Addressing Social Needs to Improve Health in Adults With Multiple Chronic Conditions
Kaiser Permanente
800 participants
Sep 1, 2025
INTERVENTIONAL
Conditions
Summary
The investigators will conduct a comparative effectiveness randomized clinical trial with two "active comparator" arms. The investigators will evaluate the two current, usual care strategies (higher intensity "telephonic navigation" vs. lower intensity "virtual outreach") for addressing social needs among patients with multiple chronic conditions.
Eligibility
Inclusion Criteria3
- Two or more chronic medical conditions from a defined list of 24 chronic conditions
- One or more gaps in evidence-based care (related to condition-specific risk factor management, evidence-based screening and preventive care, missed appointments, and medication non-adherence),
- At least one self-reported social-related barrier to care or "social need" (e.g., transportation, food, housing, utilities, and/or financial insecurity).
Exclusion Criteria2
- major cognitive barriers (dementia, psychosis).
- multiple prior year hospitalizations ("extremely high utilizers")
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Interventions
Higher Intensity (active telephonic outreach from a health navigator with follow-up contacts for up to 3 months)
Lower Intensity (outreach via text, email, and/or letter with materials that contain information about available local, state, and federal governmental benefits and services)
Locations(1)
View Full Details on ClinicalTrials.gov
For the most up-to-date information, visit the official listing.
NCT06941519