Re-Engineered Discharge for Diabetes Care Transitions
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: REDDCAT2 Post-Discharge Navigation, Treatment as Usual (TAU).
- Who it may be relevant to
- Registry conditions: Diabetes Mellitus Type 2, Social Determinants of Health (SDOH), Hospital Readmission. Basic parameters: from 18 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- United States
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
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Official title
Re-Engineered Discharge for Diabetes Care Transitions: Screening and Addressing Social Determinants of Health Needs at Hospital Discharge
Overview
The goal of this project is to test a novel bedside SDOH screening intervention coupled with post-discharge navigation for hospitalized patients with a diabetes diagnosis to reduce unmet social needs, compared to usual care.
Detailed description
The investigators are conducting this research to test a computer-based screening tool and a care coordination protocol to help people with type 2 diabetes who report unmet social determinants of health.
Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. - Office of Disease Prevention and Health Promotion Examples of SDOH include factors such as housing, transportation, education, job opportunities, income, and access to healthy food, clean air and water, and health care services. Participants who join this research will be asked to complete a screening survey about their health. Then, participants will be randomly assigned (like pulling a name out of a hat) to one of two groups:
* Those in Group 1 will be partnered with a patient navigator whose role will be to review the results of the screening survey and help coordinate care before leaving the hospital and for 90 days after. * Those in Group 2 will receive treatment as usual. A list of community-based resources will be provided.
Participants in both groups will complete surveys at the beginning of the study and again at 30 and 90 days after leaving the hospital. The investigators will make reminder calls to participants in both groups about data collection and will collect information from the medical record for as long as 90 days after leaving the hospital.
Interventions
- Behavioral REDDCAT2 Post-Discharge Navigation
Those in the REDDCAT2 intervention group will be partnered with a patient navigator whose role will be to review the results of the screening survey completed at the beginning of the study. The patient navigator will help coordinate the participant's care before leaving the hospital and for 90 days after. Together, the participant and navigator will form an action plan intended to help address personal, social, or community factors affecting the participant's health. The navigator is expected to - Other Treatment as Usual (TAU)
TAU participants will receive standard care from the UMass Memorial Healthcare (UMMH) hospitalist team as appropriate. Participants will receive a printed list of community resources. No study-related patient navigation support will be provided. In 2024, Centers for Medicare and Medicaid Services mandated social determinants of health (SDOH) screening for inpatients. UMMH will use a checklist social needs screener. It will be up to the hospitalist teams to act on SDOH screening results. The UMM
Primary outcome measures
- Time to hospital service use post-discharge [Time frame: 90 days]
Secondary outcome measures (12)
- Changes in weight/body mass index (BMI) [Time frame: Baseline, 30, and 90 days]
- Changes in Pain Management [Time frame: Baseline, 30, and 90 days]
- Changes in Self-Management Adherence [Time frame: Baseline, 30, and 90 days]
- Changes in Illness Burden perception [Time frame: Baseline, 30, and 90 days]
- Changes in Substance Use [Time frame: Baseline, 30, and 90 days]
- Changes in Alcohol Use [Time frame: Baseline, 30, and 90 days]
- Changes in Diabetes Stigma [Time frame: Baseline, 30, and 90 days]
- Changes in Economic Quality of Life [Time frame: Baseline, 30, and 90 days]
- Changes in Depressive Symptoms [Time frame: Baseline, 30, and 90 days]
- Changes in Anxiety Symptoms [Time frame: Baseline, 30, and 90 days]
- Changes in Emotional Support [Time frame: Baseline, 30, and 90 days]
- Changes in Health Seeking Behavior [Time frame: Baseline, 30, and 90 days]
Eligibility criteria
Inclusion criteria
- adult aged 18 years or older
- diagnosed with type 2 diabetes
- hospitalized at Univ of Massachusetts-affiliated hospital
- endorsed at least 1 unmet social need via screening survey
Exclusion criteria
- pregnancy
- discharge to short or long-term nursing facility or hospital
- medical contraindication
- cognitive impairment
- unable to provide informed consent
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Open label
- Primary purpose
- Prevention
Study locations
United States · 1 center
- UMASS Memorial Healthcare System — Worcester
Identifiers
NCT: NCT06869057 · STUDY00002129 · R01NR021826