Connecting adults with uncontrolled type 2 diabetes to social services using EHR-guided triage and community partners
THRIVE-DM: Improving Diabetes Care With Strategies For Addressing Health-Related Social Needs and Community Partnerships
This project will try an Epic-based triage tool plus community health workers to connect adults with uncontrolled type 2 diabetes and unmet social needs to community resources and routine medical care.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 900 (estimated) |
| Ages | 18 Years and up |
| Sex | All |
| Sponsor | Boston Medical Center Academic / other |
| Locations | 1 site (Boston, Massachusetts) |
| Trial ID | NCT07043426 on ClinicalTrials.gov |
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.
Who should consider this trial
Good fit: Adults with type 2 diabetes who have an HbA1c ≥9% and who screened positive for at least one health-related social need during a recent General Internal Medicine visit at Boston Medical Center.
Not a fit: Patients already in complex care management, receiving hospice, with type 1 diabetes, who are deceased, or who do not have uncontrolled HbA1c or identified social needs are unlikely to receive benefit from this intervention.
Why it matters
Potential benefit: If successful, patients could get faster, more reliable help for social needs that support better diabetes management and potentially improved blood sugar control.
How similar studies have performed: Previous THRIVE-like and clinic–community linkage programs have improved connections to resources and patient engagement, though impacts on long-term glycemic control have been mixed.
Eligibility criteria
Show full inclusion / exclusion criteria
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 this trial is running
Boston, Massachusetts
- 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
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.