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

This study is looking at how different ways of connecting people with social services can improve their health. It compares two approaches: "Telephonic Outreach," where a health navigator actively calls and follows up with you for up to 3 months, and "Virtual Outreach," which uses texts, emails, or letters to share information about available benefits and services. You might be able to join if you are an adult with two or more long-term health problems (chronic conditions), have gaps in your medical care, and report having social challenges that make it hard to get care. The study aims to see if these approaches help people get social services, reduce their social needs, and close gaps in their medical care. The current recruitment status is unclear.

Study design
This study is an interventional trial comparing two active approaches to care. It plans to enroll 800 participants.
What's involved
Not specified in the trial record.
Compensation
Not stated in the trial record.
Follow-up
Your receipt of social services and reduction in social needs will be measured at around 6 months. Clinical care gap closure will be measured at approximately 12 months.

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NCT06941519

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

Recruiting
NAAges 18+InterventionalHealth services
Kaiser Permanente
~800 participants
Updated 2026-06-05 on ClinicalTrials.gov
What's tested:Telephonic OutreachVirtual Outreach

At a glance

Recruiting sites
1 of 1 listed site is recruiting right now
RecruitingSuspended, closed, or not yet open
What they're measuring
Receipt of social services
Measured over approximately 6 months after enrollment
+2 more outcomes measured
Multiple Chronic Conditions
Social Needs
Care Gaps
Navigation
1 sites across 1 states
California1
  • Richard W Grant, MD MPH · PRINCIPAL_INVESTIGATOR · Kaiser Permanente

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Eligibility criteria

Inclusion

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

major cognitive barriers (dementia, psychosis).
multiple prior year hospitalizations ("extremely high utilizers")
  • Receipt of social servicesapproximately 6 months after enrollment

    Patient survey re: receipt of resources from available programs

  • Reduction in number of social needsapproximately 6 months after enrollment

    Reduction from baseline in number of unmet social needs

  • Clinical care gap closureapproximately 12 months after enrollment

    Reduction in number of evidence-based clinical care gaps