Table 1.

Concepts and Associated Variables Presented in the Model and Relevant Evidence Gaps and Research Needs

Concept and Variables	Evidence Gaps and Research Needs
Clinical Complexity of Multiple Chronic Conditions (MCC) and Serious Illness Complex care needs High symptom burden Caregiver stress Multiple providers Quality of life Functional status Increased utilization High cost Care fragmentation	Defining seriously ill adults with MCC Characterization of complex care needs specific to MCC Understanding biologic basis of symptoms Patient, caregiver, provider perspectives Functional status in seriously ill adults with MCC Strategies to improve caregiver stress and increase support Care fragmentation and high utilization in serious illness MCC Cost containing mechanisms in serious illness and MCC Measurement tools for seriously ill adults with MCC Quality of life measures specific to serious illness and MCC
Palliative Care Role in MCC and Serious Illness Primary Secondary Tertiary	Primary, secondary, and tertiary palliative care for seriously ill adults with MCC Identifying timing and specifics of targeted palliative care interventions for MCC Understanding underlying reasons for disparate access and use of palliative care in minority populations Identifying long-term needs of seriously ill adults with MCC and their caregivers The role of palliative care in Alzheimer’s Dementia and Related Dementias Exploring social and cultural barriers to palliative care acceptance Exploring perspectives of patients, caregivers, and providers about palliative care’s role in serious illness and MCC How best to educate and prepare the workforce for the aging, seriously ill with MCC
Factors Affecting Needs Sociodemographic Clinical Characteristics Social Determinants of Health Social Support Population Health Inequalities	Sociodemographic factors that impact outcomes of seriously ill adults with MCC Greater specificity of the clinical needs of seriously ill adults with MCC Identifying patterns in the social determinants of health that lead to MCC Disparities in serious illness care resulting from MCC Economic inequalities that impact needs of the seriously ill with MCC
Factors Affecting Services Received Health System Research, Evidence Base, Dissemination, & Health Policy Community Resources	Greater understanding of health system capacity to care for seriously ill with MCC Evaluation of policy efforts to impact serious illness, MCC, and palliative care Greater understanding of community-based resources for serious illness and MCC Evaluation of best methods for delivery of community-based palliative care Outcomes of community-based palliative care interventions
Service Related Variables Patient Visits Service Mix Quality of Care Patient Information Experience	Strategies to reduce patient visits to emergency department related to serious illness and MCC Improving care coordination in serious illness and MCC Integrating palliative care into patient education and dissemination Evaluation of patient, caregiver, and provider experiences Standardizing quality of care guidelines for palliative care in serious illness and MCC
Outcomes Symptom Burden Quality of Life Function Advance Care Planning Goal-concordant Care Utilization Cost Death Site of Death Satisfaction	Examining outcomes of palliative care in seriously ill populations with MCC Examining outcomes of primary, secondary, and tertiary palliative care More observational, longitudinal prospective studies describing outcomes Randomized controlled trials of interventions in seriously ill adults with MCC Utilization and cost of serious illness and MCC after palliative care integration