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Compass Rose for Generating Community-based Referrals via Epic: Best Practices and Lessons Learned [Social determinants and vulnerable populations]

Annals of Family Medicine

The workflows for use of the tool, including enrollment criteria, patient outreach, and use of the Findhelp platform for community-based referrals were standardized; however, each pilot site had different staff members responsible for using the tool.

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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care [Smoking cessation]

Annals of Family Medicine

Setting or Dataset: Electronic health record data from 11 community-based clinics within a safety-net system in the Midwest from 07/01/2021-3/31/2024. Referral to counseling (7.5% Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period.

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Substance Use Disorder Screening in Adolescent Patients in Primary Care: Findings, Challenges, Lessons Learned [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

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. Study period for urban locations: Oct 2–Dec 29, 2023; for the rural location: Nov 1, 2023–Jan 31, 2024.

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Combating Food Insecurity in Minnesota

Minnesota Academy of Family Physicians

The Minnesota Academy of Family Physicians (MAFP) adopted a resolution (policy guidance) in 2024 related to addressing food insecurity in Minnesota. An excerpt follows: 2024-04. Encourage Healthy Eating Through Vouchers: Many clinics and systems have voucher programs in place to help supplement food for patients.

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Substance Use Disorder in Aging and Serious Illness: A Podcast with Katie Fitzgerald Jones, Jessica Merlin, Devon Check

GeriPal

In particular, we talk about Katie’s and Jesica’s paper in NEJM titled “ Juggling Two Full-Time Jobs — Methadone Clinic Engagement and Cancer Care ,” which described the difficulty in managing cancer pain and methadone for opioid use disorder. ABIM MOC credit will be offered to subscribers in November, 2024.

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RCT of Chaplaincy: Lexy Torke, Karen Steinhauser, LaVera Crawley

GeriPal

Alex Practice-PC Program Information: UCSF’s Practice-PC program is now accepting applications for the 2023-2024 year. LaVera: I trained at UCSF in family medicine. Okay, I don’t necessarily want to stay clinical, but I really love that spiritual work and what’s the closest profession. LaVera: Yes.

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