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Improving Diabetes Care With Strategies For Addressing Health-Related Social Needs and Community Partnerships

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About this study

The goal of this study is to develop, implement, and evaluate a patient-centered triage and referral model designed to improve health outcomes for individuals with uncontrolled type 2 diabetes mellitus (T2DM) and unmet health-related social needs. The intervention builds on the existing THRIVE infrastructure at Boston Medical Center (BMC), which includes screening for social needs and a resource referral guide. It integrates medical and social care by embedding a data-driven triage tool within the EPIC electronic health record system, engaging community health workers trained in population health, and initiating closed-loop EPIC integrated referrals to community-based organizations. This study will use a hybrid type 3 effectiveness-implementation trial design to evaluate the implementation of the THRIVE-DM intervention at the clinic level. Preliminary effectiveness will be assessed by comparing THRIVE-DM to usual care in its ability to increase patient connections to community-based organizations and improve clinical outcomes. Using a stratified randomization approach, the investigators will compare referral closure rates, receipt of social services, hemoglobin A1C levels, and patterns of health service utilization between patients enrolled in THRIVE-DM and those receiving standard care

Condition
Diabetes Mellitus, Type 2
Tested
THRIVE-DM, Standard of care
Sponsor
Boston Medical Center

Who can join

Age
18 years and older
Sex
All sexes
Healthy volunteers
Not accepted

Inclusion 5

  • Minimum age: 18 years
  • Study condition: Diabetes Mellitus, Type 2
  • Diagnosis: Must have a diagnosis of Type 2 Diabetes Mellitus (T2DM), confirmed by a current diagnosis in the medical record or at least two billing codes in the last two years, or an HbA1c level ≥6.5% in the last two years.
  • Uncontrolled T2DM: Must have an HbA1c ≥9% at the time of screening.
  • Health-Related Social Needs: Must have been screened for health related social needs (HRSNs) during a General Internal Medicine (GIM) visit in the last 3 months and screened positive for at least one HRSN.

Exclusion 4

  • Patients enrolled in Complex Care Management (CCM).
  • Patients receiving hospice care.
  • Patients who are deceased
  • Patients with Type 1 Diabetes Mellitus (T1DM).

Where

1 site, 1 recruiting

Boston Medical Center

Boston, Massachusetts, United States

Recruiting

Contact

Potential match only. Final eligibility is determined by the study team.