Integrated Care News by CFHA

MAY 1, 2025

Bridging the 17‑Year Research–Practice Gap Implementation scientists estimate that it takes about seventeen years for new evidence to become routine care (Rubin, 2023). Evidence‑informed care was literally at his fingertips. For AI in Primary Care, Start With the Problem. Annals of Family Medicine , 23(1), 5–6.

Patient-Centered 390

Patient-Centered Integrated Care Primary Care Healthcare Professional 390

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In May 2023, Mayo Clinic implemented a revised screening tool to assess social determinants of health (SDOH) for its patients. Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Setting or Dataset: Secondary data on social needs screening and referral generated through Epic.

Primary Care 130

Primary Care Referral Routine Screenings Patients 130

Annals of Family Medicine

NOVEMBER 20, 2024

The American Academy of Pediatrics recommends universal screening; however studies have found inconsistencies in screening of FI, documentation of FI, and referral to appropriate resources. Comparison of FI for paired patients in 2022 and 2023. Enrollment and referrals in food assistance programs.

Primary Care 130

Primary Care Screening Referral Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In Ontario, multiple organizations operate under a ‘boutique’ medicine model where patients pay a block or annual fee to access primary care services. Comparatively, physicians in general practice were more likely to see patients for mental health, chronic disease, and preventive care.

Clinic 130

Clinic Referral Primary Care Physician Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives. Contact hours included a mix of in-person visits and phone calls.

Primary Care 130

Primary Care Referral Screening Patient-Centered 130

Annals of Family Medicine

NOVEMBER 20, 2024

This study aims to examine individual, organizational, and contextual factors associated with patients’ experience of access to their multidisciplinary primary healthcare clinic. A total of 122,397 patients and 999 family physicians, 107 nurse practitioners and 411 administrative staff nested into 104 clinics answered the survey.

Nurse Practitioner 130

Nurse Practitioner Clinic Family Physician Finance 130

Annals of Family Medicine

NOVEMBER 20, 2024

SUD screening is not universally done in primary care (PC). Setting: Three PC practices that routinely serve adolescents were selected: 2 urban practices (1 Family Medicine [FM] and 1 Pediatric [PED]) and 1 rural combined FM/PED practice. Outcomes: Percentages of positive CRAFFT screens in the 3 practices were calculated.

Primary Care 130

Primary Care Screening Referral Wellness Visit 130