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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

A Compass Rose episode was automatically generated in the patient’s medical record in Epic if patients indicated that they had at least one of the four social risk factors on the screening tool. Results: Between January 2024 and March 2024, the pilot sites generated 861 Compass Rose episodes.

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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. Population Studied: Inpatients were referred if they were being discharged from the Family Medicine service to home.

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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% overall) and provision of tobacco cessation medications (3.5% overall) were very low and did not significantly differ by level of SDOH risk.

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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. M Health Fairview’s Fair Table program ensures convenient access to food during medical appointments.

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New South Family Medicine and MedSpa Offers Next Level Care

New South Family Medicine and MedSpa

Direct primary care offers you and your family top-notch health care, and so much more.like a high patient and provider satisfaction with an improved quality of care. Providers at New South Family Medicine and MedSpa can address the patient's deeper needs, rather than trying to rush through a hectic day full of too-brief appointments.

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

GeriPal

Lastly, we discuss Katie’s paper on substance use disorder in an aging population and how one can incorporate the 5 Ms (ie, matters most, medications, mind, mobility, and multicomplexity) into a framework for age-friendly care for older adults with substance 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

A friend of GeriPal, and prior guest, Guy Micco commented today that we need an RCT for chaplaincy is like the idea that the humanities need to justify their value in medical training: “It’s like being told to measure the taste of orange juice with a ruler.” LaVera: I trained at UCSF in family medicine. Absolutely loved it.

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