WE CARE social needs screening and referral for families in primary care
Improving Chronic Disease Outcomes Across the Lifespan by Addressing Structural Racism
This project will test whether using the WE CARE social needs screening and referral program with an antiracist approach in family medicine can help reduce chronic conditions like diabetes, high blood pressure, depression, high cholesterol, and pediatric asthma for minoritized patients.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 68000 (estimated) |
| Sex | All |
| Sponsor | University of Massachusetts, Worcester Academic / other |
| Locations | 3 sites (Worcester, Massachusetts and 2 other locations) |
| Trial ID | NCT06903897 on ClinicalTrials.gov |
What this trial studies
A multidisciplinary team will apply an antiracism framework to the evidence-based WE CARE social determinants of health (SDOH) screening and referral system and develop a toolkit to reduce bias and unequal treatment for families of color. Investigators will conduct qualitative interviews with adult patients and caregivers about experiences with racism and SDOH screening and then share findings with clinic and community stakeholders to gather implementation ideas. The protocol will be refined with input from antiracism and implementation experts and then rolled out in three family medicine clinics using a stepped-wedge cluster randomized design as a hybrid effectiveness-implementation trial. The study will monitor clinical measures for hypertension, diabetes, hyperlipidemia, depression, and pediatric asthma to see if the intervention reduces racial/ethnic disparities in these conditions.
Who should consider this trial
Good fit: Adults and children who receive family medicine care at the participating Worcester clinics and have a diagnosis of hypertension, diabetes, hyperlipidemia, depression, or pediatric asthma—particularly patients from racial/ethnic minoritized groups—are the intended participants.
Not a fit: Patients who do not have one of the specified diagnoses, who do not receive care at the participating sites, or whose health issues are unlikely to be influenced by addressing social needs are unlikely to benefit from this intervention.
Why it matters
Potential benefit: If successful, the intervention could reduce racial and ethnic disparities in chronic disease outcomes by improving connections to social resources and reducing biased implementation in primary care.
How similar studies have performed: Prior SDOH screening-and-referral programs have shown mixed but promising results in linking patients to resources, while using an explicit antiracism-informed implementation approach at this scale is relatively novel.
Eligibility criteria
Show full inclusion / exclusion criteria
Inclusion Criteria: * Adults and children with diagnosed chronic diseases (hypertension, diabetes mellitus, hyperlipidemia, asthma, or depression) who receive Family Medicine care at one of the study sites. * Children (\<18 years of age) with a diagnosis of asthma. * Adult patients (18 years or older) with a diagnosis of diabetes mellitus, hypertension, hyperlipidemia and/or depression. Exclusion Criteria: * In adults (\>18 years of age), those without one or more of the following diagnoses as recorded by ICD-10 codes in their EHR: hypertension, hyperlipidemia, diabetes mellitus, or depression. * In children (\<18 years of age), those without a diagnosis of asthma.
Where this trial is running
Worcester, Massachusetts and 2 other locations
- (Benedict) UMass Memorial Medical Center - Adult Primary Care — Worcester, Massachusetts, United States (Not_yet_recruiting)
- UMass Memorial Medical Center - Hahnemann Campus — Worcester, Massachusetts, United States (Recruiting)
- Family Health Center of Worcester — Worcester, Massachusetts, United States (Not_yet_recruiting)
Study contacts
- Study coordinator: Arvin Garg
- Email: arvin.garg@umassmemorial.org
- Phone: 4103363261
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.