Integrated Care News by CFHA

MAY 19, 2025

This position statement from the Collaborative Family Healthcare Association (CFHA) outlines our organizational commitment to Measurement-Based Care (MBC) as a foundational element of integrated healthcare. MBC supports optimal clinical practice, demonstrates the value of integrated care teams, and improves outcomes. What is MBC?

Integrated Care 300

Integrated Care Mental Health Healthcare Clinical Practice 300

Annals of Family Medicine

NOVEMBER 20, 2024

We used the patient portal (Opal) to administer the I-Score, a 7-item electronic patient-reported outcome measure (ePROM) of barriers to ART adherence. Objective: To describe patient and service-related outcomes of the I-Score intervention and outline adherence barrier management by physicians.

Clinic 130

Clinic Patients Electronics Management 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective To assess patient perceptions of a primary care-based LM clinic. Study Design and Analysis Survey; t-test and chi-square tests to evaluate variation by race and income status, approximated by having Medicaid, based on the clinic’s goal of reaching underserved community members.

Clinic 130

Clinic Patients Primary Care Chronic Disease 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In the landscape of family medicine, scholarly pursuits play a vital role in building research capacity and fostering mentorship, as the ACGME underscores. Objective: This study aimed to use a family medicine learning network to inspire and support early to mid-career family medicine learners to take on more rigorous scholarship.

Family Medicine 130

Family Medicine DO Families Family 130

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

The ability to reach and engage in the care process varies considerably depending on patients’ socio-demographic characteristics which we need to understand to address inequitable access issues. Setting: 104 PHC clinics across Quebec, Canada.

Healthcare 130

Healthcare Clinic Chronic Condition Finance 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In Ontario, multiple organizations operate under a ‘boutique’ medicine model where patients pay a block or annual fee to access primary care services. Little is known about the characteristics of physicians and patients participating in boutique clinic practice models. Study Design and Analysis.

Clinic 130

Clinic Referral Primary Care Physician Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Large-scale electronic health record (EHR) programs have reported a number of issues to their implementation in primary care including physician patient-centredness and clinical performance. Setting: An academic primary care clinic based in a hospital. Population: Ten resident physicians and six staff physicians.

Electronics 130

Electronics Education Patients Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Patient Important Outcomes (PIOs) was first introduced in the literature with the criticism that research studies were designed with outcomes relevant to health care providers, but not relevant/important to patients. Study Design & Analysis: Mixed methods study employing physician survey and patient focus groups.

Diabetes 130

Diabetes Patients Patient-Centered Family Physician 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: We aimed to compare medication review activities between private and public clinics. Setting: One private primary care clinic and two clinics of a safety net hospital system that serves inner-city populations with significant socio-economic challenges. vs 35.4%) and less likely Hispanic (20.7 vs 41.1%) background.

Clinic 130

Clinic Medical Primary Care Insurance 130

Annals of Family Medicine

NOVEMBER 20, 2024

Family physicians' pivotal role in prevention and crisis management exposes them to mental stressors due to the highly demanding circumstances. This can potentially compromise their ability to provide optimal patient care. long-term nursing homes, clinics), highlighting their perceived needs. Context: Catastrophes (e.g.,

Family Physician 130

Family Physician Mental Health Families Family 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context Primary care must address the complex needs of patients with multiple chronic conditions, given 40% of patients seen in primary care have behavioral health needs. Integrated Behavioral Health (IBH) is associated with improved access and engagement in mental health services and mental and physical health patient outcomes.

Chronic Condition 130

Chronic Condition Primary Care Patients Clinic 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: To determine the effect of a standardized patient-delivered intervention on low-value imaging among primary care patients with acute low back pain. Study Design: Randomized clinical trial (NCT 04255199). Setting: 10 primary care clinics in Sacramento, CA. 0.81)] and conveying empathy [aSD 0.85 (0.40-1.30)].

