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MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients

MEDBRIDGE: AI-Driven Risk Stratification and Care Transition Intervention to Improve Diabetes Medication Management

Who can join

As published by the study on ClinicalTrials.gov. "Not stated" means the study hasn't said — ask the study team.

Age
18 Years and older
Sex
All sexes
Healthy volunteers
Not accepted
Compensation
Not stated

Other requirements are listed under Eligibility below. Only the study team can confirm whether you can join.

What to expect

No one can promise a trial will help you personally — that is what the research is trying to find out.

What participation involves

  • Time periods mentioned: 6 months

Only what the study's summary and detailed description on ClinicalTrials.gov say. Time periods may describe the whole study or a part of it — ask the study team what applies to you.

Show the study's own words
  • "Forty-five patients will be enrolled over 6 months at the University of Alabama at Birmingham and Cooper Green Mercy Health Services in Jefferson County, Alabama."
Compensation
Not stated
  • Study-related exams and procedures are typically provided at no cost. This is how many trials work in general — confirm the details for this study with the study team.
  • Participants are monitored closely by the research team throughout the study.
  • Some participants may receive access to an investigational treatment, which is still being studied.
  • Your participation helps researchers learn whether this approach could help future patients.

About this study

In plain language

This study tests whether 3 months of help from a nurse case manager and community health worker can support safe medicine use after a hospital stay or emergency room visit. It is for adults with type 2 diabetes who have a high risk of problems after going home. The study will check if the program is practical to offer and acceptable to patients, and track blood sugar levels and emergency room visits.

This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes manage their medications after leaving the hospital. Many patients with diabetes take multiple medications, and changes to these medications during hospital stays can cause confusion and lead to missed doses or incorrect use. This is especially common in communities with limited access to healthcare. The study uses a computer-based tool called MEDBRIDGE (MEDication BRIDGE) to identify patients who may be at higher risk for problems after discharge, such as worsening blood sugar control or return visits to the emergency department. Patients identified as high-risk will receive 3 months of support from a nurse case manager and community health worker team, who will help with medication questions, coordinate with their doctor, and provide follow-up check-ins. The main goal is to find out whether this type of support program is practical to deliver and acceptable to patients. The study will also track changes in blood sugar levels and emergency department visits. Forty-five patients will be enrolled over 6 months at the University of Alabama at Birmingham and Cooper Green Mercy Health Services in Jefferson County, Alabama.

Compensation is read from the study's own description and may be missing — always confirm with the study team.

Eligibility

Who can join

  • You are age 18 or older.
  • You have type 2 diabetes, shown by an HbA1c of 6.5% or higher or certain medical record codes. HbA1c measures your average blood sugar.
  • You have been discharged from UAB Hospital or one of its emergency departments.
  • You get primary care at Cooper Green Mercy Health Services or the UAB Post Discharge Clinic.
  • The MEDBRIDGE computer tool finds you have a high risk of rising blood sugar or diabetes-related emergency room visits or hospital stays within 3 months of going home.

Who can't join

  • You are younger than 18.
  • There is no sign that you have type 2 diabetes.
  • You do not get primary care through Cooper Green Mercy Health Services or the UAB Post Discharge Clinic.
  • You cannot give informed consent, which means understanding the study and agreeing to join.
  • You are already in another study testing support after leaving the hospital.

Simplified for readability. The official criteria below are what the study team uses.

Official eligibility criteria

Inclusion Criteria: * Adults aged 18 years or older * Diagnosis of type 2 diabetes (HbA1c of 6.5% or higher or relevant ICD-10 codes including E11, E13, E14, R73, L97.509, K31.84) * Discharged from UAB Hospital or its emergency departments * Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic * Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge Exclusion Criteria: * Under age 18 * No indication of type 2 diabetes * Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care * Unable to provide informed consent * Currently enrolled in another post-discharge intervention study

Study sites (2)

AL