Clinical trial Recruiting at 1 site Interventional

WE CARE social needs screening and referral for families in primary care

Official title: Improving Chronic Disease Outcomes Across the Lifespan by Addressing Structural Racism

Run by University of Massachusetts, Worcester · NCT06903897 · Data updated 2026-11-12

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.

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Quick facts

Study typeInterventional
SexAll
Enrollment68000 (estimated)
SponsorUniversity of Massachusetts, Worcester
Academic / other
Locations3 sites (Worcester, Massachusetts and 2 other locations)
StatusRecruiting
StartedOctober 8, 2025
Main results expectedSeptember 30, 2028
Study endsSeptember 30, 2028
Registry record updatedMay 22, 2026
Trial IDNCT06903897 on ClinicalTrials.gov

Is this trial a fit for you?

Likely a 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.

Probably 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.

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

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.

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 gone: 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.

Who can join: the full rules

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 it's running

  • UMass Memorial Medical Center - Hahnemann Campus
    Worcester, Massachusetts, United States
    Recruiting
  • Family Health Center of Worcester
    Worcester, Massachusetts, United States
    Not yet recruiting
  • UMass Memorial Medical Center -Benedict Family Medicine Clinic
    Worcester, Massachusetts, United States
    Not yet recruiting

Study contacts

Similar studies

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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.
Last reviewed 2026-11-14 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.