Re-Engineered Discharge for Diabetes Care Transitions
Ориентир для пациента и семьи
Простыми словами
Автоматическая сводка по структурированным данным реестра. Она помогает сориентироваться, но не заменяет официальный протокол или оценку врача.
- Что изучают
- В протоколе указаны: REDDCAT2 Post-Discharge Navigation, Treatment as Usual (TAU).
- Кому может быть актуально
- Состояния в реестре: Diabetes Mellitus Type 2, Social Determinants of Health (SDOH), Hospital Readmission. Базовые параметры: от 18 лет · Все.
- Что важно проверить
- Возраст, диагноз и пол — только базовые ориентиры. Предыдущее лечение, анализы и другие обязательные условия указаны ниже в критериях участия.
- Где проводится
- США
- Следующий шаг
- Сохраните исследование, покажите его лечащему врачу и уточните актуальный статус у исследовательского центра. Расходы, документы и поездка →
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Официальное название
Re-Engineered Discharge for Diabetes Care Transitions: Screening and Addressing Social Determinants of Health Needs at Hospital Discharge
Обзор
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.
Подробное описание
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.
Вмешательства
- Поведенческое 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 - Другое 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
Первичные конечные точки
- Time to hospital service use post-discharge [Срок оценки: 90 days]
Вторичные конечные точки (12)
- Changes in weight/body mass index (BMI) [Срок оценки: Baseline, 30, and 90 days]
- Changes in Pain Management [Срок оценки: Baseline, 30, and 90 days]
- Changes in Self-Management Adherence [Срок оценки: Baseline, 30, and 90 days]
- Changes in Illness Burden perception [Срок оценки: Baseline, 30, and 90 days]
- Changes in Substance Use [Срок оценки: Baseline, 30, and 90 days]
- Changes in Alcohol Use [Срок оценки: Baseline, 30, and 90 days]
- Changes in Diabetes Stigma [Срок оценки: Baseline, 30, and 90 days]
- Changes in Economic Quality of Life [Срок оценки: Baseline, 30, and 90 days]
- Changes in Depressive Symptoms [Срок оценки: Baseline, 30, and 90 days]
- Changes in Anxiety Symptoms [Срок оценки: Baseline, 30, and 90 days]
- Changes in Emotional Support [Срок оценки: Baseline, 30, and 90 days]
- Changes in Health Seeking Behavior [Срок оценки: Baseline, 30, and 90 days]
Критерии участия
Критерии включения
- 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
Критерии исключения
- pregnancy
- discharge to short or long-term nursing facility or hospital
- medical contraindication
- cognitive impairment
- unable to provide informed consent
Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.
Здоровые добровольцы: Нет
Дизайн исследования
- Распределение
- Рандомизированное
- Модель
- Параллельные группы
- Маскирование
- Открытое
- Основная цель
- Профилактика
Центры проведения
США · 1 центр
- UMASS Memorial Healthcare System — Worcester
Идентификаторы
NCT: NCT06869057 · STUDY00002129 · R01NR021826