Piloting a Clinical Decision Support Tool to Identify and Refer Patients With Social Needs to Community-based Organizations
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 251
- 试验地点
- 10
- 主要终点
- Change in the number of social determinants of health (SDOH) challenges identified during the visit at 3-month follow-up telephone survey compared to the baseline visit.
研究概览
简要总结
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.
详细描述
The aim of this phase of the study is to
- Implement the social risk score and CDS tool developed and tested in the study. The CDS tool will help providers in primary care clinics to identify patients with social needs and refer patients to relevant CBOs.
- Assess the impact of the social risk score/ CDS tool on care processes and patient outcomes compared to the standard of care.
- Evaluate the acceptability of the social risk score/ CDS tool and its impact on the clinical workflow, patient care, and HIT data quality.
To achieve these aims The investigators take the following approach;
Aim 1: The CDS tool will be implemented in the following four pilot primary care clinics; General Internal Medicine, Johns Hopkins Outpatient Clinic (GIM-JHOC), Johns Hopkins Community Physicians (JHCP) at Remington and Dundalk, as well as East Baltimore Medical Center (EBMC). The CDS tool is an electronic health record (EHR) based tool and the implementation will be completed by the Technology Innovation Center at Johns Hopkins Health System (TIC) team. The investigators have been working closely with the TIC team to complete the development of the CDS tool. Using a pre-developed EHR tool (i.e., Patient Insight) the TIC team is in the process of finalizing the CDS tool in Johns Hopkins Health System (JHHS) EHR. The CDS tool will then be available as one of the tabs in each patient's EHR main page and providers in each of the selected clinics (e.g., physicians, nurses, social workers and care managers) can access the CDS tool through EHR.
Aim 2: To assess the impact of the CDS tool the investigators will conduct an RCT. The investigators will enroll eligible patients from the pilot clinics who agree to participate in the investigators' study and sign the consent form. The investigators will work with Institute for Clinical and Translational Research (ICTR) team (contact person: Cassie Lewis-Land) to contact eligible patients via MyChart to inform the patients about the study and to obtain the consent form. The investigators will then randomize the patients to intervention or control arms.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- Single (Outcomes Assessor)
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 是
入选标准
- •Adult (18+ years old) African-American patients with low income at each clinic
排除标准
- •Children are excluded from this study. Individuals with high levels of income, and those with race other than African American
研究组 & 干预措施
Social Risk Score and Closed Loop Referral
Patients in intervention arm will have a social risk score available through the CDS tool, which the provider can review and decide whether the patient needs more assessment. If the patient is identified as with high social needs based on the risk score in the CDS tool, the providers will refer the patient to social workers/ care managers for further in-depth assessment of the participants social needs at HCC. HCC will reach out to the patients over the phone and will perform an in-depth assessment of the patients social needs. If any social needs are identified and patient agrees to address those needs HCC staff will refer the patient to CBOs.
干预措施: Social Risk Score and CDS Tool (Other)
Control
Patients randomized into the control arm will be provided with the standard-of-care screening, assessment, and addressing social needs in the clinic setting. This would not include any automated mechanism of pre-collected data in the EHR. Currently providers on an ad-hoc basis apply a series of needs-assessment tools including one available within JHHS-EHR. Patients in the control arm that are identified as someone with social needs will then be referred to appropriate services through current standard-of-care mechanisms, this may include a sheet of various educational resources, or a list of organizations that can address the identified social need.
干预措施: Standard of Care (Other)
结局指标
主要结局
Change in the number of social determinants of health (SDOH) challenges identified during the visit at 3-month follow-up telephone survey compared to the baseline visit.
时间窗: 3 month follow-up
The independent evaluator will contact patients at 3 months follow-up to assess whether the SDOH challenges identified during the visit were properly addressed. Change (decrease or increase) in the number of SDOH challenges and the type of SDOH challenge (e.g., housing issue, food insecurity, transportation issue) will be documented.
Number of Emergency Department Events
时间窗: 12 and 24 months follow-up
Number of emergency department visits, extracted from EHR
次要结局
- Difference in the number of patients with social needs identified in the intervention and control groups(Baseline and at 3 month follow-up)
- Difference in the number of patients with social needs who receive services at a CBO in intervention and control groups(Baseline and at 3 month follow-up)
- Change in the number of hospitalization events and emergency department (ED) visits between intervention and control arms(Baseline and at 3 month follow-up)
- Number of Hospitalization Events(12 and 24 months follow-up)
- Number of Resolved Social Needs(From baseline to the end of follow up period (24 months))