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

Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 03/31/2024
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Agency for Healthcare Research and Quality
Study End Date: 09/30/2022
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: National Institute on Aging
Study End Date: 08/31/2022
Investigators: Cheryl Kelly, PhD, MPH, MA and Morgan Clennin, PhD, MPH
The goal of this project is to conduct a comprehensive cross-site evaluation of 22 organizations or sites implementing strategies ranging from healthy eating and active living policies to clinical system improvements to health behavior improvement programs (e.g., Diabetes Prevention Program). The purpose of the cross-site evaluation is to document and assess changes in healthy behaviors (e.g., physical activity, healthy eating, HPV vaccination, self-measured blood pressure) and health outcomes (e.g., diabetes, cardiovascular disease, hypertension) over a three-year period. Two in-depth evaluations are also being implemented. First, an in-depth policy impact assessment is being implemented to provide estimates of the impact of policy changes on health behaviors and health outcomes and assess the quality of the policy and the intended and unintended consequences of the change. Results will inform and improve policy development, adoption, implementation, and effectiveness and build the evidence base for policy interventions. Second, behavior change programs are incorporating screening and referring for food insecurity and housing insecurity. An in-depth evaluation is being conducted to understand the barriers and facilitators to incorporating this process into their program workflows and to assess who is screened and screens positive for a need and the characteristics of individuals who accept assistance and ultimately receive assistance.  
Funder: Colorado Department of Public Health & Environment
Study End Date: 12/31/2021
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 Office of Health Equity’s (OHE) Health Disparities Grant Program (HDGP) is providing support to agencies across Colorado to address upstream determinants of health (e.g., housing, education) with the goal of improving downstream health outcomes (e.g., access to care, decreased chronic disease rates). The goal of this project is to conduct a comprehensive cross-site evaluation of these funded agencies implementing system or policy changes that reduce health disparities (e.g., housing insecurity, food insecurity, unemployment). The evaluation is assessing the role of community engagement, community capacity building, and multisectoral partnerships in advancing the community’s collective action to solve problems and how that informed policy, environmental, and system changes designed to improve access to social and economic resources. Innovative methods have been developed to measure authentic community engagement and the role of partners and community members in making decisions. Additionally, an in-depth evaluation is being conducted to assess how the partnership network and community engagement helped drive the prioritization and adoption of PSE changes.  
Funder: Colorado Department of Public Health & Environment, Office of Health Equity
Study End Date: 06/30/2021
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder:  National Institute on Aging
Study End Date: 06/30/2021
Investigator: 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
Investigator: Elizabeth A. Bayliss, MD, MSPH
Funder: Garfield Memorial Fund
Study End Date: 09/30/2020
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