Annals of Family Medicine

NOVEMBER 20, 2024

Instrument: The discussion guide included questions on 1) identifying shared social care priorities across the three groups, and 2) describing best practices, facilitators, and barriers around screening and referral for social needs learned from existing and past collaborative models.

Community 130

Community Diabetes Referral Screening 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Nearly all patients with type 2 diabetes have comorbid chronic conditions, adding complexity to self-management. The TBSD incited action in the majority of encounters (64%), with clinicians modifying treatment regimens, placing referrals, scheduling appointments, and documenting in the chart.

Primary Care 130

Primary Care Diabetes Screening Patient-Centered 130

Annals of Family Medicine

NOVEMBER 20, 2024

Early identification and intervention in behavioral aspects of chronic diseases leads to improved function with decreased healthcare utilization, yet we know little about referral patterns for behavioral support of chronic disease. 88% (n= 11,483) of BH referrals were created for the management of a mental health condition.

Referral 130

Referral Chronic Condition Medical Chronic Disease 130

Edge Family Medicine

APRIL 10, 2025

At Edge Family Medicine , we believe that one of the most powerful tools in healthcare isn’t technology — it’s trust. At Edge Family Medicine , we prioritize relationship-based care that supports your wellness every step of the way. Over time, they become familiar with your health history, lifestyle, and concerns.

Primary Care 130

Primary Care Relationship PCP PCP 130