DEDICATE: aDvancing carE Management aDoption In Community heAlTh cEnters (DEDICATE)

April 29, 2026 updated by: Nicole Cook, OCHIN, Inc.
DEDICATE will refine and test the effectiveness of evidence-based implementation support strategies designed to support care management teams' sustained use of electronic health record (EHR)-based functionalities to address unmet non-medical health-related needs through improved clinical-community linkages. This study will test the hypothesis that providing implementation support to health center care management teams will lead to increased adoption of EHR functionalities and increased screenings and referrals to community organization to address unmet non-medical health-related needs needs through a cluster-randomized trial. This study's results will have implications for patients with non-medical health-related needs receiving care management in primary care settings.

Study Overview

Status

Active, not recruiting

Conditions

Intervention / Treatment

Detailed Description

The investigators will use a hybrid effectiveness-implementation mixed methods design to assess the impact of evidence-based implementation support strategies designed to support the care management teams' adoption of EHR functionalities that enable screening and referrals to community organizations for non-medical health-related needs. After conducting a three-month pilot study with three health centers to test and refine the implementation support strategies, 20 community-based health centers will be recruited to participate in a stepped-wedge, cluster-randomized trial. Eligible OCHIN health centers include those that provide primary care, use an EHR-based care management tool for at least one care management or population health program that addresses non-medical health-related needs for more than 10 enrolled patients from April-June 2025. Once 20 health centers have been enrolled, health centers will be randomized to one of four wedges for staggered receipt of the intervention. This method will allow us to provide tailored support to five health centers at a time and enables all health centers to eventually receive the intervention. Participating sites will be provided implementation support strategies for using EHR-based functionalities to conduct screening and referrals for patients with unmet non-medical health-related needs. After receiving the intervention, participating health centers will be followed until Y4Q4 to assess primary and secondary outcomes.

The intervention includes implementation strategies to support adoption of EHR-based functionalities for non-medical health-related needs activities by care management teams in health centers. The intervention will be delivered to health center care management staff outside of patient care. Patients will not directly receive the intervention and will continue to receive regular care from the health center. For all study health centers, quantitative data will be collected (via EHR data extraction) on care team use of EHR functionalities and non-medical health-related needs screening and coordination provided by care teams. Limited clinical data will be collected on patients seen at included health centers during the study period. Qualitative data will also be collected, including semi-structured interviews with clinic staff from all enrolled study sites.

Study Type

Interventional

Enrollment (Estimated)

20

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Oregon
      • Portland, Oregon, United States, 97228
        • OCHIN

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria

• • Health centers that use an EHR-based care management tool for at least one care management or population health program that addresses non-medical health-related needs for more than 10 enrolled patients from April-June 2025.

Exclusion Criteria

  • Health center participated in pilot
  • Health center is a school-based health center
  • Health center provides care to prison population

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Crossover Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Intervention Arm
Intervention health centers will receive implementation support when they crossover from Control to Intervention.
Other: Implementation Support
Health centers receiving the intervention will have access to implementation support strategies designed to support adoption of screenings and referrals to community organizations for patients with unmet non-medical health-related needs receiving care management. Implementation support will be provided by an OCHIN trainer, practice facilitators, workflow engineer, and analysts.
No Intervention: Control Arm
Control health centers will not receive an intervention prior to crossover to Intervention.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Screening for non-medical health-related needs
Time Frame: From six months prior to the intervention, assessed up to 12 months.
Whether a patient enrolled in a care management program was screened for unmet non-medical health-related needs (binary, patient-level).
From six months prior to the intervention, assessed up to 12 months.
Referral for non-medical health-related need
Time Frame: Baseline, through study completion, an average of 7.5 months.
Among patients with one or more identified non-medical health-related need, whether a referral was made for each identified need (binary, patient-level)
Baseline, through study completion, an average of 7.5 months.

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Referrals with a documented outcome (all non-medical health-related needs)
Time Frame: Baseline, through study completion, an average of 7.5 months.
Among referrals made for any identified financial-related need, whether outcome has been recorded in the EHR. Documented outcome statuses (also referred to as dispositions), may include successful connection to services, referral closure without service delivery, service unavailability, patient ineligibility, or other outcomes as defined by the care management team (binary, financial-related need-level).
Baseline, through study completion, an average of 7.5 months.
Referrals with an outcome documented as received (all non-medical health-related needs)
Time Frame: Baseline, through study completion, an average of 7.5 months.
Among referrals made for any identified financial-related need, whether documented outcome status indicates "successful connection to services" (binary, non-medical health-related need-level).
Baseline, through study completion, an average of 7.5 months.
Controlled hypertension
Time Frame: Baseline, through study completion, an average of 7.5 months.
Binary outcome of blood pressure control (defined as <140/90) at the most recent visit among patients with hypertension
Baseline, through study completion, an average of 7.5 months.
Controlled type 2 diabetes mellitus
Time Frame: Baseline, through study completion, an average of 7.5 months.
Binary outcome in HbA1c control (defined as <9%) at the most recent visit among patients with diabetes mellitus
Baseline, through study completion, an average of 7.5 months.

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

OCHIN, Inc.

Investigators

  • Principal Investigator: Rachel Gold, PhD, OCHIN, Inc.
  • Principal Investigator: Nicole Cook, PhD, OCHIN, Inc.

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 1, 2025

Primary Completion (Estimated)

June 30, 2027

Study Completion (Estimated)

June 1, 2028

Study Registration Dates

First Submitted

June 27, 2024

First Submitted That Met QC Criteria

July 2, 2024

First Posted (Actual)

July 5, 2024

Study Record Updates

Last Update Posted (Actual)

May 6, 2026

Last Update Submitted That Met QC Criteria

April 29, 2026

Last Verified

April 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 00074727

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

All EHR data are proprietary to the OCHIN health centers and thus will not be made directly available beyond the study team.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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