Integration of Social and Medical Care

May 2024 Council

Lead Division/Office


Point(s) of Contact

Barbara Linder, M.D., Ph.D.; Pamela Thornton, Ph.D; Mary Evans, Ph.D.; Jenna Norton, Ph.D., M.P.H.; Raquel Greer, M.D., M.H.S.; Ivonne Schulman, M.D.; Katrina Serrano, Ph.D.; Shavon Artis Dickerson, Dr.P.H., M.P.H.

Executive Summary

Adverse social determinants of health, also called social risks, drive poor obesity, diabetes, and kidney disease outcomes. Social risks disproportionately affect racial and ethnic minority groups, rural populations, sexual and gender minority groups and socioeconomically disadvantaged communities, and contribute to health inequities in NIDDK diseases. RFA-DK-22-038 requested pilot trials to test approaches to integrate social and medical care in health care settings. The trials will determine: 1) feasibility and acceptability of screening for social risks, identifying social needs and implementing referral service linkages (e.g., addressing transportation, housing, or food needs, etc.) within the context of a healthcare visit; and 2) preliminary signals of the intervention’s impact on both the social risk/need(s) and NIDDK disease outcomes. These pilots will lay the foundation for larger, fully powered clinical trials.This FY24 initiative was intended to 1) jump start novel research to systematically screen for and address patients’ social risks to improve health outcomes in NIDDK diseases; and 2) grow a community of NIDDK researchers who can share effective strategies to integrate medical and social care in the context of healthcare delivery. A budget cut to the FY24 initiative decreased the number of awards and eliminated the proposed 2nd receipt date. Funds are requested to re-issue the RFA with an FY26 receipt date to better achieve the goals of this initiative.