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Community Health Workers in an Interdisciplinary Outpatient CKD Clinic to Optimize Social Care Navigation, Patient Engagement, and Home Dialysis Utilization

RecruitingNAAges 18 Years - anyAllMontefiore Medical Center
NCT06925776 on ClinicalTrials.gov ↗
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In plain words

What the trial is, and whether it could suit you

The goal of this clinical trial is to learn if this intervention (the CHOOSE Home intervention) is feasible and may lead to more home dialysis usage in a high-risk patient population. The main questions it aims to answer are: * Will there be an increase in home dialysis selection or initiation over study follow up? * Will there be a change in patient reported status of Health-Related Social Needs (HRSNs) and patient engagement at 1 year follow up? Researchers will compare the intervention group that will include interdisciplinary care (IDC) and the integration of a Community Health Worker (CHW) into the chronic kidney disease (CKD) care process to the IDC only control group. The research team will assess whether the intervention led to better social care navigation, enhanced patient engagement, and increased home dialysis use.

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📋 Eligibility rules (as published)
Inclusion Criteria: * Age ≥ 18 years * Advanced CKD (defined by estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73m2 or less using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation) * English or Spanish speaking * Provide informed consent * Followed by a nephrologist at Montefiore and seen within last 12 months * Willing to receive interdisciplinary care (i.e., nurse practitioner facilitated CKD education and care coordination) Exclusion Criteria: * Active malignancy * Anticipated survival is less than 1 year as determined by the patient's treating nephrologist * Opting to do medical management only (non- dialysis supportive care) for management of their kidney failure * Plan to relocate outside of New York City within the next 12 months
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What it tests

  • CHOOSE Home Intervention
  • Usual Care
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Where

1 site
Albert Einstein College of Medicine
The Bronx, United States
🤝 Taking part is your choice, and you can leave at any time. Only the trial team can confirm you are eligible — always decide together with your own doctor.
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