Integrated Care News by CFHA

MAY 1, 2025

Reclaiming Time and Attention Primary care professionals may log more than eleven hours a day, over half of it in the electronic health record (Menchaca, 2025). How are you integrating AI into your clinical, teaching or supervisory work? Annals of Family Medicine , 23(1), 5–6. References Menchaca, J.

Patient-Centered 390

Patient-Centered Integrated Care Primary Care Healthcare Professional 390

Annals of Family Medicine

NOVEMBER 20, 2024

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.

Appointment 130

Appointment Hospital Management Family Medicine 130

Annals of Family Medicine

NOVEMBER 20, 2024

Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach. Descriptive analysis utilized primary legal record and secondary electronic health record sources. Conclusions: Best practices for virtual model require on-site clinical champions.

Medical 130

Medical Referral Screening Internal Medicine 130

Annals of Family Medicine

NOVEMBER 20, 2024

Utilizing new electronic handgrip dynamometer and accelerometer technologies may allow for additional muscle function attributes to be feasibly measured, which in turn, may help elevate prognostic value and specificity for intervention referral. Interclass correlation coefficients were used for the analyses. for maximal strength, 0.99

Electronics 130

Electronics Primary Care Utilities Referral 130

Annals of Family Medicine

NOVEMBER 20, 2024

Economic analysis utilized "difference in difference" methodology comparing individuals who received legal services to control groups: a) in the same clinic; b) in 12 other primary care clinics within the same health system. Setting or Dataset: Medicaid Claims, Epic electronic health record.

Primary Care 130

Primary Care Medical Behavioral Health Services Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: Patients with recent hemoglobin A1c levels of ≥8% were invited to join the Diabetes Navigator program, identified through the electronic health record at two academic primary care clinics. Navigator outreach time parallels that of a standard 15-minute clinic visit, on average.

Primary Care 130

Primary Care Diabetes Referral Integrated Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: Primary care clinics. Intervention: Ongoing codesign process to optimize electronic health record (EHR) customizations and support materials for breast cancer survivorship care. Other suggestions included clinical documentation guidance to align with broader health system goals (e.g.,

Primary Care 130

Primary Care Referral Electronics Utilities 130