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

> **NIH NIH R01** · UNIV OF MASSACHUSETTS MED SCH WORCESTER · 2024 · $761,904

## Abstract

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.

## Key facts

- **NIH application ID:** 10979094
- **Project number:** 1R01NR021826-01A1
- **Recipient organization:** UNIV OF MASSACHUSETTS MED SCH WORCESTER
- **Principal Investigator:** Suzanne E Mitchell
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $761,904
- **Award type:** 1
- **Project period:** 2024-08-20 → 2029-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10979094

## Citation

> US National Institutes of Health, RePORTER application 10979094, The Re-Engineered Discharge for Diabetes Care Transitions (REDDCAT2): Screening and Addressing SDOH Needs at Hospital Discharge (1R01NR021826-01A1). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/10979094. Licensed CC0.

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