Social Needs Screening and Chronic Diseases Study (WE CARE)

Conditions studied

Hyperlipidemias, Diabetes, Depression, Pediatric Asthma, Hypertension

About this study

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?

Interventions

• 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.

Primary outcomes

• Blood pressure (BP) measurements (Every 3 months for up to 3 years)

Eligibility information

Study locations

• UMass Memorial Medical Center - Hahnemann Campus, Worcester, Massachusetts 01605 United States
• Family Health Center of Worcester, Worcester, Massachusetts 01610 United States
• UMass Memorial Medical Center -Benedict Family Medicine Clinic, Worcester, Massachusetts 01655 United States