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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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Feasibility,reliability,validity of an electronic Frailty Index based on Comprehensive Geriatric Assessment in Primary Care [Community based participatory research]

Annals of Family Medicine

To promote early management of frailty, we developed an electronic Frailty Index based on deficit accumulation in a Comprehensive Geriatric Assessment (eFI-CGA) from electronic health records. Here, we examined the feasibility, reliability, and validity of the eFI-CGA by primary care providers (PCP). by PCP, r≥0.45

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Electronically-delivered PHQ9s increase engagement in patients with depression [Population health and epidemiology]

Annals of Family Medicine

Objective: Evaluate the effectiveness of a PHQ9 outreach to patients via a mobile app to increase clinical engagement and improve depression care quality. PHQ9 results were sent to the patient’s PCP, who could create a follow-up visit reminder, or take other action. Percentage of patients who filled out a PHQ9.

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Card studies using EHR alerts linked to REDCap questionnaires: a practical session on how to build the tools [Research methodology and instrument development]

Annals of Family Medicine

Background Researchers use card studies to obtain observational data about primary care provider (PCP) knowledge, attitudes, and behaviors on a variety of topics. Card studies have been influential in changing clinical practice, such as the reduction of antibiotics in patients with upper respiratory infections.

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