Clinic 130

Clinic Primary Care Patients 130

Mesa Family Physician

APRIL 24, 2025

Whether it’s your first pap smear or you’re wondering if you can have the test while on your period, this guide walks you through the essentials of women’s health checkups, how to prepare, and common questions many patients have. Many patients search online for variations like: Can you have a pap smear while menstruating?

Screening 100

Screening Clinic Appointment Checkup 100

Annals of Family Medicine

NOVEMBER 20, 2024

Context With the goal of advancing health equity, the US healthcare sector has expanded activities to identify and intervene in patients’ experiences of social adversity, sometimes referred to as "social care". Yet, no measure of patients’ experiences with social care has been developed to date.

Patients 130

Patients Screening Relationship Healthcare 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Prenatal care can be difficult for patients to accomplish, with frequent visits and time-sensitive health screenings. During the COVID-19 pandemic, many clinics shifted to a virtual visit format. Patient interviews, providing qualitative information to augment study findings.

Patients 130

Patients Clinic Utilities Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Older adults frequently use primary care services, and family physicians exhibit differences in their knowledge and skills to care for older patients. Some family physicians pursue added training or focus their medical practice to increasingly care for older adults, which may influence quality of care and patient outcomes.

Primary Care 130

Primary Care Family Physician Families Family 130

Annals of Family Medicine

NOVEMBER 20, 2024

Community health worker (CHW) interventions show promising outcomes for T2D and HTN control particularly among low income and historically marginalized patients. However, studies on the generalizability and implementation of CHW interventions in clinical and community settings are limited. Setting 3 primary care clinics in SW Virginia.

Hypertension 130

Hypertension Community Diabetes Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: The impact of the COVID-19 pandemic on patients with acute kidney injury (AKI) in Academic Medical Centers (AMCs) remains unclear. Objective: To assess the epidemiology and mortality risk among patients with AKI discharged from AMCs in the US from October 2019 to December 2023. The mean observed LOS was 7.1

Patient-Centered 130

Patient-Centered Patients Medical Diagnosis 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: Our study investigates ID prevalence in Alberta from 2010 to 2022 and its association with patient and provider characteristics. We hypothesize that the prevalence of ID in Alberta has been increasing over the past decade based on clinical observations and anecdotes. 2020-2022).

Clinic 130

Clinic Primary Care Electronics Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

Targeted users of mHealth tools include clinicians, patients, and caregivers. In clinical settings, uptake of mHealth tools has varied, with limited use explained, in part, by suboptimal adaptation of the tool and the implementation processes. Ultimately, the synthesis included 29 reviews (16 systematic, 10 scoping, 1 rapid, 2 other).

Patients 130

Patients Clinical Practice Electronics Clinic 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context With buprenorphine prescribing restrictions lifted, primary care physicians (PCP) are frequently the first contact for patients who have opioid use disorder (OUD) and require treatment with buprenorphine. Study Design A behavioral health curriculum was designed for second year residents.

Education 130

Education Primary Care Physician Primary Care Family Medicine 130

Annals of Family Medicine

NOVEMBER 20, 2024

Despite efforts to improve patient-clinician relationships, access to care, and healthcare workflows, annual rates of missed appointments (MA) in the U.S Objective To evaluate the association between patient, health system, geosocial, and environmental factors on the likelihood of MA in Family Medicine clinics.

Appointment 130

Appointment Primary Care Family Medicine DO 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In May 2023, Mayo Clinic implemented a revised screening tool to assess social determinants of health (SDOH) for its patients. Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida.

Primary Care 130

Primary Care Referral Routine Screenings Patients 130

Annals of Family Medicine

NOVEMBER 20, 2024

However, the factors influencing the dynamics of adherence among young Chinese patients with hypertension remain unclear. Setting or Dataset general outpatient clinic of a tertiary hospital in Chengdu. Setting or Dataset general outpatient clinic of a tertiary hospital in Chengdu. Population Studied A single-center cohort study.

Hypertension 130

Hypertension Patient-Centered Families Family 130

Annals of Family Medicine

NOVEMBER 20, 2024

Continuous quality improvement (CQI) is a promising method for improving the healthcare system and responding effectively to changing patient needs. Champions in CQI refer to individuals who lead or facilitate such initiatives, and they seem to be a key ingredient in promoting quality improvement in Primary healthcare Clinics (PHC).

Healthcare 130

Healthcare Clinic Management Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective To examine utilization of the screening, and prevalence of FI at two time points in a pediatric clinic an urban pediatric practice that has implemented universal FI screening and response. Comparison of FI for paired patients in 2022 and 2023. 73% of FI families had a FI ICD-10 code documented (Table 1).

Primary Care 130

Primary Care Screening Referral Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Study Design This study was a systematic review of randomized controlled trials to identify RCTs demonstrating successful interventions that used communication interventions to impact patient outcomes. Setting or Dataset We retrieved studies from Embase, Wiley, Cochrane, and MEDLINE published until February 2022.

Provider 130

Provider Patients Utilities Healthcare 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: For many patients with long-COVID, primary care is the first point of interaction with the healthcare system. However, beyond expressions of disempowerment, the patient’s perspective regarding the quality of long-COVID care is lacking. Patients described two areas of experiences.

Healthcare 130

Healthcare Primary Care Patients Patient-Centered 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. Setting or Dataset: Clinics: AF Williams Family Medicine, Lowry Internal Medicine; EPIC data; legal records. Intervention/Instrument: Legal-needs screening tool.

Medical 130

Medical Referral Screening Internal Medicine 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Virtual visits have emerged as a new mode of accessing healthcare, however not all patients have equal access to virtual care. Patients who may benefit most from virtual care, such as those living in rural areas, may be at greatest risk of not being able to complete a clinical video visit with their provider.

Patients 130

Patients Appointment Utilities Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Persistent pain is experienced among nearly half of the patients with long COVID (LC). Objective: To document the lived experience of patients with LC pain, including how they access and receive healthcare, to improve services for LC pain evaluation and treatment.

Patients 130

Patients Insurance IT Mental Health 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context When it comes to advanced directives, research has shown that providers should initiate the conversation for their patients, however completion rates for these conversations are very low. It is important to decrease these barriers for providers, so that patients are able to benefit from these conversations.

Medical Student 130

Medical Student Education Family Medicine DO 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context Patient messaging to providers has dramatically increased since the pandemic, leading to informatics efforts to categorize messages to facilitate more efficient review. Conclusion Clinicians generally lack the time to prioritize patient messages. The increased inbox burden has particularly impacted primary care physicians.

Primary Care 130

Primary Care Management Primary Care Physician Patients 130

Minnesota Academy of Family Physicians

JUNE 20, 2025

AAFP Denounces Changes to ACIP and Vaccine Recommendations The Minnesota Academy of Family Physicians (MAFP) stands with the American Academy of Family Physicians (AAFP) in denouncing the recent decisions made by Health and Human Services (HHS) Secretary, Robert F. Kennedy, Jr.

Family Physician 71

Family Physician Vaccination Family Families 71

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Post-Covid-19 Condition (PCC), or "long-Covid," is symptomatically complex and impacts several aspects of patient’s livelihoods. Population Studied: Using purposive sampling from a long-COVID clinic, we conducted semi-structured interviews with English-speaking, adult primary care patients describing symptoms of long-COVID.

Primary Care 130

Primary Care Patients Relationship Illness 130

Annals of Family Medicine

NOVEMBER 20, 2024

OBJECTIVE We assessed feasibility and patient-reported clinical outcomes of adjunctive use of SNI in ARS. Secondary: average rate of SNI use, percentage of participants who used SNI at least 50% of study days; perceived effect on sino-nasal symptoms; association of SNI use with validated clinical outcomes instrument severity score.

Clinic 130

Clinic Management Provider Patients 130