health Coaches

Not applicable Interventional Clinical Directors Network · NCT04176510

This study tests whether health coaching can help people with multiple chronic conditions avoid hospital visits and improve their overall health compared to regular care.

Quick facts

PhaseNot applicable
Study typeInterventional
Enrollment1920 (estimated)
Ages18 Years and up
SexAll
SponsorClinical Directors Network Research network
Locations4 sites (Chicago, Illinois and 3 other locations)
Trial IDNCT04176510 on ClinicalTrials.gov

What this trial studies

This clinical trial evaluates the effectiveness of a health coaching intervention compared to standard patient-centered medical home care in preventing destabilization in patients with high comorbidity. It involves a pragmatic cluster randomized design, where patients are grouped by healthcare site within Federally Qualified Health Centers in New York City and Chicago. The health coaching intervention focuses on motivating patients through positive affect and self-affirmation techniques to enhance their self-management skills and set life goals. The goal is to reduce unplanned hospitalizations and improve overall patient outcomes.

Who should consider this trial

Good fit: Ideal candidates for this study are patients with a Charlson comorbidity index of 4 or higher who are established patients at the participating Federally Qualified Health Centers.

Not a fit: Patients with metastatic cancer, end-stage renal disease on dialysis, severe mental illness, or those unable to communicate in English or Spanish may not benefit from this study.

Why it matters

Potential benefit: If successful, this approach could significantly reduce hospitalizations and improve the quality of life for patients with multiple chronic conditions.

How similar studies have performed: Other studies have shown promise in using health coaching interventions for chronic disease management, suggesting potential success for this approach.

Eligibility criteria

Show full inclusion / exclusion criteria
Inclusion Criteria:

* Established patients of the participating Federally Qualified Health Centers (FHQCs)
* Charlson comorbidity index ≥4

Exclusion Criteria:

* Metastatic cancer,
* End stage renal disease on dialysis
* Post-transplant
* Severe mental illness
* Drug/alcohol abuse
* Cannot communicate in English or Spanish.

Where this trial is running

Chicago, Illinois and 3 other locations

Study contacts

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions ComorbiditySelf-ManagementCharlson Comorbidity IndexHealth Coach
Last reviewed 2026-06-13 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.