Health-related Social Problems, Hyperlipidemia, Hypertension, Type 2 Diabetes
Conditions
Brief summary
The goal of this study is to evaluate the effectiveness of a multi-level health-related social needs (HRSN) initiative among adult patients diagnosed with type 2 diabetes, plus hypertension or hyperlipidemia. The multi-level initiative includes HRSN data collection, training and tools for health care professionals, care coordinator support, and community resources. Patients with type 2 diabetes plus hypertension or hyperlipidemia will be screened for HRSN as part of the primary care clinic intake process to assess if patients have any social needs (like difficulty with getting food, housing, or transportation). If patients screen positive for having social needs, then patients will be offered support, which can include help from primary care providers with adjusting a patient's disease management plan, referrals to care coordinators to provide additional assistance in addressing social needs, and information about community organizations that offer resources for social needs. The initiative will be integrated as a system change across VUMC adult primary care practices. The investigators will use a prospective, single-arm clinical trial to evaluate effects on clinical outcomes for 12 months. Data will be extracted from the EHR on adult patients diagnosed with type 2 diabetes, and either hypertension or hyperlipidemia. The investigators hypothesize that the initiative will reduce the impact of HRSN on clinical outcomes over the study period. The investigators will also administer surveys to a subgroup of patients to examine trends in self-reported psychosocial and behavioral measures over the course of the initiative.
Interventions
OTHERMulti-level HRSN initiative
The multi-level health-related social needs (HRSN) initiative includes multiple components aimed at assessing and addressing HRSN in clinical practice: HRSN screening, EHR tools for clinical decision support, training and tools for health care providers to address HRSN, care coordinator support for patient outreach, and community resources for referral and support.
Sponsors
Vanderbilt University Medical Center
National Institute on Minority Health and Health Disparities (NIMHD)
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
ELIGIBILITY CRITERIA FOR EHR DATA EXTRACTION Inclusion Criteria: * 18 years of age or older * Completed the health-related social needs (HRSN) screener as part of a primary care visit * Diagnosed with type 2 diabetes, plus hypertension and/or hyperlipidemia as reflected by ICD-10 billing codes * Receive care at one of six partner Vanderbilt University Medical Center primary care clinics: South One Hundred Oaks, North One Hundred Oaks, Green Hills, Hillsboro Medical Group, Melrose, Bellevue ELIGIBILITY CRITERIA FOR PATIENT SURVEYS (subset of EHR data) Inclusion Criteria: * 18 years of age or older * Completed the HRSN screener as part of a primary care visit * Diagnosed with type 2 diabetes * Receive care at one of six partner Vanderbilt University Medical Center primary care clinics: South One Hundred Oaks, North One Hundred Oaks, Green Hills, Hillsboro Medical Group, Melrose, Bellevue * English-speaking
Exclusion criteria
* Blindness * Hearing impairment * Conditions that would interfere with survey completion (e.g., significant dementia, active psychosis or mania) * Being near the end of life (hospice or home hospice)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in glycemic control | Baseline and 12 months post-baseline | Hemoglobin A1c extracted from the electronic health record where higher values indicate worse glycemic control. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in cholesterol | Baseline and 12 months post-baseline | Low-density lipoprotein (LDL) extracted from the electronic health record where higher values indicate worse hyperlipidemia. |
| Change in blood pressure | Baseline and 12 months post-baseline | Systolic blood pressure extracted from the EHR where higher values indicate worse hypertension. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORSunil Kripalani, MD, MSc
Vanderbilt University Medical Center
Outcome results
None listed