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CareAvenue Program to address Unmet Resource Needs

Project Title:

Improving Diabetes Outcomes and Health Disparities Through a Patient Activation Intervention Addressing Unmet Resource Needs


National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)/National Institutes of Health (NIH)


We developed and piloted a feasible and acceptable theory-based, e-health intervention, CareAvenue, to 1) systematically screen for both health-related and unmet basic needs contributing to cost-related nonadherence; 2) provide links to locally available resources to address patients’ needs; and 3) create low-burden mechanisms to share information with providers so they can help refer patients to identified resources and follow up as necessary.


The aims of this randomized controlled trial are to: 1) Determine the effectiveness of CareAvenue relative to existing services in order to improve glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial stress; and 2) use quantitative methods to examine the role of patient risk factors (moderators) and behavioral factors (e.g. uptake and use of resources) (mediators) on the effectiveness of CareAvenue in improving outcomes. We are engaging 600 patients with uncontrolled diabetes and unmet social risk factors. Outcomes will be assessed at baseline and 6- and 12-month follow-up via survey data and the collection of biomarkers.

Grant Number:


Study Dates:

9/14/2018 – 6/30/2023


  • Springer M, Skolarus L, Patel MR. Food insecurity and perceived financial stress are associated with cost-related medication non-adherence in stroke. Journal of Health Care for the Poor and Underserved, 2023 (In Press).

  • Chiang YC*, Ni W*, Zhang G*, Shi X, Patel MR. Cost-related non-adherence behaviors for diabetes and comorbid conditions- association with diabetes outcomes. Journal of the American Board of Family Medicine, 2022 (In Press).

  • Ismail H*, Marshall VD, Patel MR, Tariq M, Mohammad RA. The impact of the Covid-19 pandemic on medical conditions and medication adherence in people with chronic disease J Am Pharm Assoc. 2021;S1544-3191(21)00474.

  • Patel MR, Zhang G*, Leung C, Song PXK, Heisler M, Choe HM, Mehdipanah R, Shi X, Resnicow K, Rajaee G*, Piette JD. Impacts of the COVID-19 pandemic on unmet social needs, self-care, and outcomes among people with diabetes and poor glycemic control. Prim Care Diabetes. 2021;S1751-9918(21)00189-3.

  • Patel MR, Heisler M, Piette JD, Resnicow K, Song PXK, Choe HM, Shi X, Tobi J, Smith A. Study Protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial. Contemporary Clinical Trials, 2020 Jan 7;89:105933.

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