Trial Outcomes & Findings for Unmet Social Needs Study (NCT NCT04977583)

NCT ID: NCT04977583

Last Updated: 2025-04-30

Results Overview

Defined as participant connecting to one or more resources since the index unmet need screen and assessed via a participant survey administered 8 weeks following the index unmet need screen. The survey will ask: "Since you completed the unmet social need screen on (insert date), were you able to connect with any of the programs or resources for help with (insert need(s) identified)".

• Recruitment status: COMPLETED
• Study phase: NA
• Target enrollment: 479 participants
• Primary outcome timeframe: 8 weeks
• Results posted on: 2025-04-30

Participant Flow

Recruitment took place from April 2022 - June 2023. Trained research assistants (RAs) recruited participants by phone.

Participants needed to screen positive for one of nine needs to be assigned to an arm. Participants with zero needs were not eligible for the trial and thus not randomized to an arm.

Participant milestones

Measure	Screening Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Overall Study STARTED	161	160	158
Overall Study 8 Week Screen	143	141	133
Overall Study 6 Month Screen	135	133	138
Overall Study COMPLETED	150	154	144
Overall Study NOT COMPLETED	11	6	14

Reasons for withdrawal

Measure	Screening Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Overall Study Lost to Follow-up	8	4	13
Overall Study Withdrawal by Subject	3	2	1

Baseline Characteristics

Unmet Social Needs Study

Baseline characteristics by cohort

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Total n=479 Participants Total of all reporting groups
Age, Continuous	64.58 years STANDARD_DEVIATION 11.55 • n=5 Participants	63.96 years STANDARD_DEVIATION 12.17 • n=7 Participants	64.16 years STANDARD_DEVIATION 11.50 • n=5 Participants	64.24 years STANDARD_DEVIATION 11.72 • n=4 Participants
Sex/Gender, Customized Gender · Women	12 Participants n=5 Participants	10 Participants n=7 Participants	21 Participants n=5 Participants	43 Participants n=4 Participants
Sex/Gender, Customized Gender · Men	148 Participants n=5 Participants	150 Participants n=7 Participants	137 Participants n=5 Participants	435 Participants n=4 Participants
Sex/Gender, Customized Gender · Transgender Women	1 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Ethnicity (NIH/OMB) Hispanic or Latino	11 Participants n=5 Participants	10 Participants n=7 Participants	9 Participants n=5 Participants	30 Participants n=4 Participants
Ethnicity (NIH/OMB) Not Hispanic or Latino	150 Participants n=5 Participants	150 Participants n=7 Participants	149 Participants n=5 Participants	449 Participants n=4 Participants
Ethnicity (NIH/OMB) Unknown or Not Reported	0 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	0 Participants n=4 Participants
Race (NIH/OMB) American Indian or Alaska Native	0 Participants n=5 Participants	3 Participants n=7 Participants	1 Participants n=5 Participants	4 Participants n=4 Participants
Race (NIH/OMB) Asian	0 Participants n=5 Participants	1 Participants n=7 Participants	2 Participants n=5 Participants	3 Participants n=4 Participants
Race (NIH/OMB) Native Hawaiian or Other Pacific Islander	0 Participants n=5 Participants	0 Participants n=7 Participants	1 Participants n=5 Participants	1 Participants n=4 Participants
Race (NIH/OMB) Black or African American	87 Participants n=5 Participants	70 Participants n=7 Participants	72 Participants n=5 Participants	229 Participants n=4 Participants
Race (NIH/OMB) White	74 Participants n=5 Participants	84 Participants n=7 Participants	80 Participants n=5 Participants	238 Participants n=4 Participants
Race (NIH/OMB) More than one race	0 Participants n=5 Participants	2 Participants n=7 Participants	1 Participants n=5 Participants	3 Participants n=4 Participants
Race (NIH/OMB) Unknown or Not Reported	0 Participants n=5 Participants	0 Participants n=7 Participants	1 Participants n=5 Participants	1 Participants n=4 Participants
Baseline Average Needs per Participant	2.45 Count of social needs STANDARD_DEVIATION 1.36 • n=5 Participants	2.53 Count of social needs STANDARD_DEVIATION 1.61 • n=7 Participants	2.54 Count of social needs STANDARD_DEVIATION 1.39 • n=5 Participants	2.51 Count of social needs STANDARD_DEVIATION 1.45 • n=4 Participants

PRIMARY outcome

Timeframe: 8 weeks

Population: One participant in arm 3 was excluded from analysis due to missing race information.

