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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. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

Referral 130
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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

On January 7, 2025, SAMHSA announced the award of one-year Certified Community Behavioral Health Clinics (CCBHCs) Demonstration planning grants to 14 states and Washington, D.C., Journal of clinical psychology in medical settings , 25 (2), 109–126. References Reiter, J. Dobmeyer, A. C., & Hunter, C.

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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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Effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in practice [Education and training]

Annals of Family Medicine

Context: Brief dermoscopy training has been shown to improve diagnostic accuracy on image recognition tests, but few, if any, studies have examined its effect on clinician behavior and clinical outcome measures. Setting: Divisions of Family Medicine and Community Internal Medicine at a large academic medical center in Southeast Minnesota.

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Addressing diabetes management in the context of social needs: a qualitative study of primary care providers [Diabetes and endocrine disease]

Annals of Family Medicine

Context: Diabetes management (DM) for patients with Type 2 Diabetes (T2D) can be hindered by non-medical, health-related social needs. Objective: To describe how primary care clinics have considered social needs in DM, and identify opportunities to support primary care clinics. Setting: Ambulatory clinics (e.g.,

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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).

Diabetes 130
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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.