Overview

We are seeking proposals of up to $175,000 for research projects, each lasting up to 15 months. Projects are responsive to this request if they focus on generating rigorous, timely new evidence that will inform ways to improve the management of medically complex patients, particularly those with chronic kidney disease.

Proposal Details

Projects will be prioritized if they align thematically with one of three research areas:

• Value-Based Care Models and Pathways
• Engagement and Equity Considerations in Value-Based Care
• The Effects of Payment Reform on Care Delivery Innovations

A sample of research questions and topics is provided below. This list is not exhaustive; investigators are encouraged to pursue other research ideas and approaches within these thematic areas.

Value-Based Care Models and Pathways: What can we learn from new models of care for populations with high medical needs and those with polychronic conditions, such as patients with chronic kidney disease or kidney failure who have additional comorbidities?

These models include value-based payment models and other capitated models of care designed to streamline care with a single provider or care team to reduce costs of care and minimize unnecessary specialist referrals. This could include evaluating an advanced practice provider-led model of care, which uses specialty-trained providers to deliver in-home specialty care supported by a central physician, evidence-based protocols, and order sets, alongside a multidisciplinary clinical team. It could also evaluate different models for such care, such as after-hours services, integrated palliative care services, concierge services, and population health approaches to care.

Specific examples of research topics of interest include:

• What do advanced practice providers and in-home care providers perceive as barriers and facilitators to providing high-quality, patient-centered in-home care in value-based care models?
• How are patient-reported outcomes affected by an advanced practice provider-led in-home program?
• How does the quality of care, including delaying the onset of dialysis, avoiding “crash” starts on dialysis, and reducing hospitalizations, and total costs of care compare for advanced practice provider-led in-home care versus traditional care in office-based settings?
• What is the impact of after-hours clinician availability on patient satisfaction, utilization, reductions in emergency department use, and overall outcomes?
• How do value-based kidney care services influence access to palliative care, transplantation, and home dialysis, which historically have been difficult for patients to access?
  • What variations in practice currently exist in providing these services, and what strategies can be identified that are effective and promising for dissemination?

Engagement, Trust, and Equity Considerations in Care Models: What is the impact of value-based care delivery programs on outcomes for vulnerable and underserved populations with complex care needs, as well as the providers who serve them?

Research on this theme could include quantitative analyses of available data to measure the effects of such care on patient outcomes, satisfaction with care, and costs, or qualitative evaluations of patients’ and providers’ experiences with these models. Specific examples of research topics of interest include:

• What are the challenges and benefits for physicians, advanced practice providers, and interdisciplinary team members in value-based care programs, including home-based services, after-hours services, integrated palliative care services, and population health services for patients with chronic kidney disease?
• How do patients and caregivers perceive value-based care services, such as in-home multispecialty care, compared with historical fee-for-service care on domains such as experience, trust, burden of care, and satisfaction?
• How does a focus on polychronic disease care, that is, a focus on two or more chronic medical conditions that require subspecialty care, affect disparities in kidney disease outcomes, such as by race, ethnicity, socioeconomic status, geography, and income?
• What strategies are successful in reducing burnout and decreasing turnover of in-home care providers?
• What strategies are helpful in building trust among patients and health care entities so that they might choose to participate in value-based care services?
  • What factors influence trust and engagement, and how might these factors influence the successful implementation and effectiveness of value-based care?
  • What factors contribute to variation in trust and engagement in value-based care, and how might these factors influence the effectiveness of value-based care?

The Effects of Payment Reform on Innovation in Value-Based Care: How does the current landscape for health policy and payment, including the growth of Medicare Advantage, changes in Medicaid funding, and the evolution of Centers for Medicare & Medicaid Services payment rules and priorities, affect high-risk populations and innovation in value-based care?

