Social Needs Screening and Care for Chronic Conditions in Primary Care
Tests a social needs screening and referral program in people with chronic conditions like diabetes.
Plain-language title generated from the registry record
Registry title: Social Needs Screening and Chronic Diseases Study (WE CARE)
Key facts
- Where
- Worcester, United StatesSee the 3 sites
Where in United States
- Family Health Center of WorcesterWorcester, United StatesNot yet recruiting
- UMass Memorial Medical Center - Hahnemann CampusWorcester, United StatesTaking people
- UMass Memorial Medical Center -Benedict Family Medicine ClinicWorcester, United StatesNot yet recruiting
Questions to ask the study team
- How often do I need to come in, and for how long each time?
- Are travel costs paid?
- Can I keep my own doctor?
- What happens if I want to stop?
Trial details
- Who runs it
- University of Massachusetts, Worcester
- Trial code
- NCT06903897
- Record updated
- 22 May 2026
- Original description
The goal of this clinical trial is to learn if the implementation of the WE CARE social determinants of health (SDOH) screening and referral intervention with an antiracist lens in primary care settings can lead to a meaningful decrease in chronic disease by monitoring conditions such as hypertension, diabetes, depression, hyperlipidemia, and asthma through clinical measures. The main question it aims to answer is:Read full original descriptionShow less
Improving Chronic Disease Outcomes Across the Lifespan by Addressing Structural Racism
The goal of this clinical trial is to learn if the implementation of the WE CARE social determinants of health (SDOH) screening and referral intervention with an antiracist lens in primary care settings can lead to a meaningful decrease in chronic disease by monitoring conditions such as hypertension, diabetes, depression, hyperlipidemia, and asthma through clinical measures. The main question it aims to answer is:
Does the WE CARE SDOH screening and referral intervention applying an antiracism lens informed implementation strategies have the potential to reduce racial/ethnic health inequities in chronic diseases for minoritized patients?
Inclusion: Adults and children with diagnosed chronic diseases (hypertension, diabetes mellitus, hyperlipidemia, asthma, or depression) who receive Family Medicine care at one of the study sites; Children (<18 years of age) with a diagnosis of asthma; Adult patients (18 years or older) with a diagnosis of diabetes mellitus, hypertension, hyperlipidemia and/or depression.
Exclusion: In adults (>18 years of age), those without one or more of the following diagnoses as recorded by ICD-10 codes in their EHR: hypertension, hyperlipidemia, diabetes mellitus, or depression; In children (<18 years of age), those without a diagnosis of asthma.