Social Determinants of Health (SDOH)
Conditions
Brief summary
This study is being done to determine if assistance in accessing community resources can improve health outcomes. Social determinants of health are the conditions in which individuals are born, work and live that can impact health. These can include access to healthcare, healthy food, education, safe neighborhoods, transportation, political and social environments that are safe and fair.
Interventions
BEHAVIORALThe Open Table
An organization that connects community volunteers to individuals in need to help overcome life's challenges.
Sponsors
National Center for Advancing Translational Sciences (NCATS)
Mayo Clinic
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
OTHER
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
\- Identified social determinants of health (SDOH). need that impacts healthcare outcomes (identified by the healthcare team)
Exclusion criteria
* Non-english speaking patients * Patients who are pregnant
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Baseline and 12 months | Evaluated using the CMS Accountable Health SDOH Screening Tool used to assess patient needs across the following domains: house instability, food insecurity, transportation problems, utility help needs, interpersonal safety, financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities that community services can help with. If the participant chose the underlined option, they might have an unmet health-related social need. Only domains where an unmet health-related social need was identified was included in the analysis. |
| Change in Resilience | Baseline and 12 months | Evaluated using the 6-item Brief Resilience Scale (BRS) questionnaire assessing the participants ability to bounce back on a 1-5 scale range. Total questions scores are divided by total number of questions answered for a final score range from 1.00-2.99 = low resilience; 3.00-4.30 = normal resilience; 4.31-5.00 = high resilience. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Hospitalizations | Baseline and 12 months | Difference in total number of hospitalizations in the 12 months before intervention and 12 months during intervention. |
| Emergency Room Visits | Baseline and 12 months | Difference in total number of emergency room visits in the 12 months before intervention and 12 months during intervention. |
| Primary Care Visits | Baseline and 12 months | Difference in total number of primary care visits in the 12 months before intervention and 12 months during intervention. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| The Open Table Model Subjects identified as having their health negatively impacted by Social Determinants of Health (SDOH) met with The Open Table members to determine their specific needs, decide on a plan for overcoming this need and following up to ensure resolution.
The Open Table: An organization that connects community volunteers to individuals in need to help overcome life's challenges. | 12 |
| Total | 12 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Lost to Follow-up | 3 |
Baseline characteristics
| Characteristic | The Open Table Model |
|---|---|
| Age, Continuous | 46.0 years STANDARD_DEVIATION 18.01 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 6 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 3 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 3 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 3 Participants |
| Race (NIH/OMB) More than one race | 1 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants |
| Race (NIH/OMB) White | 7 Participants |
| Region of Enrollment United States | 12 participants |
| Sex: Female, Male Female | 8 Participants |
| Sex: Female, Male Male | 4 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 12 |
| other Total, other adverse events | 0 / 12 |
| serious Total, serious adverse events | 0 / 12 |
Outcome results
Primary
Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment
Evaluated using the CMS Accountable Health SDOH Screening Tool used to assess patient needs across the following domains: house instability, food insecurity, transportation problems, utility help needs, interpersonal safety, financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities that community services can help with. If the participant chose the underlined option, they might have an unmet health-related social need. Only domains where an unmet health-related social need was identified was included in the analysis.
Time frame: Baseline and 12 months
Population: 3 participants did not complete the CMS accountable health SDOH screening assessment at 12 months.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Food Insecurity-Baseline | 6 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Food Insecurity-12 Months | 5 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Financial Strain-Baseline | 9 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Financial Strain-12 Months | 5 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Family and Community Support-Baseline | 10 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Family and Community Support-12 Months | 7 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Physical Activity-Baseline | 9 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Physical Activity-12 Months | 7 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Disability-Baseline | 12 Participants |
| The Open Table Model | Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment | Disability-12 Months | 8 Participants |
Comparison: Food Insecurityp-value: >0.999Wilcoxon (Mann-Whitney)
Comparison: Financial Insecurityp-value: 0.25Wilcoxon (Mann-Whitney)
Comparison: Social Isolationp-value: >0.999Wilcoxon (Mann-Whitney)
Comparison: Physical Inactivityp-value: >0.999Wilcoxon (Mann-Whitney)
Comparison: Disabilityp-value: >0.999Wilcoxon (Mann-Whitney)
Primary
Change in Resilience
Evaluated using the 6-item Brief Resilience Scale (BRS) questionnaire assessing the participants ability to bounce back on a 1-5 scale range. Total questions scores are divided by total number of questions answered for a final score range from 1.00-2.99 = low resilience; 3.00-4.30 = normal resilience; 4.31-5.00 = high resilience.
Time frame: Baseline and 12 months
Population: 3 participants did not complete the BRS questionnaire at 12 months.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| The Open Table Model | Change in Resilience | Baseline | 3.0 score on a scale | Standard Deviation 0.94 |
| The Open Table Model | Change in Resilience | 12 Months | 3.3 score on a scale | Standard Deviation 0.98 |
p-value: 0.461Wilcoxon (Mann-Whitney)
Secondary
Emergency Room Visits
Difference in total number of emergency room visits in the 12 months before intervention and 12 months during intervention.
Time frame: Baseline and 12 months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| The Open Table Model | Emergency Room Visits | Baseline | 1.7 Visits | Standard Deviation 1.5 |
| The Open Table Model | Emergency Room Visits | 12 Months | 1.2 Visits | Standard Deviation 1.85 |
p-value: 0.438Wilcoxon (Mann-Whitney)
Secondary
Hospitalizations
Difference in total number of hospitalizations in the 12 months before intervention and 12 months during intervention.
Time frame: Baseline and 12 months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| The Open Table Model | Hospitalizations | Baseline | 0.3 Hospitalizations | Standard Deviation 0.62 |
| The Open Table Model | Hospitalizations | 12 Months | 0.3 Hospitalizations | Standard Deviation 0.89 |
p-value: >0.999Wilcoxon (Mann-Whitney)
Secondary
Primary Care Visits
Difference in total number of primary care visits in the 12 months before intervention and 12 months during intervention.
Time frame: Baseline and 12 months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| The Open Table Model | Primary Care Visits | Baseline | 8.3 Visits | Standard Deviation 6.94 |
| The Open Table Model | Primary Care Visits | 12 Months | 5.5 Visits | Standard Deviation 5.32 |
p-value: 0.08Wilcoxon (Mann-Whitney)