Arizona CEAL: Linking Social Care With Healthcare Systems to Address SDOH (AZCEAL)

August 28, 2026 updated by: Sairam Parthasarathy
The goal of the Arizona Community Engagement Alliance (AZ-CEAL) will be to combine social care with healthcare programs. The study will be connecting selected patients from clinics with trained community health workers (CHW) who will assist participants in getting the help that is needed for their health such as transportation needs, accessing healthy food, health information, accessing good health care, job opportunities, and housing. The study will collect information from both the patients and the health care systems to test how effectively the care plan works over time.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

Social drivers of health contribute significantly to disparities in health outcomes for many chronic diseases in low income populations. Social drivers of health and health related social needs exacerbate stress, allostatic load, chronic pain, and cardiovascular outcomes. And in recent years, the consistent and compelling evidence regarding how Social drivers of health influences health has led to growing recognition within healthcare systems of the need to addressing health-related factors upstream of the clinical encounter. Whilst health systems have started collecting patient-level Social drivers of health, most front-line healthcare workers have little time, skill, or resources to address Social drivers of health challenges (Implementation Gap). And, in the health systems we serve, social worker positions employed and embedded within healthcare systems -- the key clinician professional group skilled at addressing SDOH -- are being cut for short term financial performance, leaving vulnerable patient populations disconnected from existing community resources and professional support. Community Health Workers (CHWs) are entry-level paraprofessionals known to provide robust support to link high risk populations with health and social services that could help high risk patient-clients cope with or mitigate the effects of Social drivers of health. Yet, despite their known effectiveness and the prevalent identification of Social drivers of health within healthcare systems, CHWs largely operate outside of healthcare systems and are not effectively linked to those systems in a manner to help patient-clients address identified Social drivers of health challenges and health related social needs. The key research questions that pertain to addressing Social drivers of health elements within healthcare systems are: (a) How to integrate social care (i.e., services that address health-related social risk factors and needs) into clinical practice settings? and (b) what kind of infrastructure is needed to facilitate such activities?

To address these important questions, the overarching goal of the Arizona Community Engagement Alliance (AZ-CEAL) will be to disseminate and implement social care integration within healthcare systems by connecting healthcare providers within systems with trained community health workers within the communities while studying process-level (implementation) and client-level (patient outcome) metrics in a stepped wedge design approach within a large statewide healthcare system. This 4-year project proposal will address the overarching overall goal by continuing to leverage our community based participatory research relationship with the Arizona Community Health Worker (AzCHOW) Association representing 1500 CHWs and 200 CHW employers statewide to refine and train CHWs in interventions aimed at addressing Social drivers of health within healthcare delivery settings. We propose an initial planning phase (9 months) that will enable refinement of the evidence-based CHWs and their core competency trainings that are tailored to address care within Arizona healthcare settings and build the linkage infrastructure to connect them with healthcare providers and their patients within healthcare settings. In the implementation phase (39 months), we will undertake a stepped wedge cluster randomized trial to evaluate the process-level (implementation) and client-level (patient outcome) metrics. We will conduct this study within a statewide large healthcare system with 10 clusters per step. We will collect implementation outcomes data consistent with the RE-AIM framework. We will measure effects on process-level outcomes (SDOH elements) measured by patient reports (CEAL Common survey) and healthcare system-data ("No-show" rates) as well as patient-level (client) outcomes (blood pressure, HbA1C, lipid profile, stress, healthcare utilization [i.e., composite outcome of unplanned office visits, urgent care visits, emergency room visits, and hospitalization] and even death). The conceptual framework for our proposal is based upon the five activities to better integrate social care into health care delivery that was advocated by the National Academy of Sciences. The activities are to improve awareness, adjustment, assistance, alignment, and advocacy for social care within healthcare systems with multi-level interventions at the community- and systems-level.

