Table 2 Overview of data collection methods and analysis

Aim 1, Implementation: To evaluate how the intervention is implemented

• MOHR database to identify which patients complete care plans, patient needs and wants

• Field notes, patient survey to identify the types of support provided to patients to address identified needs

• Percentage of intervention patients who complete a care plan (generalized linear mixed models)

• Frequency of patient needs and needs patients want to address (generalized linear mixed models)

• Support provided patients and consistency with patient wants (generalized linear mixed models)

Aim 2, Effectiveness: To compare the effectiveness of intervention versus usual care for control of MCC and patient-reported physical, mental, and social health

• Chart review to measure change in A1c, blood pressure, and statin and aspirin use

• Patient survey to measure diet, exercise, depression, and EQ-5D domains at baseline, 6 months, and 2 years

• Percentage of patients with controlled MCC for intervention patients versus usual care (generalized linear mixed models)

• Pre-post change in EQ-5D domains for intervention patients versus usual care (linear mixed-effects models)

Aim 3, Context: To understand the contextual factors that influence intervention implementation and effectiveness

• Patient survey to identify success in addressing needs

• Semi-structured interviews with patients, patient navigators, CHW, community providers, and program leaders

• Identification of common themes influencing success in addressing needs and controlling MCC (immersion/crystallization analysis)