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

RecruitingNAAges 18 Years - anyAllBoston Medical Center
NCT07043426 on ClinicalTrials.gov ↗
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In plain words

What the trial is, and whether it could suit you

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 c

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📋 Eligibility rules (as published)
Inclusion Criteria: * 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 Criteria: * Patients enrolled in Complex Care Management (CCM). * Patients receiving hospice care. * Patients who are deceased * Patients with Type 1 Diabetes Mellitus (T1DM).
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What it tests

  • THRIVE-DM
  • Standard of care
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Where

1 site
Boston Medical Center
Boston, 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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