DEDICATE: aDvancing carE Management aDoption In Community heAlTh cEnters

NCT06489002 | Active Not Recruiting

• 1 other identifier: 00074727
• Study Type: interventional
• Target: 20
• Locations: 1 country
• Sites: 1

Brief Summary

DEDICATE will refine and test the effectiveness of evidence-based implementation support strategies designed to support care management teams' sustained use of electronic health record (EHR)-based functionalities to address unmet non-medical health-related needs through improved clinical-community linkages. This study will test the hypothesis that providing implementation support to health center care management teams will lead to increased adoption of EHR functionalities and increased screenings and referrals to community organization to address unmet non-medical health-related needs needs through a cluster-randomized trial. This study's results will have implications for patients with non-medical health-related needs receiving care management in primary care settings.

Conditions

Social Determinants of Health; Primary Care; Diabetes Mellitus, Type 2; Hypertension; Non-medical Health-related Needs; Contextual Drivers of Health

Keywords

Social Determinants of Health; Implementation support; Primary Care; Electronic health records

Outcome Measures

Primary Outcomes (2)

• Screening for non-medical health-related needs

  Whether a patient enrolled in a care management program was screened for unmet non-medical health-related needs (binary, patient-level).

  From six months prior to the intervention, assessed up to 12 months.

• Referral for non-medical health-related need

  Among patients with one or more identified non-medical health-related need, whether a referral was made for each identified need (binary, patient-level)

  Baseline, through study completion, an average of 7.5 months.

Secondary Outcomes (4)

• Referrals with a documented outcome (all non-medical health-related needs)

  Baseline, through study completion, an average of 7.5 months.

• Referrals with an outcome documented as received (all non-medical health-related needs)

  Baseline, through study completion, an average of 7.5 months.

• Controlled hypertension

  Baseline, through study completion, an average of 7.5 months.

• Controlled type 2 diabetes mellitus

  Baseline, through study completion, an average of 7.5 months.

Study Arms (2)

Intervention Arm

EXPERIMENTAL

Intervention health centers will receive implementation support when they crossover from Control to Intervention.

Other: Implementation Support

Control Arm

NO INTERVENTION

Control health centers will not receive an intervention prior to crossover to Intervention.

Interventions

Implementation Support OTHER

Health centers receiving the intervention will have access to implementation support strategies designed to support adoption of screenings and referrals to community organizations for patients with unmet non-medical health-related needs receiving care management. Implementation support will be provided by an OCHIN trainer, practice facilitators, workflow engineer, and analysts.

Intervention Arm

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• • Health centers that use an EHR-based care management tool for at least one care management or population health program that addresses non-medical health-related needs for more than 10 enrolled patients from April-June 2025.

You may not qualify if:

• Health center participated in pilot
• Health center is a school-based health center
• Health center provides care to prison population

Sponsors & Collaborators

• OCHIN, Inc.: lead

Study Sites (1)

OCHIN

Portland, Oregon, 97228, United States

Location

Related Publications (3)

• Cook N, Gunn R, McGrath BM, Donovan J, Pisciotta M, Owens-Jasey C, Fein HL, Templeton A, Larson Z, Gold R. Implementation strategies to improve adoption of screening and linkages for non-medical drivers of health in care management using enabling technologies: study protocol for a cluster randomised trial. BMJ Open. 2025 Nov 5;15(11):e100340. doi: 10.1136/bmjopen-2025-100340.

  PMID: 41198205 DERIVED

• Cook N, Pisciotta M, Larson Z, Fein HL, Donovan J, McGrath BM, Gunn R, Owens-Jasey C, Templeton A, Volk-Britton M, Nishiike Y, Stowe S, Gold R. Using a Modified Delphi Process to Develop an Intervention to Support Care Coordination of Patient Social Needs in Primary Care. J Adv Nurs. 2026 Apr;82(4):3779-3787. doi: 10.1111/jan.70109. Epub 2025 Aug 1.

  PMID: 40747910 DERIVED

• Cook N, Gunn R, McGrath BM, Donovan J, Pisciotta M, Owens-Jasey C, Fein HL, Templeton A, Larson Z, Gold R. Implementation strategies to improve adoption of unmet social needs screening and referrals in care management using enabling technologies: study protocol for a cluster randomized trial. Res Sq [Preprint]. 2024 Oct 17:rs.3.rs-4985627. doi: 10.21203/rs.3.rs-4985627/v1.

  PMID: 39483896 DERIVED

MeSH Terms

Conditions

Diabetes Mellitus, Type 2; Hypertension

Condition Hierarchy (Ancestors)

Diabetes Mellitus; Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases; Vascular Diseases; Cardiovascular Diseases

Study Officials

• Rachel Gold, PhD

  OCHIN, Inc.

  PRINCIPAL INVESTIGATOR

• Nicole Cook, PhD

  OCHIN, Inc.

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: CROSSOVER
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Principal Investigator

Model Details: A stepped-wedge cluster randomization design will be used to assess the impact of implementation support strategies to support non-medical health-related screening and referrals for patients in care management.

Study Record Dates

• First Submitted: June 27, 2024
• First Posted: July 5, 2024
• Study Start: October 1, 2025
• Primary Completion (Estimated): June 30, 2027
• Study Completion (Estimated): June 1, 2028
• Last Updated: May 6, 2026

Record last verified: 2026-04

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)