Randomised Pilot Trial Tests Clinical Decision Support Tool for Social Needs Screening in Low-Income African-American Patients With Chronic Disease — Key Findings for Clinicians
247 Health News Editorial
·16 July 2026
·4 min read
·clinical-trialsA completed Johns Hopkins randomised pilot trial has tested a clinical decision support tool that surfaces validated social risk scores at the point of care, enabling structured referral of low-income African-American patients with chronic disease to community-based organisations. With emergency department utilisation as the primary endpoint, findings are expected to inform scalable, equity-focused care models across primary care systems internationally.
Originally reported by ClinicalTrials.gov
References
- 1.Johns Hopkins University. (2022). Piloting a clinical decision support tool to identify and refer patients with social needs to community-based organizations (NCT05574699). ClinicalTrials.gov. https://clinicaltrials.gov/study/NCT05574699
- 2.Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2021). Social determinants of health and diabetes: A scientific review. Diabetes Care, 44(1), 258–279. https://doi.org/10.2337/dci20-0053
- 3.Gottlieb, L. M., Tirozzi, K. J., Manchanda, R., Burns, A. R., & Sandel, M. T. (2015). Moving electronic medical records upstream: Incorporating social determinants of health. American Journal of Preventive Medicine, 48(2), 215–218. https://doi.org/10.1016/j.amepre.2014.08.009
- 4.Byhoff, E., Harris, J. A., Perez, A., Scherer, A. M., Tipirneni, R., Chopra, V., & Kullgren, J. T. (2019). Screening for social determinants of health in hospitalised patients: Unmet needs and resource referrals. Journal of General Internal Medicine, 34(11), 2399–2401. https://doi.org/10.1007/s11606-019-05202-4
- 5.World Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health — Final report of the Commission on Social Determinants of Health. World Health Organization. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1
- 6.Vest, J. R., Grannis, S. J., Haut, D. P., Halverson, P. K., & Menachemi, N. (2017). Using structured and unstructured data to identify patients' need for services that address the social determinants of health. International Journal of Medical Informatics, 107, 101–106. https://doi.org/10.1016/j.ijmedinf.2017.06.004
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247 Health News Editorial
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