MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients (NCT07599852) | Clinical Trial Compass
Not Yet RecruitingNot Applicable
MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients
United States45 participantsStarted 2029-05-01
Plain-language summary
This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes manage their medications after leaving the hospital. Many patients with diabetes take multiple medications, and changes to these medications during hospital stays can cause confusion and lead to missed doses or incorrect use. This is especially common in communities with limited access to healthcare.
The study uses a computer-based tool called MEDBRIDGE (MEDication BRIDGE) to identify patients who may be at higher risk for problems after discharge, such as worsening blood sugar control or return visits to the emergency department. Patients identified as high-risk will receive 3 months of support from a nurse case manager and community health worker team, who will help with medication questions, coordinate with their doctor, and provide follow-up check-ins.
The main goal is to find out whether this type of support program is practical to deliver and acceptable to patients. The study will also track changes in blood sugar levels and emergency department visits. Forty-five patients will be enrolled over 6 months at the University of Alabama at Birmingham and Cooper Green Mercy Health Services in Jefferson County, Alabama.
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:
* Adults aged 18 years or older
* Diagnosis of type 2 diabetes (HbA1c of 6.5% or higher or relevant ICD-10 codes including E11, E13, E14, R73, L97.509, K31.84)
* Discharged from UAB Hospital or its emergency departments
* Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic
* Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge
Exclusion Criteria:
* Under age 18
* No indication of type 2 diabetes
* Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care
* Unable to provide informed consent
* Currently enrolled in another post-discharge intervention study
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 listed as 'not yet recruiting' — do you know when it's expected to open for enrollment, and should I be considering other options in the meantime?
2Since this study is measuring things like recruitment rate and patient acceptability rather than whether my blood sugar actually improves, what would I personally gain from joining, given that the focus seems to be on testing whether the program itself works?
3The trial involves support from nurse case managers or community health workers after a hospital discharge — does my current situation involve the kind of care transition this study is designed for, or would this not really apply to where I am in my treatment?
4This study targets high-risk Type 2 Diabetes patients with medication adherence issues — can you help me understand whether my current medication situation is serious enough that this kind of structured post-discharge support might make a real difference for me?
5Since this is a feasibility-type study with no listed phase, what does that mean for how much is already known about this approach's safety and benefit, and is there a more established standard-of-care option I should pursue first?
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.