Community Health Workers in an Interdisciplinary Outpatient CKD Clinic to Optimize Social Care Navigation, Patient Engagement, and Home Dialysis Utilization

Recruiting now · Not applicable

Conditions studied: Kidney Replacement Therapy

In brief

The goal of this clinical trial is to learn if this intervention (the CHOOSE Home intervention) is feasible and may lead to more home dialysis usage in a high-risk patient population. The main questions it aims to answer are: * Will there be an increase in home dialysis selection or initiation over study follow up? * Will there be a change in patient reported status of Health-Related Social Needs (HRSNs) and patient engagement at 1 year follow up? Researchers will compare the intervention group that will include interdisciplinary care (IDC) and the integration of a Community Health Worker (CHW) into the chronic kidney disease (CKD) care process to the IDC only control group. The research team will assess whether the intervention led to better social care navigation, enhanced patient engagement, and increased home dialysis use.

Key facts

Study ID

NCT06925776

Run by

Montefiore Medical Center

People needed

106

Starts

2025-12-12

Expected to finish

2028-05-01

Last updated by the study team

2026-04-15

Who can join

Age: 18 and older. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• Age ≥ 18 years
• Advanced CKD (defined by estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73m2 or less using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation)
• English or Spanish speaking
• Provide informed consent
• Followed by a nephrologist at Montefiore and seen within last 12 months
• Willing to receive interdisciplinary care (i.e., nurse practitioner facilitated CKD education and care coordination)

You may not qualify if…

• Active malignancy
• Anticipated survival is less than 1 year as determined by the patient's treating nephrologist
• Opting to do medical management only (non- dialysis supportive care) for management of their kidney failure
• Plan to relocate outside of New York City within the next 12 months

Where it is running

• Albert Einstein College of Medicine — The Bronx, New York, United States (enrolling)

Full record on ClinicalTrials.gov

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