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Adoption, implementation, and impact of a Diabetes Navigator program based in primary care [Diabetes and endocrine disease]

Annals of Family Medicine

Context: Patients with diabetes who receive structured and integrated care have better control and outcomes; however, care may shift between multiple settings making coordination challenging. Outcome Measures: Number of patients engaged, resulting referrals, Navigator time per patient, and hemoglobin A1c measures across 2-years.

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Developing actionable strategies to implement evidence-based breast cancer follow-up in primary care using codesign [Dissemination and implementation research]

Annals of Family Medicine

Objective: Describe codesign methods to implement actionable strategies for breast cancer survivorship follow-up care. The resulting intervention was a care quality improvement project that engaged practice champions (n=18) from 6 primary care practices in bi-weekly virtual facilitation and monthly learning collaboratives over 3 months.

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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. Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Referral to counseling (7.5%

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Test-Retest Reliability of Electronic Handgrip Dynamometry and Accelerometry Measured Muscle Function in Older Adults [Musculoskeletal and rheumatology]

Annals of Family Medicine

Measures of handgrip strength are collected in primary care settings as a vital sign for the prevention of health conditions related to low muscle strength. However, before such measures can be considered in clinical settings, their test-retest reliability needs to be established. for maximal strength, 0.99 for asymmetry, 0.65

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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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Economic analysis of virtual Medical Legal Partnership model [Economic or policy analysis]

Annals of Family Medicine

Objective: Evaluate the economic impact of receiving tele-legal services from Medicaid’s perspective with regard to a) fee- for service (FFS) total cost of care; b) FFS cost of primary care; c) utilization for FFS primary care; d) utilization for FFS and capitated behavioral health (BH) and BH emergency department encounters.

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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

On January 7, 2025, SAMHSA announced the award of one-year Certified Community Behavioral Health Clinics (CCBHCs) Demonstration planning grants to 14 states and Washington, D.C., CCBHCs focus on comprehensive behavioral health services, ensuring 24/7 crisis care, care coordination, and a broader continuum of behavioral health treatment.