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Addressing Social Needs to Improve Health in Adults With Multiple Chronic Conditions
Recruiting
Who can join
Ages 18 and older · All sexes
Full eligibility criteria
Inclusion Criteria:
* 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 Criteria:
* major cognitive barriers (dementia, psychosis).
* multiple prior year hospitalizations ("extremely high utilizers")About the study
The investigators will conduct a comparative effectiveness randomized clinical trial with two "active comparator" arms. The investigators will evaluate the two current, usual care strategies (higher intensity "telephonic navigation" vs. lower intensity "virtual outreach") for addressing social needs among patients with multiple chronic conditions.
What is being tested
- Telephonic Outreach (behavioral)
- Virtual Outreach (behavioral)
Sponsor: Kaiser Permanente · Participants: 800 · Started: Sep 1, 2025
Contact the study team
- Karen R Estacio, MHA · Phone: 510.891.5960
Official record on ClinicalTrials.gov — NCT06941519
Locations in the U.S.
| California | Division of Research, Pleasanton |
Conditions
From ClinicalTrials.gov, data retrieved Sep 30, 2026. Each study sets its own eligibility; the study team decides who can join.