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Compass Rose for Generating Community-based Referrals via Epic: Best Practices and Lessons Learned [Social determinants and vulnerable populations]

Annals of Family Medicine

A Compass Rose episode was automatically generated in the patient’s medical record in Epic if patients indicated that they had at least one of the four social risk factors on the screening tool. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

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Practice patterns of Ontario physicians working in 'boutique' medical clinics [Economic or policy analysis]

Annals of Family Medicine

Little is known about the characteristics of physicians and patients participating in boutique clinic practice models. This study offers insight into the practice patterns of boutique clinic primary care physicians, as well as the estimated public costs of this business model in Ontario. Study Design and Analysis.

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Optimizing Medical Legal Partnerships for sustainable public funding through the tele-legal model [Mixed methods research]

Annals of Family Medicine

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

Annals of Family Medicine

Context: Despite copious evidence of the positive health impact of Medical legal partnerships (MLP), public funding remains subject to economic arguments seeking return on investment (ROI) from the perspective of public payers. Clinics: AF Williams Family Medicine, Lowry Internal Medicine.

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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

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.

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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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Visiting a Health Clinic for Women’s Health Screenings

Mesa Family Physician

A women’s health check typically includes a review of your medical history, a physical examination, and specific screenings based on your age and risk factors. These screenings might include a pap smear, pelvic exam, breast exam, or referrals for mammograms depending on your age and family history.

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