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Improving Diabetes Care With Strategies For Addressing Health-Related Social Needs and Community Partnerships

THRIVE-DM: Improving Diabetes Care With Strategies For Addressing Health-Related Social Needs and Community Partnerships

Who can join

Ages 18 and older · All sexes

Inclusion Criteria:

* Diagnosis: Must have a diagnosis of Type 2 Diabetes Mellitus (T2DM), confirmed by a current diagnosis in the medical record or at least two billing codes in the last two years, or an HbA1c level ≥6.5% in the last two years.
* Uncontrolled T2DM: Must have an HbA1c ≥9% at the time of screening.
* Health-Related Social Needs: Must have been screened for health related social needs (HRSNs) during a General Internal Medicine (GIM) visit in the last 3 months and screened positive for at least one HRSN.

Exclusion Criteria:

* Patients enrolled in Complex Care Management (CCM).
* Patients receiving hospice care.
* Patients who are deceased
* Patients with Type 1 Diabetes Mellitus (T1DM).

About the study

The goal of this study is to develop, implement, and evaluate a patient-centered triage and referral model designed to improve health outcomes for individuals with uncontrolled type 2 diabetes mellitus (T2DM) and unmet health-related social needs. The intervention builds on the existing THRIVE infrastructure at Boston Medical Center (BMC), which includes screening for social needs and a resource referral guide. It integrates medical and social care by embedding a data-driven triage tool within the EPIC electronic health record system, engaging community health workers trained in population health, and initiating closed-loop EPIC integrated referrals to community-based organizations.

This study will use a hybrid type 3 effectiveness-implementation trial design to evaluate the implementation of the THRIVE-DM intervention at the clinic level. Preliminary effectiveness will be assessed by comparing THRIVE-DM to usual care in its ability to increase patient connections to community-based organizations and improve clinical outcomes. Using a stratified randomization approach, the investigators will compare referral closure rates, receipt of social services, hemoglobin A1C levels, and patterns of health service utilization between patients enrolled in THRIVE-DM and those receiving standard care

What is being tested

• THRIVE-DM (other)
• Standard of care (other)

Sponsor: Boston Medical Center · Participants: 900 · Started: Dec 26, 2025

Contact the study team

• Michael Fischer, MD · Phone: 617-414-7288
• Uma Khemraj, MS · Phone: 617-414-7288

Official record on ClinicalTrials.gov — NCT07043426

Locations in the U.S.

Conditions

• Type 2 Diabetes

From ClinicalTrials.gov, data retrieved Sep 30, 2026. Each study sets its own eligibility; the study team decides who can join.