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DEDICATE will refine and test the effectiveness of evidence-based implementation support strategies designed to support care management teams' sustained use of electronic health record (EHR)-based functionalities to address unmet non-medical health-related needs through improved clinical-community linkages. This study will test the hypothesis that providing implementation support to health center care management teams will lead to increased adoption of EHR functionalities and increased screenings and referrals to community organization to address unmet non-medical health-related needs needs through a cluster-randomized trial. This study's results will have implications for patients with non-medical health-related needs receiving care management in primary care settings.
The investigators will use a hybrid effectiveness-implementation mixed methods design to assess the impact of evidence-based implementation support strategies designed to support the care management teams' adoption of EHR functionalities that enable screening and referrals to community organizations for non-medical health-related needs. After conducting a three-month pilot study with three health centers to test and refine the implementation support strategies, 20 community-based health centers will be recruited to participate in a stepped-wedge, cluster-randomized trial. Eligible OCHIN health centers include those that provide primary care, use an EHR-based care management tool for at least one care management or population health program that addresses non-medical health-related needs for more than 10 enrolled patients from April-June 2025. Once 20 health centers have been enrolled, health centers will be randomized to one of four wedges for staggered receipt of the intervention. This method will allow us to provide tailored support to five health centers at a time and enables all health centers to eventually receive the intervention. Participating sites will be provided implementation support strategies for using EHR-based functionalities to conduct screening and referrals for patients with unmet non-medical health-related needs. After receiving the intervention, participating health centers will be followed until Y4Q4 to assess primary and secondary outcomes.
The intervention includes implementation strategies to support adoption of EHR-based functionalities for non-medical health-related needs activities by care management teams in health centers. The intervention will be delivered to health center care management staff outside of patient care. Patients will not directly receive the intervention and will continue to receive regular care from the health center. For all study health centers, quantitative data will be collected (via EHR data extraction) on care team use of EHR functionalities and non-medical health-related needs screening and coordination provided by care teams. Limited clinical data will be collected on patients seen at included health centers during the study period. Qualitative data will also be collected, including semi-structured interviews with clinic staff from all enrolled study sites.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention Arm | Experimental | Intervention health centers will receive implementation support when they crossover from Control to Intervention. |
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| Control Arm | No Intervention | Control health centers will not receive an intervention prior to crossover to Intervention. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Implementation Support | Other | Health centers receiving the intervention will have access to implementation support strategies designed to support adoption of screenings and referrals to community organizations for patients with unmet non-medical health-related needs receiving care management. Implementation support will be provided by an OCHIN trainer, practice facilitators, workflow engineer, and analysts. |
| Measure | Description | Time Frame |
|---|---|---|
| Screening for non-medical health-related needs | Whether a patient enrolled in a care management program was screened for unmet non-medical health-related needs (binary, patient-level). | From six months prior to the intervention, assessed up to 12 months. |
| Referral for non-medical health-related need | Among patients with one or more identified non-medical health-related need, whether a referral was made for each identified need (binary, patient-level) | Baseline, through study completion, an average of 7.5 months. |
| Measure | Description | Time Frame |
|---|---|---|
| Referrals with a documented outcome (all non-medical health-related needs) | Among referrals made for any identified financial-related need, whether outcome has been recorded in the EHR. Documented outcome statuses (also referred to as dispositions), may include successful connection to services, referral closure without service delivery, service unavailability, patient ineligibility, or other outcomes as defined by the care management team (binary, financial-related need-level). |
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Inclusion Criteria
• • Health centers that use an EHR-based care management tool for at least one care management or population health program that addresses non-medical health-related needs for more than 10 enrolled patients from April-June 2025.
Exclusion Criteria
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| Name | Affiliation | Role |
|---|---|---|
| Rachel Gold, PhD | OCHIN, Inc. | Principal Investigator |
| Nicole Cook, PhD | OCHIN, Inc. | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| OCHIN | Portland | Oregon | 97228 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 41198205 | Derived | Cook N, Gunn R, McGrath BM, Donovan J, Pisciotta M, Owens-Jasey C, Fein HL, Templeton A, Larson Z, Gold R. Implementation strategies to improve adoption of screening and linkages for non-medical drivers of health in care management using enabling technologies: study protocol for a cluster randomised trial. BMJ Open. 2025 Nov 5;15(11):e100340. doi: 10.1136/bmjopen-2025-100340. | |
| 40747910 |
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All EHR data are proprietary to the OCHIN health centers and thus will not be made directly available beyond the study team.
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| ID | Term |
|---|---|
| D003924 | Diabetes Mellitus, Type 2 |
| D006973 | Hypertension |
| ID | Term |
|---|---|
| D003920 | Diabetes Mellitus |
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
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A stepped-wedge cluster randomization design will be used to assess the impact of implementation support strategies to support non-medical health-related screening and referrals for patients in care management.
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|
| Baseline, through study completion, an average of 7.5 months. |
| Referrals with an outcome documented as received (all non-medical health-related needs) | Among referrals made for any identified financial-related need, whether documented outcome status indicates "successful connection to services" (binary, non-medical health-related need-level). | Baseline, through study completion, an average of 7.5 months. |
| Controlled hypertension | Binary outcome of blood pressure control (defined as <140/90) at the most recent visit among patients with hypertension | Baseline, through study completion, an average of 7.5 months. |
| Controlled type 2 diabetes mellitus | Binary outcome in HbA1c control (defined as <9%) at the most recent visit among patients with diabetes mellitus | Baseline, through study completion, an average of 7.5 months. |
| Derived |
| Cook N, Pisciotta M, Larson Z, Fein HL, Donovan J, McGrath BM, Gunn R, Owens-Jasey C, Templeton A, Volk-Britton M, Nishiike Y, Stowe S, Gold R. Using a Modified Delphi Process to Develop an Intervention to Support Care Coordination of Patient Social Needs in Primary Care. J Adv Nurs. 2026 Apr;82(4):3779-3787. doi: 10.1111/jan.70109. Epub 2025 Aug 1. |
| 39483896 | Derived | Cook N, Gunn R, McGrath BM, Donovan J, Pisciotta M, Owens-Jasey C, Fein HL, Templeton A, Larson Z, Gold R. Implementation strategies to improve adoption of unmet social needs screening and referrals in care management using enabling technologies: study protocol for a cluster randomized trial. Res Sq [Preprint]. 2024 Oct 17:rs.3.rs-4985627. doi: 10.21203/rs.3.rs-4985627/v1. |
| D004700 | Endocrine System Diseases |
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |