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Community Integration: Pushing the Boundaries for a Better World

Integrated Care News by CFHA

The plane was piloted by a native of the island, deeply committed to helping his community. What followed was a powerful expression of community and compassion. We offered trauma-informed support and helped newly displaced individuals connect with health and community resources.

Community 130
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Implementation Evaluation of a Community Health Worker Program for Patients with Type 2 Diabetes or Hypertension [Dissemination and implementation research]

Annals of Family Medicine

Community health worker (CHW) interventions show promising outcomes for T2D and HTN control particularly among low income and historically marginalized patients. However, studies on the generalizability and implementation of CHW interventions in clinical and community settings are limited. I) There was a mean of 2.8

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Patient Perceptions of a Lifestyle Medicine Clinic in Southwest Virginia [Mixed methods research]

Annals of Family Medicine

There is limited research on implementation of LM in medically underserved communities. Objective To assess patient perceptions of a primary care-based LM clinic. Setting: LM Clinic in the SW Virginia safety net. Setting: LM Clinic in the SW Virginia safety net. Conclusion The LM clinic was perceived as effective.

Clinic 130
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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

Study Design and Analysis: We used information gathered from site visits and team meetings to understand how Compass Rose was being utilized across sites. We also assessed patterns of social risks and need for assistance among our patient populations. Of those patients with an episode (i.e.,

Referral 130
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Implementation of a novel linkage of primary care electronic medical record data with hospital data in South Eastern Ontario [Big data]

Annals of Family Medicine

Context: Currently, primary care data, community data, and hospital data are not linked in Ontario, resulting in a disconnect in continuity of care. Datasets: Primary care EMR data from the Eastern Ontario Network and acute care, post-acute, and community mental health and addictions data from the Shared Health Integrated Information Portal.

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Validation of the "Proactive" self-assessment tool for older people to identify their own risk of functional decline [Screening, prevention, and health promotion]

Annals of Family Medicine

Study Design and Analysis: In a convergent, mixed methods design, a cross-sectional survey allowed us to assess the concurrent validity of Proactive by comparing its results with those of a clinical examination. Setting: Community-based. Intervention: Proactive consists of 21 items covering nine constructs.

Screening 130
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An Open Letter to Robert F. Kennedy, Jr. On Why Integrated Care Should Be a Cornerstone of the HHS Agenda

Integrated Care News by CFHA

It offers care where people already are: their doctor’s office, their community mental health clinic, their OB/GYN’s exam room. Invest in Person-Centered, Data-Informed Care Support the use of measurement-based care (MBC), which allows providers to track symptoms over time, improve quality, and avoid unnecessary treatments.