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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. Outcome Measures: We assessed patterns of social risk factors across our patient population as well as the extent to which patients wanted assistance from the clinic.

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Multisector Health Equity Coordination in a Midwestern Primary Care Practice, 2022-2023 [Social determinants and vulnerable populations]

Annals of Family Medicine

Multisector coordination is critical for effective screening and referral initiatives. Objective: To assess the function and impact of a new role, a Health Equity Coordinator, on the reach of the social needs screening and referral program.

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Barriers to and Facilitators of Participant Engagement in a Multi-level Intervention for Type 2 Diabetes and Food Insecurity [Clinical trial]

Annals of Family Medicine

Objective: To explore participants’ barriers to and facilitators of engagement in a multilevel, cross-sector clinical trial designed to address social needs and improve health-related outcomes for individuals with T2D experiencing food insecurity. Setting: Ambulatory clinics (e.g., their 3-month endpoint visit).

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Combating Food Insecurity in Minnesota

Minnesota Academy of Family Physicians

A Collaborative Approach Between Health Care Providers and Community Partners Food insecurity affects thousands of Minnesotans, often contributing to chronic health conditions and overall poor health outcomes. Community Partnerships: Mayo Clinic collaborates with local food banks to offer mobile food distributions.

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A Call for Engagement Outside of the Exam Room

Physician's Weekly

There is robust data regarding the importance of patient connection and engagement in the hospital and clinic setting. Many of us are taught in medical school and residency the importance of patient communication on improving patient satisfaction scores, quality metrics, and professional fulfillment.

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How to Improve Care for Patients With Multiple Chronic Conditions

Physician's Weekly

Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles. It’s easy to understand why communication barriers can hinder care coordination between primary care physicians (PCPs), specialists, hospitalists, and professionals at other facilities.

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A feasibility study of the Illuminate 360o approach for monitoring the implementation of a health system innovation [Mixed methods research]

Annals of Family Medicine

Objectives: We explored how to design a system to provide near real-time feedback on context and impacts to inform health system innovations; and how to operationalize data collection across diverse patient populations and providers. Study Design and Analysis: We used a mixed-method complexity-informed methodology.

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