Pilot-Testing Strategies to Improve Outcomes for Youth With Type 2 Diabetes by Addressing Health-Related Social Needs

Participants will be texted resource lists and warm referrals specific to health-related social needs (HRSN) on a screener. Their clinician will be sent screener results and asked to talk about and address HRSN at the visit without additional guidance. If the family requested to meet with the social worker on the screener, a message will also be sent to the clinic social worker. Participants will be offered physical resources related to disclosed HRSN (e.g., food box for food insecurity).

Regardless of disclosed health-related social needs (HRSN), participants will be texted resource lists and warm referral links for food, housing, and transportation needs. At clinic visit, all will be offered physical resources and the opportunity to meet with a social worker. In place of screening results, clinicians will be sent a message requesting that, when seeing the patient in clinic, they use the provided, easily accessible empowering script about HRSN.

Participants will receive text messages once per month for 3 months. Messages will state that community-based resources to address health-related social needs (HRSN) are available if needed, with a link to opt-in to resource lists and warm referral links. Messages will include contact information for the study and clinical teams for optional HRSN discussion. CHW will not be assigned.

Participants will receive text messages about health-related social needs (HRSN) resources as described in arms without CHW but will also be assigned trained CHW from local community organizations to support connection with resources to address HRSN.