Specific examples of research topics of interest include:

• How has the growth of Medicare Advantage affected populations with chronic kidney disease and other chronic conditions, and how does that affect health care organizations, utilization, and patient outcomes?
  • What is the influence of network adequacy in Medicare Advantage on access to care for populations with chronic conditions, including access to kidney transplantation and dialysis?
• How might changes in Medicaid funding, such as the passage of H.R. 1, affect kidney care delivery?
• Under current payment policies, what are the most effective strategies for managing patients with polychronic conditions, including patients with chronic kidney disease who have additional comorbidities, such as diabetes, heart failure, and chronic obstructive pulmonary disease?
• How have payment policies affected the use of primary care, specialty care, and at-home care for patients with chronic kidney disease? How has this affected health care utilization and patient outcomes?
• What is the influence of kidney payment models, including Center for Medicare and Medicaid Innovation models such as ESRD Treatment Choices, Increasing Organ Transplant Access, and Kidney Care Choices, on care delivery for patients with chronic kidney disease and kidney failure?
  • What factors influence the acceptability and adoption of these payment models by health care systems and providers?

Available Data from Monogram Health and Humana Healthcare Research

As part of this research program, please note that the following data sources or opportunities may be made available.

• Monogram Health may make available a de-identified dataset for accepted retrospective research that draws from its clinical operations.
• Monogram Health may facilitate prospective data collection for accepted interventional or qualitative research projects.
• Humana Healthcare Research may provide access to data for projects that evaluate outcomes for beneficiaries enrolled in Medicare Advantage plans on a case-by-case basis.

Use of these data sources is not required; investigators are encouraged to propose the data sources best suited to their research questions. That said, if investigators seek to use any of these data sources or have questions about the data or the feasibility of a proposed study design, please contact Caleb Hearn at LDI.

Monogram Health Data Overview

Cohort and longitudinal follow-up: The Monogram dataset includes approximately 20,000 to 50,000 patients with at least two longitudinal data points collected during their enrollment in Monogram’s care program. The earliest data are available from 2019 forward, with variable coverage across time periods depending on patient enrollment date and market. Most of the data in scope for these research program is only available from 2022 onward. The dataset supports longitudinal analyses of patients over the course of their engagement with Monogram, including before and after key clinical events or transitions in care.

Types of data available: The dataset is drawn from Monogram’s clinical operations, not claims, and reflects what Monogram collects as a treating provider. Available data elements may include:

• Biometrics and labs: serial measurements of blood pressure, weight, eGFR, serum creatinine, HbA1c, urine albumin-to-creatinine ratio, and other point-of-care and laboratory values, with timestamps
• Visit and encounter data: visit type, such as home, telephonic, or virtual; visit date; visit frequency; and care team member type, such as NP, RN, or SW
• Medications: medication lists, changes, and recommendations, including SGLT2 inhibitors, GLP-1 agonists, and other disease-modifying therapies
• Disease and problem list: diagnoses, including CKD stage, as recorded; dialysis status and modality; comorbidities, including diabetes, CHF, COPD, hypertension, and others; and enrollment in conservative care or palliative pathways
• Social determinants of health: SDOH screening results, identified barriers, and referrals made
• Assessments: comprehensive health assessments, PHQ-9 and other behavioral health screenings, functional status, and care goals
• Enrollment and engagement: enrollment date, opt-in date, disenrollment reason, and engagement indicators

CKD stage over time: Timestamped eGFR and serum creatinine values are available for a subset of the longitudinal cohort, enabling inference of CKD stage trajectory for those patients. Coverage is not uniform across all patients or time periods. Investigators should account for this limitation in their proposed methods and note that a CKD stage variable as a discrete field may reflect the stage at first encounter rather than a longitudinal history of stage changes.

Outcomes: Outcomes are measurable within Monogram’s dataset and limited to those Monogram observes as a treating provider. Monogram-observed indicators for hospitalizations, emergency department use, dialysis initiation, and dialysis modality (home versus in-center) are present in the dataset, though their completeness is still being characterized. We recommend that investigators treat these as supplementary rather than primary outcome sources in their proposed methods. Full claims-based utilization and cost data are not available through this program. Investigators seeking to link Monogram data to external datasets, such as Medicare claims, CMS program data, USRDS, or area-level data using ZIP codes or counties, are encouraged to describe their linkage approach in their proposals; Monogram can provide geographic identifiers to support such linkage where permitted.

Provider-level data: The dataset supports analysis at the provider type level, such as NP-led versus RN-led encounters, and by care region. Individual provider identifiers are available for linkage within the dataset, but will be handled in accordance with applicable data use agreements.

