COMPLETED

Social Risk Score, Clinical Decision Support Tool and Closed Loop Referral for Social Risk Screen and Referral

Study Overview

This clinical trial focuses on testing the efficacy of different digital interventions to promote re-engagement in cancer-related long-term follow-up care for adolescent and young adult (AYA) survivors of childhood cancer.

Description

The overarching goal of this project is to leverage health information technology (HIT) to integrate available digital information on social needs to improve care for racial and ethnic minorities and socially disadvantaged populations with chronic diseases. In the previous phases of this project the investigators developed a social risk score to identify social needs among medically under-served patients with special emphasis on application among African American patients with low income and chronic diseases who face social determinants, risk factors, and needs (SDRN) challenges. The investigators also developed a clinical decision support (CDS) tool to present the social risk score to clinical providers and sought feedback from different users on the face and content validity of the CDS tool. In the current project the investigators will run a randomized clinical trial (RCT) study to pilot test the new risk score and CDS tool in selected primary care clinics at Johns Hopkins Health System (JHHS) and in collaboration with selected community-based organizations (CBOs). This system will help identify, manage, and refer patients with both high levels of disease burden and modifiable SDRN challenges.

Official Title

Piloting a Clinical Decision Support Tool to Identify and Refer Patients With Social Needs to Community-based Organizations

Quick Facts

Study Start:2023-04-30
Study Completion:2025-05-27
Study Type:Not specified
Phase:Not Applicable
Enrollment:Not specified
Status:COMPLETED

Study ID

NCT05574699

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Ages Eligible for Study:18 Years
Sexes Eligible for Study:ALL
Accepts Healthy Volunteers:Yes
Standard Ages:ADULT, OLDER_ADULT
Inclusion CriteriaExclusion Criteria
  1. * Adult (18+ years old) African-American patients with low income at each clinic
  1. * Children are excluded from this study. Individuals with high levels of income, and those with race other than African American

Contacts and Locations

Principal Investigator

Elham Hatef, MD, MPH
PRINCIPAL_INVESTIGATOR
Johns Hopkins University

Study Locations (Sites)

Johns Hopkins GreenSpring Station
Baltimore, Maryland, 21093
United States
Johns Hopkins Community Physicians - EBMC
Baltimore, Maryland, 21202
United States
Johns Hopkins Community Physicians - Remington
Baltimore, Maryland, 21211
United States
Johns Hopkins Bayview Medical Center - Comprehensive Care Practice
Baltimore, Maryland, 21224
United States
Johns Hopkins JHOC-GIM Clinic
Baltimore, Maryland, 21287
United States

Collaborators and Investigators

Sponsor: Johns Hopkins University

  • Elham Hatef, MD, MPH, PRINCIPAL_INVESTIGATOR, Johns Hopkins University

Study Record Dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Registration Dates

Study Start Date2023-04-30
Study Completion Date2025-05-27

Study Record Updates

Study Start Date2023-04-30
Study Completion Date2025-05-27

Terms related to this study

Additional Relevant MeSH Terms

  • Chronic Disease
  • Diabetes Mellitus
  • Hypertension
  • Congestive Heart Failure