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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

Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization. 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.

Referral 130
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Risks and Needs: Lessons Learned from Assessing Patients Willingness to Receive Help for Social Risks in Primary Care [Social determinants and vulnerable populations]

Annals of Family Medicine

Context: In May 2023, Mayo Clinic implemented a revised screening tool to assess social determinants of health (SDOH) for its patients. Objective: To assess the impact of a question on need for assistance with social risk factors identified through routine screening.

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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. Results: Among 119,926 patients, 40% did not have SDOH assessed; 31% had 3 or more social needs identified during screening, 11% had 2, 7% had 1, and 11% had no social needs.

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"Sludge audits" identify obstacles to completing colorectal cancer screening

Common Sense Family Doctor

Michelle Rockwell and colleagues at the Carilion Clinic in Roanoke, Virginia, performed a sludge audit of their colorectal cancer (CRC) screening services in 2021 and 2022. In contrast, patients who reported no or minimal sludge were more likely to complete screenings and less likely to report distrust in the health system.

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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

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives.

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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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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