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.
Quick facts
| Study type | Interventional |
|---|---|
| Sex | All |
| Enrollment | 68000 (estimated) |
| Sponsor | University of Massachusetts, Worcester Academic / other |
| Locations | 3 sites (Worcester, Massachusetts and 2 other locations) |
| Status | Recruiting |
| Started | October 8, 2025 |
| Main results expected | September 30, 2028 |
| Study ends | September 30, 2028 |
| Registry record updated | May 22, 2026 |
| Trial ID | NCT06903897 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
- Study coordinator: Arvin Garg
- Email: arvin.garg@umassmemorial.org
- Phone: 4103363261
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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.