A Study of Overcoming Social Determinants of Health

Social and Relational Capital to Overcome Social Determinants of Health.

This study is being done to determine if assistance in accessing community resources can improve health outcomes. Social determinants of health are the conditions in which individuals are born, work and live that can impact health. These can include access to healthcare, healthy food, education, safe neighborhoods, transportation, political and social environments that are safe and fair.

Study Overview

• Status: Completed
• Conditions: Social Determinants of Health (SDOH)
• Intervention / Treatment: Behavioral: The Open Table

• Study Type: Interventional
• Enrollment (Actual): 12
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Arizona
    • Scottsdale, Arizona, United States, 85050
      • Mayo Clinic Arizona

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

- Identified social determinants of health (SDOH). need that impacts healthcare outcomes (identified by the healthcare team)

Exclusion Criteria:

• Non-english speaking patients
• Patients who are pregnant

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: The Open Table Model; Subjects identified as having their health negatively impacted by Social Determinants of Health (SDOH) will meet with The Open Table members to determine their specific needs, decide on a plan for overcoming this need and following up to ensure resolution.	Behavioral: The Open Table; An organization that connects community volunteers to individuals in need to help overcome life's challenges.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment	Evaluated using the CMS Accountable Health SDOH Screening Tool used to assess patient needs across the following domains: house instability, food insecurity, transportation problems, utility help needs, interpersonal safety, financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities that community services can help with. If the participant chose the underlined option, they might have an unmet health-related social need. Only domains where an unmet health-related social need was identified was included in the analysis.	Baseline and 12 months
Change in Resilience	Evaluated using the 6-item Brief Resilience Scale (BRS) questionnaire assessing the participants ability to bounce back on a 1-5 scale range. Total questions scores are divided by total number of questions answered for a final score range from 1.00-2.99 = low resilience; 3.00-4.30 = normal resilience; 4.31-5.00 = high resilience.	Baseline and 12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hospitalizations	Difference in total number of hospitalizations in the 12 months before intervention and 12 months during intervention.	Baseline and 12 months
Emergency Room Visits	Difference in total number of emergency room visits in the 12 months before intervention and 12 months during intervention.	Baseline and 12 months
Primary Care Visits	Difference in total number of primary care visits in the 12 months before intervention and 12 months during intervention.	Baseline and 12 months

Collaborators and Investigators

• Sponsor: Mayo Clinic
• Collaborators: National Center for Advancing Translational Sciences (NCATS)
• Investigators: Principal Investigator: Nathan Delafield, MD, Mayo Clinic

Publications and helpful links

Helpful Links

• Mayo Clinic Clinical Trials

Study record dates

Study Major Dates

• Study Start (Actual): June 15, 2023
• Primary Completion (Actual): July 17, 2024
• Study Completion (Actual): July 17, 2024

Study Registration Dates

• First Submitted: March 10, 2023
• First Submitted That Met QC Criteria: March 10, 2023
• First Posted (Actual): March 17, 2023

Study Record Updates

• Last Update Posted (Actual): July 17, 2025
• Last Update Submitted That Met QC Criteria: June 27, 2025
• Last Verified: June 1, 2025

More Information

Terms related to this study

• Other Study ID Numbers: 22-012939; UL1TR002377 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No