Community Health Worker–integrated outpatient care to boost home dialysis use
Community Health Workers in an Interdisciplinary Outpatient CKD Clinic to Optimize Social Care Navigation, Patient Engagement, and Home Dialysis Utilization- the CHOOSE Home Trial
NA · Montefiore Medical Center · NCT06925776
This trial will test whether adding a community health worker to interdisciplinary outpatient kidney care helps adults with advanced CKD choose and start home dialysis and improves social needs and engagement.
Quick facts
| Phase | NA |
|---|---|
| Study type | Interventional |
| Enrollment | 106 (estimated) |
| Ages | 18 Years and up |
| Sex | All |
| Sponsor | Montefiore Medical Center (other) |
| Locations | 1 site (The Bronx, New York) |
| Trial ID | NCT06925776 on ClinicalTrials.gov |
What this trial studies
Participants with advanced chronic kidney disease who are followed at Montefiore will be assigned to receive interdisciplinary care with a Community Health Worker (CHW) integrated into care or to interdisciplinary care alone. The team will use mixed quantitative and qualitative measures organized by the RE-AIM framework to evaluate feasibility, acceptability, and possible effects. Main outcomes include changes in home dialysis selection or initiation, patient-reported health-related social needs, and patient engagement at one year. The protocol was refined with input from community partners and brings together experts in CKD care, social determinants of health, and implementation science.
Who should consider this trial
Good fit: Adults (≥18) with advanced CKD (eGFR ≤ 25 ml/min/1.73 m2), English- or Spanish-speaking, followed by a Montefiore nephrologist, able to consent and willing to receive interdisciplinary care are ideal candidates.
Not a fit: Patients with active malignancy, anticipated survival under one year, those choosing medical (non-dialysis) supportive care, or those planning to leave New York City within 12 months are unlikely to benefit from this intervention.
Why it matters
Potential benefit: If successful, this approach could increase home dialysis uptake and help patients better navigate social needs and engage with their care.
How similar studies have performed: Community health worker and interdisciplinary care models have improved engagement and social needs in other chronic diseases, but using CHWs specifically to increase home dialysis uptake is relatively novel and not extensively tested.
Eligibility criteria
Show full inclusion / exclusion criteria
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
Where this trial is running
The Bronx, New York
- Albert Einstein College of Medicine — The Bronx, New York, United States (RECRUITING)
Study contacts
- Principal investigator: Tanya S Johns, MD, MHS — Albert Einstein College of Medicine
- Study coordinator: Yaxkyn A Mejia, BS
- Email: yaxkyn.mejia@einsteinmed.edu
- Phone: 718-430-2064
How to participate
- Review the eligibility criteria above with your treating physician.
- Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
- Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions: Kidney Replacement Therapy, Community Health Worker, Interdisciplinary Care, home dialysis, Health-Related Social Needs, patent engagement, Hemodialysis, home hemodialysis