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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

Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization. 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.

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Artificial Intelligence in Health Care

Integrated Care News by CFHA

Traylor and colleagues (2025) show that generative‑AI tools can boost health literacy by translating medical jargon into plain language. At a recent conference, a neurologist demonstrated an AI tool that captured and structured his clinical notes while he was able to be present and maintain eye contact with the patient. Traylor, D.

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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.

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Visiting a Health Clinic for Women’s Health Screenings

Mesa Family Physician

Women’s health screenings are an essential part of preventive care, yet many people aren’t sure what to expect during these visits—or when the right time is to schedule them. 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.

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Evaluation of Universal Food Insecurity Screening in the Primary Care Setting [Social determinants and vulnerable populations]

Annals of Family Medicine

The American Academy of Pediatrics recommends universal screening; however studies have found inconsistencies in screening of FI, documentation of FI, and referral to appropriate resources. Outcome Measures Percent eligible families that completed a food insecurity screening. 24% who were FI in 2022 became not FI in 2023.

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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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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. Results: Among 119,926 patients, 40% did not have SDOH assessed; 31% had 3 or more social needs identified during screening, 11% had 2, 7% had 1, and 11% had no social needs.