Study Type

Interventional

Enrollment (Estimated)

740

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 Contact

Study Locations

  • United States
    • Arizona
      • Tucson, Arizona, United States, 85713
        • Recruiting
        • Banner University Medical Center South
        • Principal Investigator:
          • Sairam Parthasarathy, MD
        • Contact:
      • Tucson, Arizona, United States, 85724
        • Recruiting
        • UAHS Center for Sleep, Circadian, & Neuroscience Research Department of Medicine, University of Arizona
        • Principal Investigator:
          • Sairam Parthasarathy, MD
        • Contact:
        • Sub-Investigator:
          • Sabrina Oesterle, PhD
        • Sub-Investigator:
          • Samantha Sabo, DPH, MPH
        • Sub-Investigator:
          • Jon Tilburt, MD, MPH
        • Sub-Investigator:
          • Floribella Redondo-Martinez, CCHW, BS

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

Yes

Description

Inclusion Criteria:

  • 18 years of age or older

  • Must meet at least one of the three criteria:

    • Medicaid or dual-insured beneficiary or
    • Racial/ethnic minority or rural resident and
    • Household income in the bottom national quartile of household median income (low SES definition).

Exclusion Criteria:

  • Unable to provide informed consent due to cognitive impairment
  • Other specified reason that, in the opinion of the investigator makes the participant unsuitable for enrollment

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: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Social Care Linkage within an Healthcare System

Participants will be assigned to CHWs with knowledge of the local community resources based upon participant's residential area. The CHWs will assist the patient participant by systematically assessing and addressing the social drivers of health and Health Related Social Needs (HRSNs). A standardized assessment tool will be implemented to systematically identify baseline drivers of health. The CHWs will set long term goals and create an action plan with the patient.

Through CHW core competencies of coaching, advocacy, and individual capacity building, the CHWs will use an adapted Goal Setting and Action Planning tool to prioritize short and long term goals to ensure patient self-sufficiency, self-determination and ensure patient navigation and mediation are people-centered.
Other: Community Health Worker intervention
CHWs with knowledge of local community resources will address social needs through through a IVR platform. Both CHWs and participants can access each other through the IVR system. Patients are observed repeatedly so that measurements are nested within members. We will recruit participants into the closed cohort prior to the sequential roll-out of the intervention to ensure individual-level informed consent and patient-reported data. Recruiting individuals before the intervention is rolled into the clinic (cluster) enables both concurrent comparisons of participants receiving care across clinics as well as pre-post comparisons of individual level (patient-reported) data in addition to passive data collection at a system or clinic level. Primary Data collected through patient reported surveys and passive EMR collection will occur at baseline and 6 months. Patients may opt-in to additional data collection at 12, 18, 24, 36 month time points.
Active Comparator: Usual Care
Comparator (Description of usual care): Participants receiving care in clinics at the same time of a stepped-wedge design in a different clinic cluster but before the rolling in of the CHW-intervention described in the active comparator. These participants (patients) do not have CHWs addressing social issues and HRSNs within the healthcare system. The social drivers of health are assessed by phone interview as part of annual population health assessments and entered into the Electronic Medical Records system.
Other: Usual Care
Participants (patients) do not have CHWs addressing social issues and HRSNs within the healthcare system. The healthcare personnel act upon the identified social issues independently or with assistance from local clinic resources as usual. The social drivers of health are assessed by phone interview as part of annual population health assessments and entered into the Electronic Medical Records system and that in turn informs the healthcare provider.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Healthcare utilization
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Composite outcome of unplanned office visits, urgent care visits, emergency room visits, and hospitalizations. Data is passively collected through the EMR system. The data is expressed as a rate (events/year) that is calculated from 6 months of data
Baseline, 6 months, 12 months, 18 months, and 24 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Patient No-Show Rate
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Missed clinic appointment (numerator) compared to total clinic appointments (denominator). Data is passively collected through the EMR system. This is calculated as a rate (No-shows/year) from 6-months of data
Baseline, 6 months, 12 months, 18 months, and 24 months

