MEDBRIDGE-Guided Support for Type 2 Diabetes Patients

This study is testing a support program called MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention. It aims to help adults with type 2 diabetes (T2D) manage their medications after leaving the hospital. The program involves a nurse case manager (NCM) and a community health worker (CHW) who use a computer tool called MEDBRIDGE to identify patients at high risk for problems after discharge. The study wants to see if this support helps patients with their medication adherence and care transition. To join, you must be 18 or older, have type 2 diabetes (HbA1c of 6.5% or higher), and have been discharged from UAB Hospital or its emergency departments, receiving primary care at specific clinics. The study is currently unclear on its recruitment status.

Study design
This is a single-arm feasibility pilot study, meaning all 45 participants will receive the MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention. It is not specified if participants will be blinded to the intervention.
What's involved
Participants will receive a 3-month post-discharge care coordination intervention. This includes an initial contact after discharge to review medications and ongoing monthly check-ins by a community health worker.
Compensation
Not stated in the trial record.
Follow-up
The study measures retention rate at 3 months post-enrollment and patient acceptability at the end of the 3-month intervention.

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NCT07599852

MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients

Not Yet Recruiting
NAAges 18+InterventionalTreatment
University of Alabama at Birmingham
~45 participants
Updated 2026-05-20 on ClinicalTrials.gov
What's tested:MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention

At a glance

Recruiting sites
0 of 2 listed sites are recruiting right now
RecruitingSuspended, closed, or not yet open
What they're measuring
Recruitment Rate
Measured over 6-month recruitment window
+3 more outcomes measured
Type 2 Diabetes
Medication Adherence
Care Transition
Medication Discrepancy
2 sites across 1 states
Alabama2
  • Seung-Yup Lee, PhD · PRINCIPAL_INVESTIGATOR · University of Alabama at Birmingham

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Eligibility criteria

Inclusion

Adults aged 18 years or older
Diagnosis of type 2 diabetes (HbA1c of 6.5% or higher or relevant ICD-10 codes including E11, E13, E14, R73, L97.509, K31.84)
Discharged from UAB Hospital or its emergency departments
Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic
Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge

Exclusion

Under age 18
No indication of type 2 diabetes
Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care
Unable to provide informed consent
Currently enrolled in another post-discharge intervention study
  • Recruitment Rate6-month recruitment window

    Number of patient enrollments per month compared against threshold of 6 enrollments per month. Enrollment rate calculated as the percentage of eligible patients (based on MEDBRIDGE recommendations) who enrolled in the intervention (completed first interaction); target 50% or higher.

  • Retention Rate3 months post-enrollment

    Percentage of enrolled patients completing each round of the intervention (first, second, and up to the final round). Target completion rate of 60% or higher. Estimated 85% retention per subsequent interaction, yielding approximately 61% final retention.

  • Patient AcceptabilityEnd of 3-month intervention

    Patient scores on the Acceptability of Intervention Measure (AIM), assessed using a 5-point Likert scale. Target mean score of 4 or higher. Surveys assess comfort with the intervention process and communication with the NCM/CHW team.

  • Intervention FidelityThroughout 3-month intervention

    NCM/CHW self-report logs including interaction start and end timestamps and a checklist of core intervention components performed, compared against adherence threshold of 0.85. Bi-weekly supervision sessions review logs to ensure protocol adherence.