Defined as participant connecting to one or more resources since the index unmet need screen and assessed via a participant survey administered 8 weeks following the index unmet need screen. The survey will ask: "Since you completed the unmet social need screen on (insert date), were you able to connect with any of the programs or resources for help with (insert need(s) identified)".

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=157 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Number of Participants Who Connected With a New Resource	40 Participants	41 Participants	51 Participants

PRIMARY outcome

Timeframe: 8 weeks

Population: One participant in arm 3 was excluded from analysis due to missing race information.

Defined as a count of resources that a participant connected to since the index unmet need screen and assessed via a participant survey administered 8 weeks following the index unmet need screen. The survey will ask: "Since you completed the unmet social need screen on (insert date), were you able to connect with any of the programs or resources for help with (insert need(s) identified)".

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=157 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Mean Count of Resources Connected To	0.40 Count of resources connected Standard Deviation .79	0.40 Count of resources connected Standard Deviation 0.83	0.47 Count of resources connected Standard Deviation 0.77

SECONDARY outcome

Timeframe: 6 months

The investigators will compare the results from the index screen for unmet needs to those from the unmet needs screen administered six months after the index screen. The investigators will define unmet need reduction in two ways. This measure is one or more of baseline unmet needs no longer identified as an unmet need at the 6-month rescreen.

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Unmet Need Reduction - Any	82 Participants	73 Participants	74 Participants

SECONDARY outcome

Timeframe: 12 months compared to baseline

The measure is change in Emergency Department and urgent care visits. Change is calculated as (mean at 12 months - mean at baseline). The investigators will assess this measure using CDW.

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Emergent Visits (Urgent Care and Emergency Department Visits)	0.19 Mean difference in emergent visits Standard Deviation 2.36	0.53 Mean difference in emergent visits Standard Deviation 2.64	-0.01 Mean difference in emergent visits Standard Deviation 2.15

SECONDARY outcome

Timeframe: 12 months compared to baseline

The investigators will assess adherence to CVD and CVD risk factor medications, including all possible drug class codes (CV000-CV900, encompassing Antilipemic agents and antihypertensives for the subsets of patients prescribed these medications) and, among the subset of patients with DM, diabetes medications (HS501-509). The measure will be based on pharmacy dispensing data from CDW to specify the proportion of days covered (PDC) of each medication. To calculate this, the investigators will count the # of days dispensed in relation to the dispensing period. The numerator will be based on the prescription fill dates and # of days dispensed to determine the number of outpatient days for which each medication was supplied. Patients will be considered adherent if they achieved a PDC > 80%. The measure is change in medication adherence. Change is calculated as (mean at 12 months - mean at baseline). The investigators will assess this measure using CDW.

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Medication Adherence	0.01 med adherence% post - med adherence% pre Standard Deviation 0.15	0.01 med adherence% post - med adherence% pre Standard Deviation 0.12	0.03 med adherence% post - med adherence% pre Standard Deviation 0.13

SECONDARY outcome

Timeframe: 12 months compared to baseline

For each patient, the investigators will calculate a no-show rate, or the proportion of primary care and cardiology appointments that are classified as no-show, relative to the total number of appointments scheduled in both, following the approach taken by other VA investigators using CDW data to assess this metric. The numerator ("no-shows") consists of appointments marked as a no-show and appointments canceled by the patient or clinic after the appointment time. The denominator ("total appointments") consists of no-shows and completed appointments. The measure is change in no shows. Change is calculated as (mean at 12 months - mean at baseline). The investigators will assess this measure using CDW.

