ClinicalTrials.gg
CompletedNCT06831162Updated Nov 5, 2026

Evaluating the Effectiveness of a Multi-level Health-Related Social Needs Initiative

An interventional study of Multi-level HRSN initiative in Type 2 Diabetes, Hypertension and Hyperlipidemia, sponsored by Vanderbilt University Medical Center. Completed at 1 site in United States. Open to participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2026-11-05.

Sponsored by Vanderbilt University Medical Center · Not applicable, Interventional, and Health services research

Updated Nov 5, 2026Now CompletedStudy documents posted+3 moreGo to Updates ↓
Phase
Not applicable
Study type
Interventional
Enrollment
6,928
Allocation
Not applicable
Ages
18 Years and older
Sex
All
01

Where this study stands

Counted across the records on this site · 2026-11-12

Among 21 studies in Diabetes Mellitus, Type 2 by Vanderbilt University Medical Center — 4 open to participants now, 5 under way, none of them phase 3. Diabetes Mellitus, Type 2 · Vanderbilt University Medical Center.

Enrollment
Largest of 18
6,928 · median 135
Started
2025
with 3 others
No phase
13 of 21
2 open now
Registered
18th of 21
by date

Among the 21 studies in Diabetes Mellitus, Type 2 by Vanderbilt University Medical Center, this one has the largest enrollment of the 18 interventional ones that give a count, is one of 4 that started in 2025, is one of 13 with no phase, and was the 18th registered.

Diabetes Mellitus, Type 2

10,371 studies on the registry are indexed under Diabetes Mellitus, Type 2; 1,406 are open to participants now.

Browse Diabetes Mellitus, Type 2 studies →

Open to participants now

4 of the 21 studies in Diabetes Mellitus, Type 2 by Vanderbilt University Medical Center are open now, in 1 country. Recruiting first, the newest first:

By country, each count listing its studies:

All 4 open studies →

Where they have run

Who these studies take

Of the 883 Diabetes Mellitus, Type 2 studies recruiting now, 373 (42%) set no upper age limit and 384 (43%) stop at 75 or younger; 52 take children under 18; 203 take healthy volunteers.

This study: 18 Years and older · all sexes · no healthy volunteers.

The full table on the hub →

This tab as a report to print or save as PDF → With an account.

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Watch this landscapeDownload CSVNarrow it in search →With an account: a weekly mail of what changed among 21 studies in Diabetes Mellitus, Type 2 by Vanderbilt University Medical Center, or all of them as a file.
02

Study summary

The goal of this study is to evaluate the effectiveness of a multi-level health-related social needs (HRSN) initiative among adult patients diagnosed with type 2 diabetes, plus hypertension or hyperlipidemia. The multi-level initiative includes HRSN data collection, training and tools for health care professionals, care coordinator support, and community resources. Patients with type 2 diabetes plus hypertension or hyperlipidemia will be screened for HRSN as part of the primary care clinic intake process to assess if patients have any social needs (like difficulty with getting food, housing, or transportation). If patients screen positive for having social needs, then patients will be offered support, which can include help from primary care providers with adjusting a patient's disease management plan, referrals to care coordinators to provide additional assistance in addressing social needs, and information about community organizations that offer resources for social needs. The initiative will be integrated as a system change across VUMC adult primary care practices.

The investigators will use a prospective, single-arm clinical trial to evaluate effects on clinical outcomes for 12 months. Data will be extracted from the EHR on adult patients diagnosed with type 2 diabetes, and either hypertension or hyperlipidemia. The investigators hypothesize that the initiative will reduce the impact of HRSN on clinical outcomes over the study period. The investigators will also administer surveys to a subgroup of patients to examine trends in self-reported psychosocial and behavioral measures over the course of the initiative.

