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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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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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Creative Dissemination: Community-Engaged Mural to Disseminate the PORTRAIT Registry on Peripheral Arterial Disease [Cardiovascular disease]

Annals of Family Medicine

Public health initiatives, including community engagement projects, are vital for promoting early diagnosis and encouraging behaviors to combat PAD. Materials detailed resources for PAD screening, physical activity, and smoking cessation and were distributed through dissemination activities and partners.

Community 130
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Pap-HPV co-testing adoption trends for cervical cancer screening in a multi-state Practice Research Network (PBRN) 2012-2017 [Health care disparities]

Annals of Family Medicine

Context: In 2012, the United States cervical cancer screening (CCS) guidelines changed to add co-testing (Papanicolaou [Pap] and human papillomavirus [HPV] test) to Pap-only. Little is known about variation in adoption of CCS modalities in federally qualified health centers (FQHCs) in communities where cervical cancer disparities persist.

Screening 130
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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

Therefore, we have developed Proactive, a self-administered screening questionnaire that enables older people to independently monitor their risk of functional decline. Setting: Community-based. Population studied: Individuals aged 65 years and older recruited in primary care clinics or senior residences.

Screening 130
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The role of primary care teams in identifying modifiable risk factors for food insecurity in rural dwelling older adults [Screening, prevention, and health promotion]

Annals of Family Medicine

There is a gap in the literature on understanding experiences of food insecurity in rural dwelling older adults and the role primary care providers can play in systematically screening older adults for age related food issues. Data were analyzed using reflexive thematic analysis.

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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.