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Clinic Visit Appointment Attendance ("No-show")	-0.14 Number of appointments missed Standard Deviation 1.52	-0.06 Number of appointments missed Standard Deviation 1.40	0.22 Number of appointments missed Standard Deviation 1.27

SECONDARY outcome

Timeframe: 12 months compared to baseline

BP is measured at every PC visit, and the investigators will obtain these measurements from CDW. In the rare case of missing BP data, the investigators will exclude such Veterans from the analysis. Because BP outcomes are also affected by clinicians' adjustment or titration of antihypertensive medications, the investigators will assess the effects of controlling for treatment intensification (TI), using methods similar to the published approaches used in prior work. The investigators will use the following formula to measure TI: (visits with medication changes-visits with elevated BP) / (number of clinic visits).

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Systolic Blood Pressure (BP)	-1.20 Mean change in mmHg Standard Deviation 9.37	-0.27 Mean change in mmHg Standard Deviation 12.80	-0.23 Mean change in mmHg Standard Deviation 13.61

SECONDARY outcome

Timeframe: 12 months compared to baseline

Population: This only contains people who are indicated as having diabetes

HbA1c is available from CDW. The investigators anticipate approximately 40% of our RCT sample to have DM, based on a preparatory-to-research analysis of CDW data. To ensure the values reflect health status around the time of the index screen and the 6 and 12-month follow-up window, the investigators will only include Veterans with DM who have an Hba1c in the 6 months prior to each time point. Approximately 17% of patients with DM do not have an HbA1c test within VA in the prior year.

Outcome measures

Measure	Screening n=75 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=81 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=52 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Hemoglobin A1c (HbA1c)	-0.42 Mean % glycated hemoglobin Standard Deviation 1.11	-0.03 Mean % glycated hemoglobin Standard Deviation 1.43	0.11 Mean % glycated hemoglobin Standard Deviation 1.12

SECONDARY outcome

Timeframe: 6 months

The investigators will compare the results from the index screen for unmet needs to those from the unmet needs screen administered six months after the index screen. The investigators will define unmet need reduction in two ways. This measure is percentage of baseline needs not reported as unmet needs at 6-month rescreen.

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Unmet Need Reduction - Percent	30.37 Percent of Needs not reported as unmet Standard Deviation 36.6	27.11 Percent of Needs not reported as unmet Standard Deviation 35.98	27.88 Percent of Needs not reported as unmet Standard Deviation 35.91

SECONDARY outcome

Timeframe: 12 months compared to baseline

BP is measured at every PC visit, and the investigators will obtain these measurements from CDW. In the rare case of missing BP data, the investigators will exclude such Veterans from the analysis. Because BP outcomes are also affected by clinicians' adjustment or titration of antihypertensive medications, the investigators will assess the effects of controlling for treatment intensification (TI), using methods similar to the published approaches used in prior work. The investigators will use the following formula to measure TI: (visits with medication changes-visits with elevated BP) / (number of clinic visits).

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=158 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Diastolic Blood Pressure (BP)	-0.43 Mean change in mmHg Standard Deviation 6.11	-1.17 Mean change in mmHg Standard Deviation 7.07	-0.11 Mean change in mmHg Standard Deviation 7.44

POST_HOC outcome

Timeframe: 8 weeks

Population: Participants in arm 3 could refuse to speak with a social worker. This analysis is with arm 3 refusals removed. The participant with no race info refused arm 3 and is excluded from the 125.

Defined as participant connecting to one or more resources since the index unmet need screen and assessed via a participant survey administered 8 weeks following the index unmet need screen. The survey will ask: "Since you completed the unmet social need screen on (insert date), were you able to connect with any of the programs or resources for help with (insert need(s) identified)".

