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OpenTrials
Completed

NCT Number: NCT05773313

A Study of Overcoming 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.

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Key information

Conditions

Social Determinants of Health (SDOH)

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Mayo Clinic Arizona

Scottsdale, Arizona, 85050, United States

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

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

Treatment and study plan

The Open Table

Behavioral

An organization that connects community volunteers to individuals in need to help overcome life's challenges.

Primary outcomes

  1. Change in Participant Center for Medicare and Medicaid Services (CMS) Accountable Health Social Determinants of Health (SDOH) Screening Assessment

    Time frame: Baseline and 12 months

    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.

  2. Change in Resilience

    Time frame: Baseline and 12 months

    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.

Secondary outcomes

  1. Hospitalizations

    Time frame: Baseline and 12 months

    Difference in total number of hospitalizations in the 12 months before intervention and 12 months during intervention.

  2. Emergency Room Visits

    Time frame: Baseline and 12 months

    Difference in total number of emergency room visits in the 12 months before intervention and 12 months during intervention.

  3. Primary Care Visits

    Time frame: Baseline and 12 months

    Difference in total number of primary care visits in the 12 months before intervention and 12 months during intervention.

Sponsors and collaborators

Lead sponsor

Mayo Clinic

Other

Collaborators

  • National Center for Advancing Translational Sciences (NCATS)

Registry information

Official study title

Social and Relational Capital to Overcome Social Determinants of Health.

Important dates

Study start
2023
Primary completion
2024
Study completion
2024
First posted
Mar 17, 2023
Registry last updated
Jul 17, 2025

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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