Project Summary/Abstract Adults with Multiple Chronic Conditions (MCC) experience persistent health care burdens and account for the majority of U.S. health care expenditures. These patients experience a disproportionate impact of preventable morbidity and mortality from receiving less than optimal medical therapy. Many adults with MCC also face the added challenge of socially-related barriers to care related to transportation, food, housing, utilities, and/or finances. These unmet social needs are linked to worse disease outcomes and to decreased life expectancy. As a result, the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services now incentivize health systems to more broadly screen for unmet social needs, which will lead to more frequent identification of adults with MCC facing barriers to both obtaining social resources and to navigating clinical care systems. New strategies are therefore needed to more effectively care for this large, growing, highly burdened, and costly patient population. We propose to combine prediction modeling in a data-driven strategy to identify patients with MCC at highest risk for persistent care gaps (i.e., not meeting evidence-based clinical care goals for 1 or more chronic conditions in the next year) with a “Whole Person” Navigation strategy that links each high-risk patient to a Whole Person Navigator who can help guide and support the patient to prioritize competing needs and to develop a navigation plan for obtaining social services and addressing clinical care barriers. In this proposal we focus on patients with MCC not meeting evidence- based clinical care goals and with self-reported social barriers to care. Our specific aims are to develop and implement a prediction model to identify patients with the highest predicted risk of not closing MCC-related care gaps over the next 1- and 2-year periods (Aim 1); define requirements and care protocols for a Whole Person Navigator role that integrates evidence-based principles of social resource and care system navigation for high- risk adults with MCC (Aim 2); and evaluate the impact of this data-driven Whole Person Navigation intervention compared to usual care in a randomized clinical trial (n = 400) conducted across 2 care systems located in Northern California and Washington State. We hypothesize that this Whole Person Navigator intervention will lead to a greater proportion of patients with closure of baseline clinical care gaps (H1) and better patient- reported outcomes (e.g., improvement in goals setting, problem solving, and care coordination, and reduction in treatment burden and unmet social needs) compared to usual care. Our proposal addresses AHRQ priorities to evaluate and disseminate evidence on whole health practices, to advance health equity, and to optimize care for people living with MCC. If successful, results and protocols from this multi-site study will inform new care practices designed to close ca...