Connecting adults with uncontrolled type 2 diabetes to social services using EHR-guided triage and community partners

Is this trial a fit for you?

A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.

What this trial studies

This clinic-level hybrid type 3 effectiveness-implementation effort embeds a data-driven THRIVE-DM triage tool into the Epic electronic health record and initiates closed-loop referrals to community-based organizations. Community health workers trained in population health will be deployed to manage referrals and link medical and social care. Clinics using THRIVE-DM will be compared with usual care to measure preliminary effectiveness for increasing patient connections to community resources and for changes in glycemic control. Implementation outcomes such as reach, adoption, fidelity, and integration with clinic workflows will also be measured to inform broader rollout.

Why it matters

Who can join: the full rules

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).

Where it's running

• Boston Medical Center
  Boston, Massachusetts, United States Recruiting

Study contacts

• Principal investigator: Michael Fischer, MD — Boston Medical Center, Internal Medicine
• Study coordinator: Michael Fischer, MD
• Email: Michael.Fischer@bmc.org
• Phone: 617-414-7288

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How to take part

1. Review the eligibility criteria above with your treating physician.
2. Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
3. Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.