MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients

Starting soon · Not applicable

Conditions studied: Type 2 Diabetes, Medication Adherence, Care Transition, Medication Discrepancy

In brief

This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes manage their medications after leaving the hospital. Many patients with diabetes take multiple medications, and changes to these medications during hospital stays can cause confusion and lead to missed doses or incorrect use. This is especially common in communities with limited access to healthcare. The study uses a computer-based tool called MEDBRIDGE (MEDication BRIDGE) to identify patients who may be at higher risk for problems after discharge, such as worsening blood sugar control or return visits to the emergency department. Patients identified as high-risk will receive 3 months of support from a nurse case manager and community health worker team, who will help with medication questions, coordinate with their doctor, and provide follow-up check-ins. The main goal is to find out whether this type of support program is practical to deliver and acceptable to patients. The study will also track changes in blood sugar levels and emergency department visits. Forty-five patients will be enrolled over 6 months at the University of Alabama at Birmingham and Cooper Green Mercy Health Services in Jefferson County, Alabama.

Key facts

Study ID

NCT07599852

Run by

University of Alabama at Birmingham

People needed

45

Starts

2029-05-01

Expected to finish

2031-04-30

Last updated by the study team

2026-05-20

Who can join

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

You may qualify if…

• Adults aged 18 years or older
• Diagnosis of type 2 diabetes (HbA1c of 6.5% or higher or relevant ICD-10 codes including E11, E13, E14, R73, L97.509, K31.84)
• Discharged from UAB Hospital or its emergency departments
• Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic
• Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge

You may not qualify if…

• Under age 18
• No indication of type 2 diabetes
• Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care
• Unable to provide informed consent
• Currently enrolled in another post-discharge intervention study

Where it is running

• University of Alabama at Birmingham — Birmingham, Alabama, United States
• Cooper Green Mercy Health Services — Birmingham, Alabama, United States

Full record on ClinicalTrials.gov

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