Outcome measures

Measure	Screening n=161 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=160 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=125 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Number of Participants Who Connected With a New Resource (With Arm 3 Refusals Removed)	40 Participants	41 Participants	44 Participants

POST_HOC outcome

Timeframe: 8 weeks

Population: Elixhauser score \>=4 only.

Defined as participant connecting to one or more resources since the index unmet need screen and assessed via a participant survey administered 8 weeks following the index unmet need screen. The survey will ask: "Since you completed the unmet social need screen on (insert date), were you able to connect with any of the programs or resources for help with (insert need(s) identified)". This was an ad-hoc sub-group analysis consisting of Veterans with an Elixhauser score of 4 or greater. The Elixhauser comorbidity index is a measure of comorbidity based on ICD-10 codes. A higher number indicates more comorbidities. The scale is 0-30.

Outcome measures

Measure	Screening n=96 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=89 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=79 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Number of Participants Who Connected With a New Resource (Elixhauser Score >=4 Only)	21 Participants	23 Participants	31 Participants

POST_HOC outcome

Timeframe: 8 weeks

Population: VA Priority groups 4 \& 5 only

Defined as participant connecting to one or more resources since the index unmet need screen and assessed via a participant survey administered 8 weeks following the index unmet need screen. The survey will ask: "Since you completed the unmet social need screen on (insert date), were you able to connect with any of the programs or resources for help with (insert need(s) identified)". This was an ad-hoc sub-group analysis consisting of Veterans in VA priority groups 4 & 5 (of which 95% of Veterans were in priority group 5). Veterans applying for VHA healthcare are assigned to one of eight priority groups based on eligibility criteria including income and service connected disability. A lower score signifies a higher priority for enrollment. Veterans in priority group 5 are unique in that they're eligibility is based not on disability, but on income status (i.e. Medicaid eligibility).

Outcome measures

Measure	Screening n=43 Participants Participants in this arm will be screened for unmet social needs and receive a post card that includes a list of generic VA crisis and homeless hotlines. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization.	Awareness n=48 Participants Participants in this arm will be screened for unmet social needs, receive a post card that includes a list of generic VA crisis and homeless hotlines, and receive a Resource Sheet tailored to the unmet needs identified in the unmet need screen. The Resource Sheet will include the names of available resources within the VA and/or local community that can help to address the identified need(s) and contact information and hours of operation. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.	Assistance n=52 Participants Participants in this arm will receive the same interventions as Arm 2 (screened by phone for unmet social needs, receive post card listing generic resources, and receive tailored resource sheets) plus be offered assistance from a Social Worker. If accepted, the SW will contact the participant and work with them over a period of 8 weeks to help facilitate their connection to resources than can help to address the unmet need(s) identified in the unmet need screen. Unmet Need Screening: Participants are screened by phone for unmet social needs (e.g., utility insecurity, social isolation), hereafter referred to as the "index screen". The index screen occurs prior to randomization. Unmet Need Referral - Resource Sheet: Participants receive a Resource Sheet(s) tailored to the unmet need(s) identified in the index screen. For each unmet need, a Resource Sheet will include the names of available resource within the VA and/or the local community that can help address the unmet need and contact information (address, phone, website, email) and hours of operation.
Number of Participants Who Connected With a New Resource (VA Priority Groups 4 & 5 Only)	5 Participants	9 Participants	18 Participants

Adverse Events

Screening

Serious events: 0 serious events

Other events: 0 other events

Deaths: 5 deaths

Awareness

Serious events: 0 serious events

Other events: 0 other events

Deaths: 3 deaths

Assistance

Serious events: 0 serious events

Other events: 0 other events

Deaths: 2 deaths

Serious adverse events

Adverse event data not reported

Other adverse events

Adverse event data not reported

Additional Information

Dr. Grant Huang

Department of Veterans Affairs

Phone: (202) 443-5700

Email: CSP@va.gov

Results disclosure agreements

• Principal investigator is a sponsor employee
• Publication restrictions are in place