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:



Chronic Conditions Researchers


Featured Projects

Investigators: Rebecca S. Boxer, MD, MS, John F. Steiner, MD, MPH, and Cheryl Kelly, PhD, MPH, MA
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: Cheryl Kelly, PhD, MPH, MA and Morgan Clennin, PhD, MPH
The Cancer, Cardiovascular and Pulmonary Disease (CCPD) Grant Program funds over 20 community agencies across the state of Colorado to implement 13 different evidence-based strategies ranging from healthy eating and active living policies, clinical systems improvement and asthma management. The purpose of the evaluation is to determine the reach, effectiveness, and population dose of the CCPD program within and across evidence-based strategies and estimate the overall impact of these initiatives on Colorado’s chronic disease rates and population health over time.  
Funder: Colorado Department of Public Health and Environment
Study End Date: 2021
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Garfield Memorial Fund
Study End Date: 09/30/2020
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 08/31/2022
Investigator: John F. Steiner, MD, MPH
The goal of this project is to improve care for patients with hypertension at the First Nations Community HealthSource, an Urban Indian Health Organization in Albuquerque New Mexico. A hypertension registry will be developed, and information from that registry will be used to support 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
Investigator: John F. Steiner, MD, MPH
This project (1) compared the effects of the values-affirmation exercise with a control exercise on antihypertensive medication adherence in African American patients across three clinical settings; (2) compared the effects of the values-affirmation exercise in African American patients with its effects in white patients with similar socioeconomic and clinical characteristics; and (3) assessed the suitability of the intervention for widespread dissemination using the RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework.
Funder: National Institutes of Health
Study End Date: 05/31/2020
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Agency for Healthcare Research and Quality
Study End Date: 09/30/2022