[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-study-detail:100639134":3},{"organization":4,"armGroups":7,"interventions":14,"overallOfficials":21,"centralContacts":20,"locations":25,"responsibleParty":53,"collaborators":20,"id":56,"slug":57,"hasResults":58,"nctId":59,"briefTitle":60,"officialTitle":61,"acronym":62,"eligibilityCriteria":63,"healthyVolunteers":58,"sex":64,"minAge":65,"maxAge":20,"enrollmentInfo":66,"targetDuration":20,"studyType":69,"phases":70,"briefSummary":72,"conditions":73,"keywords":78,"overallStatus":90,"whyStopped":20,"lastUpdateSubmitDate":91,"lastUpdatePostDateStruct":92,"startDateStruct":95,"completionDateStruct":97,"leadSponsor":99,"locationsCount":100},{"fullName":5,"class":6},"University of Alabama at Birmingham","OTHER",[8],{"label":9,"type":10,"description":11,"interventionNames":12},"MEDBRIDGE-Guided NCM\u002FCHW Support","EXPERIMENTAL","High-risk patients with type 2 diabetes identified by the MEDBRIDGE risk stratification tool receive a 3-month post-discharge support intervention delivered by a nurse case manager (NCM) and community health worker (CHW) team.",[13],"Behavioral: MEDBRIDGE-Guided NCM\u002FCHW Post-Discharge Support Intervention",[15],{"type":16,"name":17,"description":18,"armGroupLabels":19,"otherNames":20},"BEHAVIORAL","MEDBRIDGE-Guided NCM\u002FCHW Post-Discharge Support Intervention","A 3-month post-discharge care coordination intervention delivered by a nurse case manager (NCM) and community health worker (CHW) team, guided by MEDBRIDGE AI-driven risk stratification. The intervention follows a four-phase workflow: (1) Risk Assessment, where the NCM reviews the daily MEDBRIDGE-generated high-risk patient list; (2) Initial Patient Contact, where the NCM\u002FCHW team initiates contact after discharge to review medications and identify discrepancies; (3) Ongoing Support, where the CHW provides monthly check-ins to monitor adherence, address barriers, and coordinate with primary care providers; and (4) Transition to Routine Care, where the team facilitates handoff to the patient's primary care provider with a summary of activities and recommendations. Participants receive a minimum of 3 contacts over the intervention period.",[9],null,[22],{"name":23,"affiliation":5,"role":24},"Seung-Yup Lee, PhD","PRINCIPAL_INVESTIGATOR",[26,44],{"facility":5,"status":20,"city":27,"state":28,"zip":29,"country":30,"countryCode":31,"cosmosGeoPoint":32,"geoPoint":37,"contacts":38},"Birmingham","Alabama","35223","United States","US",{"type":33,"coordinates":34},"Point",[35,36],-86.80249,33.52066,{"lat":36,"lon":35},[39,43],{"name":23,"role":40,"phone":41,"phoneExt":20,"email":42},"CONTACT","205-934-4315","slee9@uab.edu",{"name":23,"role":24,"phone":20,"phoneExt":20,"email":20},{"facility":45,"status":20,"city":27,"state":28,"zip":46,"country":30,"countryCode":31,"cosmosGeoPoint":47,"geoPoint":49,"contacts":50},"Cooper Green Mercy Health Services","35233",{"type":33,"coordinates":48},[35,36],{"lat":36,"lon":35},[51,52],{"name":23,"role":40,"phone":41,"phoneExt":20,"email":42},{"name":23,"role":24,"phone":20,"phoneExt":20,"email":20},{"type":24,"investigatorFullName":54,"investigatorTitle":55,"investigatorAffiliation":5,"oldNameTitle":20,"oldOrganization":20},"Seung-Yup Lee","Assistant Professor","100639134","medbridge-guided-ncmchw-post-discharge-support-for-high-risk-t2d-patients-100639134",false,"NCT07599852","MEDBRIDGE-Guided NCM\u002FCHW Post-Discharge Support for High-Risk T2D Patients","MEDBRIDGE: AI-Driven Risk Stratification and Care Transition Intervention to Improve Diabetes Medication Management","MEDBRIDGE","Inclusion Criteria:\n\n* Adults aged 18 years or older\n* Diagnosis of type 2 diabetes (HbA1c of 6.5% or higher or relevant ICD-10 codes including E11, E13, E14, R73, L97.509, K31.84)\n* Discharged from UAB Hospital or its emergency departments\n* Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic\n* Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge\n\nExclusion Criteria:\n\n* Under age 18\n* No indication of type 2 diabetes\n* Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care\n* Unable to provide informed consent\n* Currently enrolled in another post-discharge intervention study","ALL","18 Years",{"count":67,"type":68},45,"ESTIMATED","INTERVENTIONAL",[71],"NA","This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes manage their medications after leaving the hospital. Many patients with diabetes take multiple medications, and changes to these medications during hospital stays can cause confusion and lead to missed doses or incorrect use. This is especially common in communities with limited access to healthcare.\n\nThe study uses a computer-based tool called MEDBRIDGE (MEDication BRIDGE) to identify patients who may be at higher risk for problems after discharge, such as worsening blood sugar control or return visits to the emergency department. Patients identified as high-risk will receive 3 months of support from a nurse case manager and community health worker team, who will help with medication questions, coordinate with their doctor, and provide follow-up check-ins.\n\nThe main goal is to find out whether this type of support program is practical to deliver and acceptable to patients. The study will also track changes in blood sugar levels and emergency department visits. Forty-five patients will be enrolled over 6 months at the University of Alabama at Birmingham and Cooper Green Mercy Health Services in Jefferson County, Alabama.",[74,75,76,77],"Type 2 Diabetes","Medication Adherence","Care Transition","Medication Discrepancy",[74,79,80,81,82,83,84,85,86,87,88,89],"Medication Management","Care Transitions","Post-Discharge","Nurse Case Manager","Community Health Worker","Risk Stratification","Artificial Intelligence","HbA1c","Social Determinants of Health","Deep South","Underserved Populations","NOT_YET_RECRUITING","2026-05-14",{"date":93,"type":94},"2026-05-20","ACTUAL",{"date":96,"type":68},"2029-05-01",{"date":98,"type":68},"2031-04-30",{"name":5,"class":6},2]