Reducing Chronic Diseases by Addressing Social Needs and Structural Racism in Family Medicine

What this Trial Is About

Researchers are studying whether the WE CARE social determinants of health SDOH screening and referral intervention, enhanced with an antiracist approach, can reduce chronic diseases such as hypertension, diabetes, depression, hyperlipidemia, and asthma in racially and ethnically diverse patients. This study focuses on addressing racial and ethnic health disparities by applying community engagement and antiracism frameworks to existing screening and referral processes in primary care. The study is a hybrid effectiveness-implementation trial using a randomized stepped wedge cluster design in family medicine clinics serving low-income families. The study compares the refined WE CARE intervention against usual care, which involves standard pediatric care and existing screening practices. The WE CARE protocol includes brief training for clinical staff, a short screening tool for identifying social needs, and access to community resource listings. Families indicating unmet social needs receive referrals, with clinic staff assisting connections to resources. The study is conducted across three family medicine clinics and involves implementing the refined WE CARE protocol informed by patient and stakeholder input. Participants include adults and children diagnosed with chronic diseases receiving care at study sites. The study monitors clinical outcomes such as blood pressure, LDL cholesterol, HbA1c, emergency department visits, and hospitalizations every three months for up to three years. Data collection includes electronic health records and assessments of implementation outcomes like equity and patient-centeredness. The trial runs from October 2025 to September 2028, involving ongoing evaluation of the interventions impact on health disparities and chronic disease outcomes across the lifespan.

Social Needs Screening and Chronic Diseases Study (WE CARE)