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

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

Context: Medical legal partnerships (MLP) are an effective intervention for social determinants of health, like housing, education, and employment status. Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach.

Medical 130

Medical Referral Screening Internal Medicine 130

Integrated Care News by CFHA

MAY 1, 2025

I believe that as clinicians, educators and supervisors, we are called to guide this shift. 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?

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Dr. Zaar

JUNE 1, 2025

Certified Diabetes Educators (CDE): While not doctors, they play a key role in diabetes education and lifestyle support. Firsthand referrals often lead to trusted and patient-focused providers. Endocrinologist: A specialist trained in treating hormonal disorders, including diabetes.

Diabetes 52

Diabetes Board-Certified Management Internal Medicine 52

Physician's Weekly

JUNE 25, 2025

Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles. Have clinical indicators of disease complexity or advancement. Communicate clearly with appropriate non-clinical staff. Have open gaps in care or medications not filled.

Chronic Condition 59

Chronic Condition Patients Management Primary Care Physician 59

GeriPal

SEPTEMBER 7, 2023

Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their guidelines for care of older adults to state that all older adults receiving systemic therapy (including chemo, immuno, targeted, hormonal therapy) should receive geriatric assessment guided care. Mazie, welcome to GeriPal. William: Sure.

Patient-Centered 129

Patient-Centered IT Patients Clinic 129