Re-Engineered Discharge for Diabetes Care Transitions

Part of paid clinical trials in Worcester, Massachusetts.

Sponsor
University of Massachusetts, Worcester
Study ID
NCT06869057
Status
Recruiting
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Conditions

  • Diabetes Mellitus Type 2
  • Hospital Readmission
  • Social Determinants of Health (SDOH)

Eligibility Criteria

Sex
ALL
Age
18 Years - N/A
Healthy Volunteers
Not accepted

Interventions

  • REDDCAT2 Post-Discharge Navigation — BEHAVIORAL
    Those in the REDDCAT2 intervention group will be partnered with a patient navigator whose role will be to review the results of the screening survey completed at the beginning of the study. The patient navigator will help coordinate the participant's care before leaving the hospital and for 90 days after. Together, the participant and navigator will form an action plan intended to help address personal, social, or community factors affecting the participant's health. The navigator is expected to contact the participant every 2 weeks, though this can be adjusted based on their preference.
  • Treatment as Usual (TAU) — OTHER
    TAU participants will receive standard care from the UMass Memorial Healthcare (UMMH) hospitalist team as appropriate. Participants will receive a printed list of community resources. No study-related patient navigation support will be provided. In 2024, Centers for Medicare and Medicaid Services mandated social determinants of health (SDOH) screening for inpatients. UMMH will use a checklist social needs screener. It will be up to the hospitalist teams to act on SDOH screening results. The UMMH hospitalist teams may consult endocrinology and/or inpatient social services to provide support and consultation for all patients regardless of study participation or group assignment. If medically appropriate, the endocrinology service may manage medications and provide referrals for continued treatment post discharge. All services that are normally provided by hospital care teams will remain available.

Study Details

The goal of this project is to test a novel bedside SDOH screening intervention coupled with post-discharge navigation for hospitalized patients with a diabetes diagnosis to reduce unmet social needs, compared to usual care.

Key Dates

Start date
Jun 8, 2026
Status verified
Jan 2026
Primary completion
Dec 1, 2028
Completion
May 30, 2029

Study Design

Enrollment
412 participants (estimated)
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION

Arms

  • Other: Control
    Treatment as usual (TAU)
  • Experimental: Intervention
    REDDCAT2 Intervention

Primary Outcome Measure

Time to hospital service use post-discharge [ Time Frame: 90 days ]

Central Contacts

Locations (1)

FacilityCityStateZIPSite coordinators
UMASS Memorial Healthcare SystemWorcesterMassachusetts01665
Suzanne Mitchell
[email protected]
774-442-3748

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UMASS Memorial Healthcare System· Worcester, MA

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