for people ages 18 years and up (full criteria)
at San Francisco, California and other locations
study started
completion around
Principal Investigator
by Laura Gottlieb, MD, MPH
Headshot of Laura Gottlieb
Laura Gottlieb



This study was designed to develop and test clinical decision support (CDS) tools that present clinical care team members with a given patient's social risk information and recommend care plan adaptations based on those risks. This study will test the hypothesis that providing care team members with CDS about patients' known social risks will result in improved outcomes. This study's primary outcomes are hypertension and diabetes control, but the results will have implications for a wide range of morbidities.


The investigators will use a randomized quasi-experimental design to assess impact of the CDS tools designed to support social risk-informed care. After conducting a 12-month pilot study with 3 CHCs to test and further refine the CDS tools, 6 CHCs will be recruited to participate in the main trial. All OCHIN clinics with >200 SDH screenings (excluding the pilot clinics) will be identified and randomized to a potential intervention group or a control group. Clinics from the potential intervention group will be recruited in a random order until 6 agree to participate. This recruitment method ensures randomization between intervention and control clinics, without recruiting CHCs to a study in which they might not receive an intervention. Intervention sites will be trained in how to use the tools shortly before the tools are activated and will be followed for 12 months to assess tool adoption and impact on the CQMs of interest. Use of the CDS tools will occur as part of the regular care patients receive and will not require special clinic visits. Patients will interact with providers as they normally would, augmented by the intervention when clinicians choose to utilize the CDS tools. For all study clinics, quantitative data will be collected (via EHR data extraction) on social risk data collection and action by care team members. Limited clinical data will be collected on patients who are seen at a study CHC during the study period. Qualitative data will also be collected which includes semi-structured interviews with clinic staff from all study CHCs enrolled in the main trial.

NOTE: Individual patients will not be assigned to an intervention. Instead, randomization and intervention will occur at the clinic level. While CHCs will be recruited that have previously screened patients for social risks, it is unlikely that these CHCs will have screened all patients in their clinics. Thus, the CDS tools will not apply to all patients in participating clinics, and it cannot be guaranteed that individual patients will receive an intervention.


Hypertension, Diabetes Mellitus, Type 2, Social Determinants of Health, Decision Support Systems, Clinical, Electronic Health Records, Community Health Centers, Health Status Disparities, Type 2 Diabetes Mellitus, CDS Tool Access


You can join if…

Open to people ages 18 years and up

  • Clinic has conducted >200 social risk screenings in the last 12 months at the time of randomization.
  • Clinic provides primary care
  • Joined OCHIN by 07/01/2021

You CAN'T join if...

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


  • UCSF
    San Francisco California 94143 United States
  • OCHIN, Inc
    Portland Oregon 97228 United States
  • Kaiser Permanente Center for Health Research
    Portland Oregon 97227 United States

Lead Scientist at UCSF

  • Laura Gottlieb, MD, MPH
    Laura Gottlieb, MD, MPH, is a Professor of Family and Community Medicine at UCSF. A former National Health Services Scholar and safety-net family physician with fellowship training in social determinants of health, Dr. Gottlieb now serves as Principal Investigator on multiple quantitative and qualitative projects examining the integration of social and medical care services.


in progress, not accepting new patients
Start Date
Completion Date
Kaiser Permanente
Study Type
About 50 people participating
Last Updated