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Unmet Social Needs Study

CompletedNA

Sponsor: VA Office of Research and Development

Conditions: Cardiovascular Disease, Hypertension, Diabetes Mellitus, Hyperlipidemia

Interventions: Unmet Need Screening, Unmet Need Referral - Resource Sheet, Unmet Need Referral Assistance

Countries: United States

The impacts of unmet social needs, such as homelessness, inconsistent access to food, and exposure to violence on health are well-established, especially for cardiovascular disease. A limited but growing body of evidence suggests that screening for and addressing these needs - also referred as social determinants of health -- in clinic settings helps to connect patients to resources to address unmet needs and has the potential to improve health outcomes. Veterans carry a high burden of unmet needs. At present, VA systematically screens for only two unmet needs; homelessness and food insecurity. The investigators propose to assess the efficacy of systematically screening Veterans for nine unmet needs (i.e., housing, food insecurity, utility insecurity, transportation, legal problems, employment, safety, stress, and social isolation), and compare the effect of referral mechanisms of varying intensity on Veterans' connection to resources, reduction of unmet needs, treatment adherence, reduced preventable hospitalizations, and clinical outcomes.

Eligibility overview

Sex: ALL

Healthy volunteers: No

Study type: INTERVENTIONAL

Eligibility criteria

Inclusion Criteria:

* Veterans enrolled in one of three VA medical centers:

  * 1\) VA Boston Healthcare System
  * 2\) Corporal Michael J. Crescenz VA Medical Center (Philadelphia)
  * 2\) Ralph H. Johnson VA Medical Center (Charleston)
* Veterans with, or at risk for, cardiovascular disease (CVD) who had at least 1 PC visit in the prior year
* CVD patients are defined as those with International Classification of Disease 10 (ICD10) diagnoses indicating:

  * coronary artery disease
  * cerebrovascular disease
  * peripheral artery disease
* Patients at-risk for CVD are defined as having diagnoses of hypertension, diabetes mellitus (DM), or hyperlipidemia

Exclusion Criteria:

* Impaired decision-making
* Illiterate or have limited or no English proficiency

Locations (3)

Boston, Massachusetts, United States
Philadelphia, Pennsylvania, United States
Charleston, South Carolina, United States