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NCT05574699

Social Risk Score, Clinical Decision Support Tool and Closed Loop Referral for Social Risk Screen and Referral

Completed NA Last updated 4 September 2025
What this trial tests

NA trial testing Social Risk Score and CDS Tool in Chronic Disease in 251 participants. Completed in 27 May 2025.

Timeline
30 April 2023
Primary endpoint
27 May 2025
27 May 2025

Quick facts

Lead sponsorJohns Hopkins University
PhaseNA
StatusCompleted
Study typeINTERVENTIONAL
Allocationrandomized
Designparallel
Maskingsingle
Primary purposehealth services research
Enrollment251
Start date30 April 2023
Primary completion27 May 2025
Estimated completion27 May 2025
Sites5 locations across United States

Drugs / interventions tested

Conditions studied

Sponsor

Johns Hopkins University

Who can join

18 and older, any sex, with Chronic Disease or Diabetes Mellitus. Patients with the condition only — healthy volunteers not accepted.

Sponsor's own description

The overarching goal of this project is to leverage health information technology (HIT) to integrate available digital information on social needs to improve care for racial and ethnic minorities and socially disadvantaged populations with chronic diseases. In the previous phases of this project the investigators developed a social risk score to identify social needs among medically under-served patients with special emphasis on application among African American patients with low income and chronic diseases who face social determinants, risk factors, and needs (SDRN) challenges. The investigators also developed a clinical decision support (CDS) tool to present the social risk score to clinical providers and sought feedback from different users on the face and content validity of the CDS tool. In the current project the investigators will run a randomized clinical trial (RCT) study to pilot test the new risk score and CDS tool in selected primary care clinics at Johns Hopkins Health System (JHHS) and in collaboration with selected community-based organizations (CBOs). This system will help identify, manage, and refer patients with both high levels of disease burden and modifiable SDRN challenges.

Publications & conference data

2 peer-reviewed publications reference this trial (live from Europe PMC):

  1. Piloting a Clinical Decision Support Tool to Identify Patients With Social Needs and Provide Navigation Services and Referral to Community-Based Organizations: Protocol for a Randomized Controlled Trial.
    Hatef E, Richards T, Topel K, Hail S, et al · · 2024 · cited 4× · PMID 39042426 · DOI 10.2196/57316
  2. An Electronic Health Record-Based Platform for Social Needs Assessment and Navigation Services: Preliminary Results of an RCT.
    Hatef E, Richards T, Hail S, Zhang T, et al · · 2025 · PMID 40475024 · DOI 10.1016/j.focus.2025.100344

Verify or expand the search:

Other recruiting trials for Chronic Disease

Currently open trials in the same condition.

Other Johns Hopkins University trials

Trials by the same sponsor.

Verify against primary sources

Data sources for this page

Drug Landscape aggregates and links these public records for informational use only. Always verify against the primary source before clinical or regulatory decisions. Canonical URL: https://druglandscape.com/trial/NCT05574699.

Primary sources · FDA · ClinicalTrials.gov · EMA · SEC EDGAR · ChEMBL · Wikidata · full sourcing