Addressing Social Needs to Improve Health in Adults With Multiple Chronic Conditions

Launched by KAISER PERMANENTE · Apr 16, 2025

Keywords

ClinConnect Summary

This clinical trial is designed to find out which of two different support methods is better at helping adults with multiple chronic health conditions manage their social needs. The study will compare a more intensive approach called "telephonic navigation," where patients receive more personal phone support, to a less intensive method known as "virtual outreach," which offers support through online channels. The goal is to see which method helps patients better address issues that can affect their health, like transportation problems, food insecurity, or difficulties paying for basic needs.

To participate in this trial, individuals must be aged 65 to 74 and have at least two chronic health conditions from a specific list. They also need to experience some barriers related to their social needs that might make it harder for them to get the care they need. However, those with serious cognitive issues or a history of frequent hospitalizations won't be eligible. Participants will have the opportunity to receive either type of support and contribute to important research that could improve care for many others in similar situations.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • 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 Criteria:
• • major cognitive barriers (dementia, psychosis).
• • multiple prior year hospitalizations ("extremely high utilizers")