The goal of this study is to develop, implement, and evaluate a patient-centered triage and referral model designed to improve health outcomes for individuals with uncontrolled type 2 diabetes mellitus (T2DM) and unmet health-related social needs. The intervention builds on the existing THRIVE infrastructure at Boston Medical Center (BMC), which includes screening for social needs and a resource referral guide. It integrates medical and social care by embedding a data-driven triage tool within the EPIC electronic health record system, engaging community health workers trained in population health, and initiating closed-loop EPIC integrated referrals to community-based organizations. This study will use a hybrid type 3 effectiveness-implementation trial design to evaluate the implementation of the THRIVE-DM intervention at the clinic level. Preliminary effectiveness will be assessed by comparing THRIVE-DM to usual care in its ability to increase patient connections to community-based organizations and improve clinical outcomes. Using a stratified randomization approach, the investigators will compare referral closure rates, receipt of social services, hemoglobin A1C levels, and patterns of health service utilization between patients enrolled in THRIVE-DM and those receiving standard care
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
900
Low-SS and High-SS will be referred by the CHW to appropriate community-based organizations through the THRIVE Directory. High-SS participants will also receive additional support from a patient navigator (PN), who will follow up to facilitate service connection and address barriers to engagement. CHWs and PNs will coordinate care to ensure services are aligned with the patient's assessed needs.
Standard of care may include support from the primary care team, health related social needs (HRSN) screening via the THRIVE screener, printed resource guides, and referrals to community-based organizations initiated at the discretion of clinic staff using the THRIVE Directory.
Boston Medical Center
Boston, Massachusetts, United States
RECRUITINGNumber of participants that connect to Community-Based Organizations
Connection to Community-Based Organizations will be assessed through several sources and documented in REDCap
Time frame: 3 months, 6 months, 3 months post intervention
Number of participants that are helped by Community-Based Organizations
Data will be collected from participant interviews
Time frame: 3 months, 6 months, 12 months post intervention
Changes in HbA1c
HbA1c data will be extracted from the EPIC electronic health record (EHR).
Time frame: 3 months, 6 months, 12 months post intervention
Number of participants hospitalized
Data will be obtained from the EHR.
Time frame: 3 months, 6 months, 12 months post intervention
Number of participants that had an emergency department visit
Data will be obtained from the EHR.
Time frame: 3 months, 6 months, 12 months post intervention
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