RECRUITINGINTERVENTIONAL

Social Needs Screening and Chronic Diseases Study (WE CARE)

Improving Chronic Disease Outcomes Across the Lifespan by Addressing Structural Racism

About This Trial

The goal of this clinical trial is to learn if the implementation of the WE CARE social determinants of health (SDOH) screening and referral intervention with an antiracist lens in primary care settings can lead to a meaningful decrease in chronic disease by monitoring conditions such as hypertension, diabetes, depression, hyperlipidemia, and asthma through clinical measures. The main question it aims to answer is: Does the WE CARE SDOH screening and referral intervention applying an antiracism lens informed implementation strategies have the potential to reduce racial/ethnic health inequities in chronic diseases for minoritized patients?

Who May Be Eligible (Plain English)

Who May Qualify: - Adults and children with diagnosed chronic diseases (hypertension, diabetes mellitus, hyperlipidemia, asthma, or depression) who receive Family Medicine care at one of the study sites. - Children (\<18 years of age) with a diagnosis of asthma. - Adult patients (18 years or older) with a diagnosis of diabetes mellitus, hypertension, hyperlipidemia and/or depression. Who Should NOT Join This Trial: - In adults (\>18 years of age), those without one or more of the following diagnoses as recorded by ICD-10 codes in their EHR: hypertension, hyperlipidemia, diabetes mellitus, or depression. - In children (\<18 years of age), those without a diagnosis of asthma. Always talk to your doctor about whether this trial is right for you.

Original Eligibility Criteria

View original clinical language

Inclusion Criteria: * Adults and children with diagnosed chronic diseases (hypertension, diabetes mellitus, hyperlipidemia, asthma, or depression) who receive Family Medicine care at one of the study sites. * Children (\<18 years of age) with a diagnosis of asthma. * Adult patients (18 years or older) with a diagnosis of diabetes mellitus, hypertension, hyperlipidemia and/or depression. Exclusion Criteria: * In adults (\>18 years of age), those without one or more of the following diagnoses as recorded by ICD-10 codes in their EHR: hypertension, hyperlipidemia, diabetes mellitus, or depression. * In children (\<18 years of age), those without a diagnosis of asthma.

Treatments Being Tested

OTHER

WE CARE SDOH System

The WE CARE System: A family-centered, highly efficacious approach for addressing adverse SDOH in the clinical setting. Arvin Garg, MD, MPH developed and conceptualized the WE CARE (Well-Child care visit, Evaluation, Community Resources, Advocacy, Referral, Education) intervention in 2005. This approach relies on existing clinical processes and infrastructure and social service resources, thereby making implementation, dissemination, and sustainability feasible. The intervention components include brief training of the clinical team; administration of a short screening tool to parents/patients identifying their desire for help with specific unmet social needs; and provider/clinic staff access to a physical or electronic family resource book containing community- resource listings. Providers generate referrals for families who indicate that they want help with unmet social needs on the WE CARE screener. Existing staff members may assist patients in connecting to referred resources.

OTHER

Standard Pediatric Care

Standard pediatric care includes any existing screening practices, which can vary at each clinic.

Locations (3)

(Benedict) UMass Memorial Medical Center - Adult Primary Care

Worcester, Massachusetts, United States

UMass Memorial Medical Center - Hahnemann Campus

Worcester, Massachusetts, United States

Family Health Center of Worcester

Worcester, Massachusetts, United States