Re-Engineered Discharge for Diabetes Care Transitions

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 interventional study tests a bedside social determinants of health (SDOH) screening tool combined with a care-coordination protocol after discharge for adults with type 2 diabetes. Participants are randomized to receive either a post-discharge navigation service or usual care, with follow-up surveys at 0, 30, and 90 days. A patient navigator helps address identified social needs during the 90 days after hospital discharge, while the control group receives standard resources. Data collection includes self-reported surveys and medical record abstraction to assess impact on readmission-related outcomes and social needs. The trial is conducted at UMASS Memorial Healthcare System with collaboration from NINR and the University of Michigan.

Why it matters

Who can join: the full rules

Inclusion Criteria:

* adult aged 18 years or older
* diagnosed with type 2 diabetes
* hospitalized at Univ of Massachusetts-affiliated hospital
* endorsed at least 1 unmet social need via screening survey

Exclusion Criteria:

* pregnancy
* discharge to short or long-term nursing facility or hospital
* medical contraindication
* cognitive impairment
* unable to provide informed consent

Where it's running

• UMASS Memorial Healthcare System
  Worcester, Massachusetts, United States Recruiting

Study contacts

• Study coordinator: Suzanne Mitchell, MD, MS
• Email: Suzanne.Mitchell2@umassmed.edu
• Phone: 774-441-6225

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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.