News Release

Enhanced care coordination can benefit patients with multiple chronic illnesses

George Mason University Study examined experience of patients with multiple chronic illnesses in the CareFirst Patient-Centered Medical Home (PCMH) program

Peer-Reviewed Publication

George Mason University

Dr. Debora Goetz Goldberg, George Mason University

image: Dr. Debora Goetz Goldberg led the George Mason University study that examined the experience of patients with multiple chronic illnesses in the CareFirst Patient-Centered Medical Home (PCMH) program. view more 

Credit: George Mason University

Few studies to date have evaluated patient experiences with payer-based CareFirst Patient-Centered Medical Home (PCMH) programs. The CareFirst BlueCross Blue Shield PCMH program aims to improve health care services, particularly for patients with multiple chronic conditions. It includes nurse care coordinators and individualized patient care plans.

“Patients with multiple chronic conditions are at an increased risk for hospitalization, and need additional coordination of care, and have high health care costs,” explains Dr. Debora Goetz Goldberg, who led the study at George Mason University’s College of Health and Human Services.

Goldberg and colleagues found that payer-based patient-centered medical home models with enhanced care coordination may be beneficial to patients with multiple chronic illness. Patients who completed their care plans had more positive experiences than those who did not. This suggests the care plan is key to the success of this model. Nurse care coordinators—who work closely with patients on developing the care plan and meeting individual goals—also played an important role in the program.

“Individuals with multiple chronic conditions often do not have their needs met in traditional primary care settings,” explains Goldberg. “Alternative models of care, such as the CareFirst PCMH, are approaches providers are experimenting with to improve the quality of care for these patients.”

In addition to improving health care quality, PCMH aims to slow rising health care costs over time. The program functions by focusing on the relationship between patients and their primary care provider.

For the study published in Population Health Management, Goldberg and colleagues surveyed 1,308 adults from 2015-2017. This study was supported by a research grant from CareFirst BlueCross BlueShield.

Future research on new models of care in primary care settings should assess patient experience, provider perspectives as well as implementation time, resources, and outcomes.

About George Mason University

George Mason University is Virginia's largest and most diverse public research university. Located near Washington, D.C., Mason enrolls 38,000 students from 130 countries and all 50 states. Mason has grown rapidly over the past half-century and is recognized for its innovation and entrepreneurship, remarkable diversity and commitment to accessibility. For more information, visit

About the College of Health and Human Services

George Mason University's College of Health and Human Services prepares students to become leaders and shape the public's health through academic excellence, research of consequence and interprofessional practice. The College enrolls 1,917 undergraduate students and 950 graduate students in its nationally recognized offerings, including: 5 undergraduate degrees, 12 graduate degrees, and 11 certificate programs. The College is transitioning to a college public health in the near future. For more information, visit

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