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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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Clinical outcomes of administering an ePROM of barriers to adherence to ART to people with HIV through a patient portal [Clinical research (other)]

Annals of Family Medicine

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.

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Implementation of a novel linkage of primary care electronic medical record data with hospital data in South Eastern Ontario [Big data]

Annals of Family Medicine

Context: Currently, primary care data, community data, and hospital data are not linked in Ontario, resulting in a disconnect in continuity of care. 1072 patients with COPD were identified within the merged dataset, 50% of whom visited the ED within two years. Following patient review by clinician, 77 patients were deemed eligible.

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Intensity of medication review activities in private and public clinics [Prescribing and pharmacotherapeutics]

Annals of Family Medicine

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

Clinic 130
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Electronic Health Record Use and Patient-Centredness [Education and training]

Annals of Family Medicine

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.

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An Open Letter to Robert F. Kennedy, Jr. On Why Integrated Care Should Be a Cornerstone of the HHS Agenda

Integrated Care News by CFHA

It offers care where people already are: their doctor’s office, their community mental health clinic, their OB/GYN’s exam room. Fund technology that supports behavioral health labs —routine assessments just like bloodwork—to inform care in real time and empower patients. You don’t have to build it from scratch.

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SGLT-2 inhibitor, cardiovascular risk and outcome in patients with comorbidity of hypertension and diabetes [Cardiovascular disease]

Annals of Family Medicine

Context Two thirds of diabetes patients complicated with hypertension, and comorbidity increase 4-fold risk of atherosclerotic cardiovascular disease (ASCVD). Setting or Dataset Five electronic systems of community clinic. Outcome Measures Changes of China-PAR score and cardiovascular hospitalization events.