New tool aims to connect patients with housing and food resources

NCT ID NCT05574699

Completed Knowledge-focused Sponsor: Johns Hopkins University Source: ClinicalTrials.gov ↗

First seen Jun 26, 2026 · Last updated Jul 16, 2026 · Updated 2 times

Summary

This study tested a clinical decision support tool that helps doctors identify social needs—like food, housing, or transportation—in African American patients with chronic diseases such as diabetes or heart failure. The tool uses a social risk score to flag patients who may need help and then refers them to community organizations. Researchers compared this approach to standard care in 251 patients to see if it improved how well social needs were addressed.

What this could mean

Our plain-language read of the trial. This is informational only — not medical advice or a prediction.

Active substance: Social risk score and clinical decision support tool
What this could lead to: If successful, this tool could help doctors better connect patients with community resources to address social needs like food or housing, potentially improving chronic disease management.
What could go wrong: This is a small pilot study with 251 participants, so results may not apply broadly. The tool only identifies needs—it does not guarantee that patients will receive help.

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Conditions

The condition(s) this trial relates to.

Chronic Disease congestive heart failure diabetes mellitus heart failure hypertensive disorder

As listed by the trial registrant

The condition terms exactly as the trial's registrant entered them.

CHRONIC DISEASE CONGESTIVE HEART FAILURE DIABETES MELLITUS HYPERTENSION

Contacts and locations

Locations

Johns Hopkins Bayview Medical Center - Comprehensive Care Practice

Baltimore, Maryland, 21224, United States
Johns Hopkins Community Physicians - EBMC

Baltimore, Maryland, 21202, United States
Johns Hopkins Community Physicians - Remington

Baltimore, Maryland, 21211, United States
Johns Hopkins GreenSpring Station

Baltimore, Maryland, 21093, United States
Johns Hopkins JHOC-GIM Clinic

Baltimore, Maryland, 21287, United States

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