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The Re-Engineered Discharge for Diabetes Care Transitions (REDDCAT2): Screening and Addressing SDOH Needs at Hospital Discharge

Award Number: R01NR021826
ORGANIZATION: NATIONAL INSTITUTE OF NURSING RESEARCH
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 08/20/2024
PERIOD OF PERFORMANCE END DATE: 05/31/2029

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The Re-Engineered Discharge for Diabetes Care Transitions (REDDCAT2): Screening and Addressing SDOH Needs at Hospital Discharge - REDDCAT2 Project Abstract Summary Over 36 million Americans are diagnosed with type 2 diabetes mellitus (T2DM), accounting for more than 7.8 million hospital admissions and $327 billion in healthcare costs each year. Fully, 1 in 5 hospitalizations involve patients with diabetes, largely due to diabetes complications that are attributable to social determinants of health leading to unmet health-related social needs. Often unmet SDOH needs are identified in the course of clinical care, however, there is no streamlined process to comprehensively and proactively identify, prioritize and address the most important health-related social needs of our patients at the time of hospitalization. Our previous research has increased our understanding of the multitude of SDOH impacting readmission risk and poor outcomes. With NIDDK funding, we developed a measurement system (REDD-CAT) designed to efficiently capture and create a personalized profile of health-related social needs for patients with diabetes to reduce avoidable hospitalization and emergency department visits. We now aim to study a novel intervention that couples our innovative SDOH screening intervention tool (REDD-CAT) with an evidence-based patient navigation protocol (REDDCAT2) also developed in past NIH-funded work. We will implement this intervention during hospital care transitions in order to leverage hospitalization as an opportunity to resolve unmet SDOH needs for people living with diabetes. We will study the impact of the REDDCAT2 intervention compared with discharge care as usual readmission risk measured as time to rehospitalization in the 90 days following discharge. The goal of the comparative effectiveness trial is to assess the impact of REDD-CAT on medical service outcome, diabetes outcomes and SDOH outcomes at 30-days and 90-days following hospital discharge. The REDD-CAT tool will rapidly identify individuals with unmet social needs that place them at risk of poor health outcomes. The REDDCAT2 patient navigator will work with the patient to collaboratively prioritize each individual patient’s SDOH needs at the hospital bedside and provide post-discharge PN support for 90-days care transition period to resolve unmet SDOH needs. We will also use this research opportunity to generate a unique patient risk profile algorithm for future work.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2026 ( Subtotal = $747,672 )
2026	2026	UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL	55 LAKE AVE N	WORCESTER	MA	01655	WORCESTER	USA	Nursing Research	000	3	5/8/2026	NON-COMPETING CONTINUATION	$747,672
														Subtotal = $747,672

Issue Date FY: 2025 ( Subtotal = $716,802 )
2025	2025	UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL	55 LAKE AVE N	WORCESTER	MA	01655	WORCESTER	USA	Nursing Research	001	2	6/20/2025	NON-COMPETING CONTINUATION	$747,711
2025	2024	UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL	55 LAKE AVE N	WORCESTER	MA	01655	WORCESTER	USA	Nursing Research	000	1	2/18/2025	NEW	-$30,909
														Subtotal = $716,802

Issue Date FY: 2024 ( Subtotal = $792,813 )
2024	2024	UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL	55 LAKE AVE N	WORCESTER	MA	01655	WORCESTER	USA	Nursing Research	000	1	8/20/2024	NEW	$792,813
														Subtotal = $792,813

Grand Total All Awards = $2,257,287

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The Re-Engineered Discharge for Diabetes Care Transitions (REDDCAT2): Screening and Addressing SDOH Needs at Hospital Discharge

Award Number: R01NR021826

ORGANIZATION: NATIONAL INSTITUTE OF NURSING RESEARCH

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

PERIOD OF PERFORMANCE START DATE: 08/20/2024

PERIOD OF PERFORMANCE END DATE: 05/31/2029

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