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.
Chronic Disease, Diabetes Mellitus, Hypertension, Congestive Heart Failure
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.
Social Risk Score, Clinical Decision Support Tool and Closed Loop Referral for Social Risk Screen and Referral
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Johns Hopkins GreenSpring Station, Baltimore, Maryland, United States, 21093
Johns Hopkins Community Physicians - EBMC, Baltimore, Maryland, United States, 21202
Johns Hopkins Community Physicians - Remington, Baltimore, Maryland, United States, 21211
Johns Hopkins Bayview Medical Center - Comprehensive Care Practice, Baltimore, Maryland, United States, 21224
Johns Hopkins JHOC-GIM Clinic, Baltimore, Maryland, United States, 21287
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.
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18 Years to
ALL
Yes
Johns Hopkins University,
Elham Hatef, MD, MPH, PRINCIPAL_INVESTIGATOR, Johns Hopkins University
2025-03-31