REDDCAT2 Project Abstract Summary Over 36 million Americans are diagnosed with type 2 diabetes mellitus (T2DM), accounting for more than 7.8 million hospital admissions and $327 billion in healthcare costs each year. Fully, 1 in 5 hospitalizations involve patients with diabetes, largely due to diabetes complications that are attributable to social determinants of health leading to unmet health-related social needs. Often unmet SDOH needs are identified in the course of clinical care, however, there is no streamlined process to comprehensively and proactively identify, prioritize and address the most important health-related social needs of our patients at the time of hospitalization. Our previous research has increased our understanding of the multitude of SDOH impacting readmission risk and poor outcomes. With NIDDK funding, we developed a measurement system (REDD-CAT) designed to efficiently capture and create a personalized profile of health-related social needs for patients with diabetes to reduce avoidable hospitalization and emergency department visits. We now aim to study a novel intervention that couples our innovative SDOH screening intervention tool (REDD-CAT) with an evidence-based patient navigation protocol (REDDCAT2) also developed in past NIH-funded work. We will implement this intervention during hospital care transitions in order to leverage hospitalization as an opportunity to resolve unmet SDOH needs for people living with diabetes. We will study the impact of the REDDCAT2 intervention compared with discharge care as usual readmission risk measured as time to rehospitalization in the 90 days following discharge. The goal of the comparative effectiveness trial is to assess the impact of REDD-CAT on medical service outcome, diabetes outcomes and SDOH outcomes at 30-days and 90-days following hospital discharge. The REDD-CAT tool will rapidly identify individuals with unmet social needs that place them at risk of poor health outcomes. The REDDCAT2 patient navigator will work with the patient to collaboratively prioritize each individual patient’s SDOH needs at the hospital bedside and provide post-discharge PN support for 90-days care transition period to resolve unmet SDOH needs. We will also use this research opportunity to generate a unique patient risk profile algorithm for future work.

REDDCAT2 Project Narrative Often unmet social needs are identified in the course of clinical care; however, there is no streamlined process to comprehensively and proactively identify and address the most important health-related social needs at the time of hospitalization. The goal of the comparative effectiveness trial is to assess the impact of REDD-CAT on medical service outcomes, diabetes outcomes, and underlying social determinants at 30-days and 90-days following discharge. In partnership with the patient, the REDDCAT2 patient navigator will prioritize reported social needs at the hospital bedside and provide post-discharge navigation support.