03

Conditions studied

  • Type 2 Diabetes
  • Hypertension
  • Hyperlipidemia
  • Health-related Social Problems
04

Who can participate

Ages eligible
18 Years and older
Sexes eligible
All
Accepts healthy volunteers
No

Eligibility criteria

ELIGIBILITY CRITERIA FOR EHR DATA EXTRACTION

Inclusion Criteria:

  • 18 years of age or older
  • Completed the health-related social needs (HRSN) screener as part of a primary care visit
  • Diagnosed with type 2 diabetes, plus hypertension and/or hyperlipidemia as reflected by ICD-10 billing codes
  • Receive care at one of six partner Vanderbilt University Medical Center primary care clinics: South One Hundred Oaks, North One Hundred Oaks, Green Hills, Hillsboro Medical Group, Melrose, Bellevue

ELIGIBILITY CRITERIA FOR PATIENT SURVEYS (subset of EHR data)

Inclusion Criteria:

  • 18 years of age or older
  • Completed the HRSN screener as part of a primary care visit
  • Diagnosed with type 2 diabetes
  • Receive care at one of six partner Vanderbilt University Medical Center primary care clinics: South One Hundred Oaks, North One Hundred Oaks, Green Hills, Hillsboro Medical Group, Melrose, Bellevue
  • English-speaking

Exclusion Criteria:

  • Blindness
  • Hearing impairment
  • Conditions that would interfere with survey completion (e.g., significant dementia, active psychosis or mania)
  • Being near the end of life (hospice or home hospice)
05

Study design

Phase
Not applicable
Primary purpose
Health services research
Allocation
Not applicable
Intervention model
Single group
Masking
None (open label)
Enrollment
6,928 participants (actual)

Study arms

  • Experimental
    Multi-level HRSN initiative

    Eligible patients will receive the HRSN initiative as part of their primary care appointments

    Other: Multi-level HRSN initiative

Interventions

  • OtherMulti-level HRSN initiative

    The multi-level health-related social needs (HRSN) initiative includes multiple components aimed at assessing and addressing HRSN in clinical practice: HRSN screening, EHR tools for clinical decision support, training and tools for health care providers to address HRSN, care coordinator support for patient outreach, and community resources for referral and support.

06

What researchers measure

Primary outcomes

  1. Change in glycemic control

    Hemoglobin A1c extracted from the electronic health record where higher values indicate worse glycemic control.

    Time frame: Baseline and 12 months post-baseline

Secondary outcomes

  1. Change in cholesterol

    Low-density lipoprotein (LDL) extracted from the electronic health record where higher values indicate worse hyperlipidemia.

    Time frame: Baseline and 12 months post-baseline

  2. Change in blood pressure

    Systolic blood pressure extracted from the EHR where higher values indicate worse hypertension.

    Time frame: Baseline and 12 months post-baseline

Other outcomes

  1. Change in medication adherence (survey)

    As assessed by the Adherence to Refills and Medications Scale-Diabetes (ARMS-D) with scores ranging from 11-44, where higher scores indicate more problems with medication adherence (worse).

    Time frame: Baseline and 6 months post-baseline

  2. Change in dietary behavior (survey)

    As assessed by the short version of the Personal Diabetes Questionnaire scale (PDQ-11) Eating Behavior Problems subscale with scores ranging 1-6, where higher scores indicate more problem eating behaviors (worse).

    Time frame: Baseline and 6 months post-baseline

  3. Change in dietary behavior (survey)

    As assessed by the short version of the Personal Diabetes Questionnaire scale (PDQ-11) Use of Information for Decision Making subscale with scores ranging 1-6, where higher scores indicate more use of dietary information for decision making (better).

    Time frame: Baseline and 6 months post-baseline

  4. Change in physical activity (survey)

    As assessed by scores on the Exercise Vital Sign (EVS) Tool with scores ranging 0-1,050 minutes or greater per week of moderate to strenuous physical activity.

    Time frame: Baseline and 6 months post-baseline

  5. Change in diabetes distress (survey)

    As assessed by the Problem Areas in Diabetes-5 (PAID-5) scale with scores ranging from 0 to 20, where higher scores indicate greater diabetes-related emotional distress (worse).

    Time frame: Baseline and 6 months post-baseline

  6. Change in diabetes self-efficacy (survey)

    As assessed by the Perceived Diabetes Self-Management Scale (PDSMS) with scores ranging 8 to 40, where higher scores indicate more self-efficacy (better).

    Time frame: Baseline and 6 months post-baseline

  7. Change in interpersonal processes of care (survey)

    As assessed by the Interpersonal Processes of Care (IPC) survey with scores ranging from 1-5 (calculated as the mean of non-missing responses to the corresponding items), where higher scores indicate higher frequency of the labeled interpersonal process (e.g., decided together; lack of clarity). Scoring occurs for 7 interpersonal processes: lack of clarity; elicited concerns, responded; explained results; decided together; emotional support, compassion; discriminated due to race/ethnicity; and disrespectful office staff.

