Phone or virtual outreach to connect adults with multiple chronic conditions to social services
Official title: Addressing Social Needs to Improve Health in Adults With Multiple Chronic Conditions
Run by Kaiser Permanente · NCT06941519 · Data updated 2026-11-12
This project will test whether higher-intensity phone outreach from a health navigator or lower-intensity virtual outreach better helps adults with multiple chronic conditions get social services, meet social needs, and close care gaps.
Quick facts
| Study type | Interventional |
|---|---|
| Ages | 18 Years and up |
| Sex | All |
| Enrollment | 800 (estimated) |
| Sponsor | Kaiser Permanente Academic / other |
| Locations | 1 site (Pleasanton, California) |
| Status | Recruiting |
| Started | September 1, 2025 |
| Main results expected | September 15, 2029 |
| Study ends | December 1, 2029 |
| Registry record updated | June 5, 2026 |
| Trial ID | NCT06941519 on ClinicalTrials.gov |
Is this trial a fit for you?
✓Likely a good fit
Ideal candidates are adults with two or more chronic medical conditions who have at least one self-reported social need and one or more gaps in evidence-based care, and who do not have major cognitive impairment.
✕Probably not a fit
Patients with major cognitive barriers (such as dementia or active psychosis), those with extremely high prior-year hospital use, or those without identifiable social needs are unlikely to benefit from these outreach approaches.
A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.
What this trial studies
This is a randomized comparative-effectiveness trial that assigns adults with multiple chronic conditions who report social needs and care gaps to one of two active outreach strategies: higher-intensity telephonic navigation with follow-up for up to three months, or lower-intensity virtual outreach via text, email, and/or mailed materials. Primary outcomes include receipt of social services, resolution of reported social needs, and closing of clinical care gaps, with secondary patient-centered outcomes also measured. The study includes qualitative focus groups with patients and interviews with navigators to understand how each approach works and barriers to impact. The trial is conducted within Kaiser Permanente's member population in the study region and uses both remote and system-linked data to track outcomes.
Why it matters
Potential benefit: If successful, the preferred outreach approach could help more patients with multiple chronic conditions obtain needed social services, reduce unmet social needs, and improve management of medical care.
How similar studies have gone: Previous work on patient navigation and social needs interventions has shown mixed but promising results, with higher-touch navigation often linking more people to services though effects on clinical outcomes have varied.
Who can join: the full rules
Show full inclusion / exclusion criteria
Inclusion Criteria:
* Two or more chronic medical conditions from a defined list of 24 chronic conditions
* One or more gaps in evidence-based care (related to condition-specific risk factor management, evidence-based screening and preventive care, missed appointments, and medication non-adherence),
* At least one self-reported social-related barrier to care or "social need" (e.g., transportation, food, housing, utilities, and/or financial insecurity).
Exclusion Criteria:
* major cognitive barriers (dementia, psychosis).
* multiple prior year hospitalizations ("extremely high utilizers")
Where it's running
-
Division of Research
Pleasanton, California, United States Recruiting
Study contacts
- Principal investigator: Richard W Grant, MD MPH — Kaiser Permanente
- Study coordinator: Karen R Estacio, MHA
- Email: karen.r.estacio@kp.org
- Phone: 510.891.5960
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How to take part
- Review the eligibility criteria above with your treating physician.
- Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
- Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.