Chronic Conditions
Multiple IHR projects focus on improving care for individuals with one or more chronic medical conditions at Kaiser Permanente Colorado and in the broader community. Areas of single condition focus include diabetes, cardiovascular disease, and dementia. Many individuals have more than one chronic condition (multimorbidity), and may benefit from specialized care processes to ensure patient-centered care and outcomes, manage multiple medications, address social or psychological needs and minimize their personal care burden.
Members of:
- U.S. Deprescribing Research Network
- Advancing Geriatrics Infrastructure & Network Growth (AGING) Initiative
Chronic Conditions Researchers
Featured Projects
Investigator: John F. Steiner, MD, MPH
The goal of this project is to promote excellence in translational research and capacity-building to improve diabetes-related health in American Indian/Alaska Native (AI/AN) populations.
Funder: National Institute for Diabetes, Digestive and Kidney Diseases
Study End Date: 2026
The goal of this project is to promote excellence in translational research and capacity-building to improve diabetes-related health in American Indian/Alaska Native (AI/AN) populations.
Funder: National Institute for Diabetes, Digestive and Kidney Diseases
Study End Date: 2026
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 03/31/2024
Funder: National Institute on Aging
Study End Date: 03/31/2024
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 02/29/2024
Funder: National Institute on Aging
Study End Date: 02/29/2024
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 07/31/2024
Funder: National Institute on Aging
Study End Date: 07/31/2024
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 01/31/2024
Funder: National Institute on Aging
Study End Date: 01/31/2024
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Agency for Healthcare Research and Quality
Study End Date: 09/30/2022
Funder: Agency for Healthcare Research and Quality
Study End Date: 09/30/2022
Investigators:Rebecca S. Boxer, MD, MS, John F. Steiner, MD, MPH,
Meals Matter is a collaboration between three Kaiser Permanente Regions (KPCO, KPNW and KPNC) and local Colorado hospitals (Saint Joseph Hospital and Good Samaritan Medical Center) to determine if medically tailored meals provided for either 2 or 4 weeks (1 meal per day) after hospital discharge will improve health in patients with one or more of 6 chronic health conditions. Medically tailored meals are meals that are approved by a dietitian and shown to help people with certain health conditions. The study is measuring depression/anxiety, general well-being & functional status, and rehospitalization & emergency department visits. Additionally, researchers will assess the feasibility, acceptability, and scalability of the Meals Matter Program to KP members, their households, and hospital leadership and staff.
Funder: KP National
Study End Date: 06/30/2021
Meals Matter is a collaboration between three Kaiser Permanente Regions (KPCO, KPNW and KPNC) and local Colorado hospitals (Saint Joseph Hospital and Good Samaritan Medical Center) to determine if medically tailored meals provided for either 2 or 4 weeks (1 meal per day) after hospital discharge will improve health in patients with one or more of 6 chronic health conditions. Medically tailored meals are meals that are approved by a dietitian and shown to help people with certain health conditions. The study is measuring depression/anxiety, general well-being & functional status, and rehospitalization & emergency department visits. Additionally, researchers will assess the feasibility, acceptability, and scalability of the Meals Matter Program to KP members, their households, and hospital leadership and staff.
Funder: KP National
Study End Date: 06/30/2021
Investigators: Morgan Clennin, PhD, MPH and Sheridan Green, PhD, MS
Funder: Colorado Department of Public Health & Environment, Office of Health Equity
Study End Date: 06/30/2025
- The CDPHE Office of Health Equity funds two separate grant programs under the Health Disparity and Community Grant Program (HDCGP, two programs under a single contract)
- The first grant program funded 14 lead agencies with multi-sector partnerships to implement evidence-based strategies to overcome health disparities in the prevention, early detection, and treatment of cancer, cardiovascular and pulmonary diseases in underrepresented populations by working on systems and policy changes that are community led. Community organizations were funded by the Health Disparities and Community Grant Program (Amendment 35). The goal of this evaluation was to conduct a comprehensive evaluation to assess 1) how the grant program built community power through authentic community engagement, capacity building, and establishing strategic and diverse partnerships; 2) the extent to which improved community power advanced progress towards policy, system, and environmental (PSE) changes to improve social infrastructure (e.g., housing insecurity, food insecurity, unemployment); and 3) the impact of achieved PSE changes on access to upstream social and economic resources (that will eventually lead to improved health outcomes and reduced health inequities and disparities).
- The second grant program provided funding to 30 community and grassroots organizations to develop local plans and capacity toward achieving health equity. Goal is to create a foundation to improve social infrastructure and health outcomes that eventually lead to the reduction of health inequities and disparities. Funds are explicitly intended for projects that create and/or launch a foundation for making changes to public, systems-level, and/or organizational practices, rules, laws, and regulations that influence the health of underrepresented communities. Using the power ecosystem framework, the goal of this project is to conduct a comprehensive evaluation to document how grantees’ build community power and resilience; develop community-led, collaborative solutions that contribute to systemic change; and shift power in communities.
Funder: Colorado Department of Public Health & Environment, Office of Health Equity
Study End Date: 06/30/2025
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 01/31/2024
Funder: National Institute on Aging
Study End Date: 01/31/2024
Investigators: Stacie L. Daugherty, MD, MSPH and John F. Steiner, MD, MPH
The aims of this project are (1) to compare the effects of a values-affirmation exercise with a control exercise on antihypertensive medication adherence in African American patients across three clinical settings; and (2) compare the effects of the values-affirmation exercise in African American patients with its effects in white patients with similar socioeconomic and clinical characteristics.
Funder: National Institutes of Health
Study End Date: 05/31/2021
The aims of this project are (1) to compare the effects of a values-affirmation exercise with a control exercise on antihypertensive medication adherence in African American patients across three clinical settings; and (2) compare the effects of the values-affirmation exercise in African American patients with its effects in white patients with similar socioeconomic and clinical characteristics.
Funder: National Institutes of Health
Study End Date: 05/31/2021
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Garfield Memorial Fund
Study End Date: 09/30/2020
Funder: Garfield Memorial Fund
Study End Date: 09/30/2020
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Garfield Memorial Fund
Study End Date: 01/30/2020
Funder: Garfield Memorial Fund
Study End Date: 01/30/2020
Investigator: John F. Steiner, MD, MPH
The goal of this project was to improve care for patients with hypertension at the First Nations Community HealthSource, an Urban Indian Health Organization in Albuquerque New Mexico. The study supported a randomized, controlled trial of interactive voice-response outreach to patients with hypertension, with the goal of improving blood pressure control through reducing missed clinic appointments and improving medication adherence.
Funder: American Heart Association
Study End Date: 06/30/2020
The goal of this project was to improve care for patients with hypertension at the First Nations Community HealthSource, an Urban Indian Health Organization in Albuquerque New Mexico. The study supported a randomized, controlled trial of interactive voice-response outreach to patients with hypertension, with the goal of improving blood pressure control through reducing missed clinic appointments and improving medication adherence.
Funder: American Heart Association
Study End Date: 06/30/2020