    Time frame: Baseline and 6 months post-baseline

  8. Change in perceived discrimination (survey)

    As assessed on the Discrimination in Medical Settings scale with scores ranging from 7-35, where higher scores indicate higher frequency of experiences with discrimination in medical settings.

    Time frame: Baseline and 6 months post-baseline

07

Study locations

1 site
08

References and documents

Study documents

PDFs hosted by the registry, ClinicalTrials.gov.

Individual participant data

Plan to share: Yes — After study results are posted on clinical trials and published, de-identified data will be available upon requests made to the principal investigator.

Supporting information: Study protocol, Statistical analysis plan, Informed consent form

Time frame: After study results are posted on clinical trials and outcomes published in a peer-reviewed journal, until 5 years later

Access criteria: Contact the principal investigator

09

Timeline

1 registry update since Sep 25, 2026
ElapsedEstimatedEstimated, not yet reachedDate before it movedWhere the date was before it movedSimilar studies: half by the dot; the band is the middle halfHalf of similar studies reached it by the dot; the band is the middle half, from a quarter to three quarters

Ran from Jan 2025 to primary completion in Aug 2026, 18 months.

Of 2,066 non-industry interventional studies with no phase under Diabetes Mellitus, Type 2, half reached primary completion within 21 months of starting (the median), counting those still running; a quarter within 10 and three quarters within 40. This study's 18 months is below that.

Counting every sponsor, half of 2,243 studies reached it within 21 months; a quarter within 10 and three quarters within 39.

Since we started tracking on Sep 25, 2026, the dates moved once, on Nov 5, 2026: primary completion Sep 2026 → Aug 2026 and completion Sep 2026 → Aug 2026.

Earlier changes are on the record history on ClinicalTrials.gov ↗

How these figures are worked out, and which studies are left out of them.

Registered
Feb 13, 2025
First posted
Feb 17, 2025
StartActual
Jan 24, 2025
Primary completionActual
Aug 18, 2026was Sep 2026
CompletionActual
Aug 18, 2026was Sep 2026
Last update
Nov 5, 2026
What these dates mean
Start.
When the first participant enrolled; while estimated, when the study expects to open to recruitment.
Primary completion.
When the last participant was examined or treated to collect data for the study's main question, its primary outcome. A study that stopped early gives the date its data collection stopped.
Completion.
When the last participant's last visit took place, for every outcome, secondary ones and side effects included: the end of the study. Often later than primary completion, sometimes the same day.
Actual and Est.
Actual means the registry says the date has happened. Est. (estimated) is a date the sponsor plans or expects. It can still move, and the sponsor is expected to change it to actual once it has passed.
Status
Enrolling by invitation→Completed
changed Nov 5, 2026
Primary completion
Sep 4, 2026→Aug 18, 2026 (actual)
Nov 5, 2026
Study completion
Sep 4, 2026→Aug 18, 2026 (actual)
Nov 5, 2026
Enrollment
4809 (estimated)→6928 (actual)
Nov 5, 2026
Documents
Nov 5, 2026
Show all 1 update
  1. Nov 5, 2026
    Enrolling by invitation→Completed
    Documents Informed consent form ↗ posted
    Primary completion Sep 4, 2026→Aug 18, 2026 (now actual)
    Study completion Sep 4, 2026→Aug 18, 2026 (now actual)
    Enrollment 4809 (estimated)→6928 (actual)
    + 1 other change: verification date

From the registry record's own update history. This site started tracking changes on Sep 25, 2026; for anything earlier, see the record history on ClinicalTrials.gov ↗

10

Registry details

Key details

Study ID
NCT06831162
Responsible party
Sunil Kripalani (Principal Investigator, Vanderbilt University Medical Center) — Principal investigator
First posted
Feb 17, 2025
Start date
Jan 24, 2025
Primary completion
Aug 18, 2026
Completion
Aug 18, 2026
Last update
Nov 5, 2026

Study contacts

Sunil Kripalani, MD, MSc
principal investigator · Vanderbilt University Medical Center

Oversight

Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
View the source record on ClinicalTrials.gov ↗

Not currently enrolling

This study is completed, as verified in Nov 2026. You cannot join it, but the record below documents what was studied.

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