# Addressing Social Determinants in Diabetes Care: the REDD-CAT health-related social needs screening tool

> **NIH NIH R21** · BOSTON MEDICAL CENTER · 2020 · $291,513

## Abstract

PROJECT SUMMARY
Over 27 million Americans have Type 2 Diabetes Mellitus (T2DM), accounting for more than 7.7 million
hospital admissions and $245 billion in healthcare costs each year. Hospitalized T2DM patients are at
increased risk of readmission; in 2010, 20.3% of patients admitted for DM with complications were readmitted
within 30 days, making diabetes one of the top conditions for rehospitalizations. In many instances, the social
determinants of health—such as housing and food instability, benefits denials, and lack of income—are
responsible for preventable hospitalizations, as they undermine the patient’s ability to self-manage diabetes
and prevent complications. Often these unmet social needs are informally identified in the course of clinical
care. However, there is no streamlined process to comprehensively identify, prioritize, and address the most
important health-related social needs of our most vulnerable patients. Our previous research has increased our
understanding of the multitude of social determinants related to readmission risk and poor outcomes. It has
underscored the importance of developing methods to efficiently assess and prioritize social determinants and
to develop profiles of the individuals at the highest risk of readmission. We propose to develop a measurement
system, Re-Engineered Discharge for Diabetes-Computer Adaptive Testing (REDD-CAT) 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. Our aims are: 1) to develop and validate the REDD-CAT; 2)
to utilize the newly developed REDD-CAT measures, existing measures from PROMIS, medical record data,
and retrospective claims data to generate personalized risk assessment profiles; and 3) to conduct a pilot
feasibility trial to assess the acceptability of implementing the REDD-CAT in a clinical context. Achievement of
these three aims will set the stage for a prospective, randomized trial of the REDD-CAT implementation in a
hospital setting to assess its impact on 30-day readmissions. As the name of our proposed assessment tool
implies, the longer-term goal of our research is to create a process for the Re-Engineered Discharge for
Diabetes and to embed the REDD-CAT in this process as the primary data source. Ultimately, we anticipate
that the methods we use to research and develop the REDD-CAT will find wide application across a number of
different settings and chronic diseases.

## Key facts

- **NIH application ID:** 9913522
- **Project number:** 5R21DK121092-02
- **Recipient organization:** BOSTON MEDICAL CENTER
- **Principal Investigator:** Noelle E. Carlozzi
- **Activity code:** R21 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $291,513
- **Award type:** 5
- **Project period:** 2019-04-11 → 2022-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9913522

## Citation

> US National Institutes of Health, RePORTER application 9913522, Addressing Social Determinants in Diabetes Care: the REDD-CAT health-related social needs screening tool (5R21DK121092-02). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9913522. Licensed CC0.

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