Prospective and operationalized studies: For research proposals that extend beyond the currently available data scope, Monogram Health may support prospective data collection for investigator-defined populations over specified study periods. Such an arrangement might capture additional predefined clinical, operational, and patient-centered outcomes needed to address research questions that cannot be fully evaluated using existing retrospective data. By collecting standardized, real-world data on interventions that may improve patient outcomes, Monogram Health can support more comprehensive evaluations of effectiveness and implementation and, where appropriate, facilitate development of comparator or control cohorts to strengthen study design and comparative analysis. Investigators with prospective or interventional study ideas are encouraged to reach out to discuss feasibility before submitting.

Data access process: Investigators interested in using Monogram data should indicate this in their application and describe the specific data elements needed. We will leverage existing structures and protocols to ensure data transfer is done appropriately. Monogram will work with selected investigators to provide a de-identified dataset consistent with the scope of the approved proposal.

Available Data from Humana Healthcare Research

Humana may provide access to data for projects that evaluate outcomes for beneficiaries enrolled in Medicare Advantage plans on a case-by-case basis. This approval is a separate process from the Monogram data access process described above. Investigators interested in using Humana Healthcare Research data should indicate this in their application and describe the specific data elements needed. We will leverage existing structures and protocols to ensure data transfer is done appropriately. Humana will work with selected investigators to provide a de-identified dataset consistent with the approved proposal’s scope.

Data Information from Humana Healthcare Research (click the arow on the left for the dropdown)

HHR The Value of Integrated Health Databases (4)Download

HHR DEID Database – Table 1Download

HHR Data Element DetailsDownload

Eligibility

Proposals must be led by an LDI Senior Fellow. Penn faculty without an LDI affiliation and LDI Associate Fellows may participate as co-investigators. Non-Penn collaborators are permitted with justification.

Application Process and Timeline

The Advisory Committee will select up to two projects, each lasting 15 months.

Applications will be due Monday, September 28, 2026, at 11:59 p.m. ET. Funding decisions are expected to be made in October 2026. IRB approval is required before funds are released. PIs must submit their projects to the IRB for approval upon notice of funding. Selected projects are expected to start by January 2027.

Budget

Project budgets may not exceed $175,000. Faculty salaries and benefits may be included only with strong justification and may not exceed 20% of the award. Conference travel, equipment, or indirect costs are not allowed.

Selection Criteria

Up to two proposals will be funded. Applications will be reviewed by the Advisory Committee, including LDI experts, representatives from Monogram Health, and other external researchers.

Proposals will be evaluated based on:

• Impact: Potential to inform policymaking, improve value-based care models, or improve care delivery and outcomes for patients with complex care needs, such as patients with chronic kidney disease or patients with polychronic conditions, with preference for projects likely to inform practice.
• Investigator(s) and Team: The qualifications of the PI and team.
• Methods: Rigor and appropriateness of the research design, with preference for rigorous mixed-methods research, quasi-experimental study designs, or other rigorous study designs that appropriately address research questions in the listed thematic areas.
• Feasibility of Timeline: Likelihood of completion within the proposed timeline.

How to Apply

LDI Senior Fellows should complete the online application, which includes:

• Format: single-spaced, 11-point font, 0.5-inch margins
• Project Abstract: fewer than 250 words.
• Project Description including:
  • Aim(s) and Significance: approximately one page (or less), including a review of current literature.
  • Research Plan and Methods: approximately two pages (or more), including data sources, measures, and an analysis plan
• Budget:
  • An itemized budget of up to $175,000.
    • A budget justification, describing and justifying each budget item.
• Timeline and Milestones: up to 15 months, including quantifiable milestones.
• Biosketch(es): PI and co-investigators, following NIH format.
• Other Pending and Funded Proposals: with overlap noted.
• Appendices: essential supporting information only, such as survey instruments, interview guides, or letters of support.

Contact Information

If you have an idea but are unsure whether your project is feasible within this framework or proposed timeline, or if you have questions about Monogram data and would like to speak to a Monogram representative, please email Caleb Hearn.

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