Social Risk Score, Clinical Decision Support Tool and Closed Loop Referral for Social Risk Screen… (NCT05574699) | Clinical Trial Compass
CompletedNot Applicable
Social Risk Score, Clinical Decision Support Tool and Closed Loop Referral for Social Risk Screen and Referral
United States251 participantsStarted 2023-04-30
Plain-language summary
The overarching goal of this project is to leverage health information technology (HIT) to integrate available digital information on social needs to improve care for racial and ethnic minorities and socially disadvantaged populations with chronic diseases.
In the previous phases of this project the investigators developed a social risk score to identify social needs among medically under-served patients with special emphasis on application among African American patients with low income and chronic diseases who face social determinants, risk factors, and needs (SDRN) challenges. The investigators also developed a clinical decision support (CDS) tool to present the social risk score to clinical providers and sought feedback from different users on the face and content validity of the CDS tool.
In the current project the investigators will run a randomized clinical trial (RCT) study to pilot test the new risk score and CDS tool in selected primary care clinics at Johns Hopkins Health System (JHHS) and in collaboration with selected community-based organizations (CBOs). This system will help identify, manage, and refer patients with both high levels of disease burden and modifiable SDRN challenges.
Who can participate
Age range
18 Years
Sex
ALL
See this in plain English?
AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.
Inclusion Criteria:
* Adult (18+ years old) African-American patients with low income at each clinic
Exclusion Criteria:
* Children are excluded from this study. Individuals with high levels of income, and those with race other than African American
Questions worth asking your doctor
Bring these to your next appointment. They're a starting point for a shared conversation — not a sign you qualify or a recommendation to enrol.
1This trial is already completed — has the data been published yet, and if so, did the social risk screening and referral tool actually reduce emergency department visits for patients with conditions like mine, such as diabetes or hypertension?
2How does a 'closed loop referral' work in practice — meaning, if I were screened for social risks like housing or food insecurity, what would actually happen next and how would my care team know if I got the help I was referred to?
3Since this study focused on chronic diseases like congestive heart failure and hypertension, do you currently use any similar social risk screening tools in our own clinic, and would that kind of support be available to me?
4The trial measured emergency department visits as its main outcome — does that suggest my social circumstances, like transportation or financial stress, might be contributing to my risk of ending up in the ER, and is that something we should be addressing together?
5Are there any findings from this completed trial that might change how you approach my care plan, particularly around connecting me to community resources alongside my medical treatment?
Generated to help you prepare — always confirm anything about your own eligibility and care with the study team and your doctor.
Questions for the trial coordinator
The trial coordinator is the person who runs the study day to day. These cover the practical side — logistics, costs, and what taking part would actually mean for your life. The study team confirms whether you meet the criteria; these are questions to ask, not a sign you qualify.
1What does taking part actually involve week to week — how many visits, where, and how long does each one take?
2What costs are covered by the study, and what might I have to pay for myself, including travel, parking, or time off work?
3What happens during screening, and what happens if the study team confirms I don't meet the criteria after those tests?
4Who pays for the scans, blood work, and other tests the trial requires — the study, my insurance, or me?
5How will being in the trial affect my regular care, and will my own doctor stay informed and involved?
6Can I leave the trial at any point if I change my mind, and what would happen to my care if I do?
A starting point for the conversation — always confirm anything about your own eligibility, costs, and care with the study team and your doctor.