Other Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Social Determinants of Health Risk Burden Assessed Using PRAPARE
Time Frame: Baseline, 6 months, 12 months, 18 months, and/or end of treatment
Participant-reported social determinants of health will be assessed using the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE). The instrument evaluates social and economic factors potentially affecting health, including housing, transportation, financial strain, employment, education, access to resources, and social support. The outcome will be assessed as the change from baseline in the number of identified social risk factors, with higher counts indicating greater social risk burden.
Baseline, 6 months, 12 months, 18 months, and/or end of treatment
Change in Systolic blood pressure
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Passively collect systolic blood pressure data from the EMR systems. It will be adjusted for number of anti-hypertensive medications and dosage.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change in Diastolic blood pressure
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Passively collect diastolic blood pressure data from the EMR systems. It will be adjusted for number of anti-hypertensive medications and dosage.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change in HBA1C
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Passively collect HBA1C data from the EMR systems. It will be adjusted for number of anti-diabetic medications and dosage.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change in Lipid panel level
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Passively collectlppid panel data from the EMR systems (Total cholesterol, HDL, VLDL, and TGL). It will be adjusted for number of anti-lipidemic medications and dosage.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change in Patient Telemedicine Availability
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Assess patient utilization of telemedicine visits (numerator) compared to total clinic visits (denominator). Data is passively collected through the EMR system and expressed as a proportion of the total visits in the same time period.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change From Baseline in Patient Satisfaction as Measured by the CAHPS Overall Provider Rating at 6 Months
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Patient satisfaction is measured by the Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Adult Visit Survey 3.0 overall provider rating item ("Using any number from 0 to 10...rate this provider"). Scores range from 0 to 10, with higher scores indicating greater satisfaction. Change is calculated as the 6-month score minus the baseline score; possible change scores range from -10 to +10, with positive values indicating improved satisfaction.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change From Baseline in Health Literacy as Measured by the Brief Health Literacy Screen at 6 Months
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Health literacy is assessed using the 3-item Brief Health Literacy Screen (BHLS; Chew items), a self-report measure of subjective health literacy comprising: (1) confidence completing medical forms independently; (2) frequency of needing help reading health materials; and (3) frequency of difficulty understanding written health information. Each item is rated on a 5-point scale scored 1 to 5. Items are coded so that higher values reflect greater health literacy [state which item(s) are reverse-scored under your coding] and summed to yield a total score ranging from 3 to 15, with higher scores indicating higher subjective health literacy. Change is calculated as the 6-month score minus the baseline score (range -12 to +12); positive values indicate improved health literacy.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change From Baseline in Sleep Disturbance as Measured by the PROMIS Sleep Disturbance Short Form 8a T-Score at 6 Months
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Sleep disturbance is assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance Short Form 8a, an 8-item self-report measure with a 7-day recall period. Each item is rated on a 5-point scale, yielding a raw score of 8 to 40. Raw scores are converted to a standardized T-score using the PROMIS Sleep Disturbance scoring manual conversion table. T-scores are calibrated to the US general population, with a mean of 50 and a standard deviation of 10; the observed T-score range for this form is approximately 28.9 to 76.5. Higher T-scores indicate greater sleep disturbance (worse sleep). Change is calculated as the 6-month T-score minus the baseline T-score; negative values indicate improvement in sleep.
Baseline, 6 months, 12 months, 18 months, and 24 months
Change From Baseline in Sleep-Related Impairment as Measured by the PROMIS Sleep-Related Impairment Short Form 8a T-Score at 6 Months
Time Frame: Baseline, 6 months, 12 months, 18 months, and 24 months
Sleep-related impairment is assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep-Related Impairment Short Form 8a v1.0, an 8-item self-report measure with a 7-day recall period assessing perceived alertness, sleepiness, and functional impairment during waking hours associated with sleep problems. Each item is rated on a 5-point scale (1=Not at all to 5=Very much), yielding a raw score of 8 to 40. Raw scores are converted to a standardized T-score using the PROMIS Sleep-Related Impairment scoring manual conversion table. T-scores are calibrated to the US general population, with a mean of 50 and a standard deviation of 10; higher T-scores indicate greater sleep-related impairment (worse daytime functioning). Change is calculated as the 6-month T-score minus the baseline T-score; negative values indicate improvement.
Baseline, 6 months, 12 months, 18 months, and 24 months

Collaborators and Investigators

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

Sponsor

Sairam Parthasarathy

Collaborators

Mayo Clinic
National Heart, Lung, and Blood Institute (NHLBI)
Arizona State University
University of Arizona
Northern Arizona University

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)

December 5, 2024

Primary Completion (Estimated)

April 1, 2028

Study Completion (Estimated)

April 1, 2028

Study Registration Dates

First Submitted

August 25, 2026

First Submitted That Met QC Criteria

August 28, 2026

First Posted (Actual)

September 2, 2026

Study Record Updates

Last Update Posted (Actual)

September 2, 2026

Last Update Submitted That Met QC Criteria

August 28, 2026

Last Verified

August 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 2011244240
  • OT2HL158287 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

UNDECIDED

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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