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

What this Trial Is About

Researchers are evaluating two current approaches to address social needs among adults with multiple chronic conditions. This randomized clinical trial compares higher intensity telephonic navigation against lower intensity virtual outreach to see which strategy better helps patients access social services, meet social needs, and close clinical care gaps. The study also explores how different patient groups may respond to these interventions and investigates the pathways linking social support to improved health outcomes. Participants will be assigned to one of two groups: the higher intensity arm involves active telephonic outreach from a health navigator with follow-up contacts for up to three months, while the lower intensity arm consists of outreach via text, email, or letter providing information about available governmental benefits and services. The trial includes qualitative assessments through patient focus groups and navigator interviews to understand the impact and mechanisms of each intervention. During the study, participants will be monitored for receipt of social services and reduction in social needs approximately six months after enrollment, as well as clinical care gap closure around 12 months. Outcomes will be assessed through patient reports and health records. The study plans to provide evidence to guide healthcare systems on effective strategies to support patients with multiple chronic conditions by addressing their social needs over time.

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