THRIVE-DM: Improving Diabetes Care with Strategies for Addressing Health-Related Social Needs and Community Partnerships

PROJECT SUMMARY/ABSTRACT We propose to implement and assess THRIVE-DM, an expansion of our existing THRIVE health-related social needs (HRSN) screening and referral program, with the aim of maximizing the proportion of T2DM patients with HRSN who connect to social services and use these services to address HRSN and improve their T2DM

outcomes. This will be achieved through developing, implementing, and evaluating the THRIVE-DM intervention, which enhances THRIVE in 3 key ways: 1) a community health worker-led referral support protocol; 2) a community-engaged and patient-centered case management working group; and 3) a data- driven triage tool to identify patients who are well-suited for a low versus high support strategy to connect with

social services. Together these innovations aim to increase patients’ ability to receive services that mitigate or even resolve their HRSN, while also ensuring high acceptability among both patients and social service providers. We will conduct a hybrid type 3 implementation-effectiveness trial to assess the feasibility and

preliminary effectiveness of the THRIVE-DM intervention. The rationale underlying this proposal encompasses two key foundations. First, it recognizes that HRSN screening and referral initiatives, while valuable, tend to favor individuals with a stronger locus of control, greater socioeconomic resources, superior health status, and

enhanced social capital, facilitating their successful navigation of referrals and participation in subsequent programs. Whereas, individuals who lack these advantages achieve lower levels of success. Second, it acknowledges the challenge of effectively allocating health system-based resources to effectively implement

closed-loop HRSN service referral linkages based on individual patient characteristics. Consequently, patients with T2DM exhibiting greater or more severe HRSN may encounter barriers to accessing social services due to these very same social needs. Moreover, these patients may also experience difficulties in managing their

T2DM, partly as a result of these unaddressed social needs. Thus, enhanced HRSN screening and referral protocols, complemented by community-engaged case management based on the complexity of HRSN, build upon our existing program to facilitate more successful connections between patients and social services.

Successfully alleviating HRSN that directly affect patients' ability to manage T2DM is a mechanism by which, at scale, we can reduce inequities in T2DM management. However, community-level interventions addressing the root causes of HRSN must occur simultaneously to eliminate these inequities. The proposed work will pilot

the implementation of enhanced, tiered, case management HRSN screening and referral protocols for patients with uncontrolled T2DM. We will assess the feasibility of data collection on key person-centered clinical outcome measures to evaluate the effectiveness of this enhanced protocol in mitigating self-identified HRSN

among T2DM patients and its impact on connections with social services, and hemoglobin A1C levels.