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

Sponsor: Sairam Parthasarathy • ClinicalTrials.gov ID: NCT07799961

Registry updated: 2026-09-02

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Description

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.

Interventions

Community Health Worker intervention (Other)
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.
Usual Care (Other)
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.

Eligibility criteria

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

Conditions

Social Determinants of Health (SDOH) Hypertension Diabetes Mellitus Hypercholesterolaemia

Locations

Banner University Medical Center South — Tucson, Arizona, United States
UAHS Center for Sleep, Circadian, & Neuroscience Research Department of Medicine, University of Arizona — Tucson, Arizona, United States

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Official Source

Data sourced from ClinicalTrials.gov, a service of the U.S. National Institutes of Health.

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