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Suzanne Mitchell

University of Massachusetts Chan Medical School, MA·Public Health & Epidemiology

About 1 in 5 hospital stays in the United States involve a patient with diabetes. Many of these admissions stem from complications driven by social determinants of health (SDOH), the everyday conditions that shape health, such as housing, food, money and transportation.

Fields

Public Health & Epidemiology

Medicine & Clinical Research

Topics

type 2 diabetes

social determinants of health

health-related social needs

Grants
1 known grant, through May 2029

What they work on

  1. Test whether REDDCAT2 delays hospital readmission within 90 days compared with usual discharge care for patients with type 2 diabetes, in a comparative effectiveness trial. The intervention pairs REDD-CAT social-needs screening with patient navigation.
  2. Assess the effect of REDDCAT2 on medical service use, diabetes outcomes and resolution of social needs at 30 and 90 days after discharge, with a navigator helping patients prioritize and address needs.
  3. Develop a patient risk profile algorithm from trial data on social determinants of health, to identify people with diabetes at highest risk of poor outcomes after hospitalization.

More about the research

When these needs go unmet, patients do worse. Hospital staff often notice such needs during care, but there is no streamlined way to find, prioritize and address them during a hospital stay. The project treats hospitalization as an opportunity to resolve these social needs for people living with type 2 diabetes.

Why it matters

People with type 2 diabetes often return to hospital because of unmet needs such as food, housing or transportation. If screening at discharge combined with patient navigation reduces readmissions and emergency visits, hospitals could adopt the approach as a practical way to address these needs. That could improve diabetes outcomes and lower health care costs.

Known grants

From NIH and NSF research grants. Labs often have other funding we can't see.

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

NIH · Aug 2024 – May 2029

Closest labs

Sae Takada

University of California-Los Angeles, CA·Public Health & Epidemiology

Evaluate whether Whole Person Care-Los Angeles, a social care program for Medicaid enrollees, improves diabetes screening, retention in care, medication adherence and blood sugar control compared with propensity score-matched non-enrollees.

Arthi Rao

Georgia Institute of Technology, GA·Engineering

Refine socioecological theories of transportation disadvantage and its effect on healthcare access through extensive engagement with community, health-system and industry stakeholders.

Daniel Liebzeit

University of Iowa, IA·Medicine & Clinical Research

Identify barriers and facilitators to adding the 4Ms of age-friendly care to hospital-to-home transitions through interviews with older adults, caregivers, clinicians, administrators and community service professionals.

The school

University of Massachusetts Chan Medical School: 29 labs on PI Pages, $350M a year on research, 55 research doctorates a year.

More about University of Massachusetts Chan Medical School

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