Addressing Social Needs to Improve Health in Adults With Multiple Chronic Conditions

Recruiting now · Not applicable

Conditions studied: Multiple Chronic Conditions, Social Needs, Care Gaps, Navigation

In brief

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.

Key facts

Study ID

NCT06941519

Run by

Kaiser Permanente

People needed

800

Starts

2025-09-01

Expected to finish

2029-12-01

Last updated by the study team

2026-06-05

Who can join

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

You may qualify if…

• 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).

You may not qualify if…

• major cognitive barriers (dementia, psychosis).
• multiple prior year hospitalizations ("extremely high utilizers")

Where it is running

• Division of Research — Pleasanton, California, United States (enrolling)

Full record on ClinicalTrials.gov

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