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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

We also assessed patterns of social risks and need for assistance among our patient populations. 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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Factors associated with patients' experience of access to their primary health care clinic: a multilevel analysis [Health care services, delivery, and financing]

Annals of Family Medicine

Context: Understanding patients’ experience accessing primary health care (PHC) is necessary in order to move toward better service organization and more equitable PHC access. This cross-sectional study builds on survey data collected in multidisciplinary PHC clinics. 104 PHC clinics across 14 regions of Quebec, Canada.

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

Annals of Family Medicine

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.

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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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Risks and Needs: Lessons Learned from Assessing Patients Willingness to Receive Help for Social Risks in Primary Care [Social determinants and vulnerable populations]

Annals of Family Medicine

Context: In May 2023, Mayo Clinic implemented a revised screening tool to assess social determinants of health (SDOH) for its patients. Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Study Design and Analysis: Descriptive analysis of secondary data.

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Development of a Multidisciplinary Clinic for the Treatment of Obesity in a Canadian University Family Medicine Group (U-FMG) [Obesity, exercise and nutrition]

Annals of Family Medicine

Population Studied Patients with obesity enrolled in the Méta-Santé clinic. Setting The North of Lanaudière University Family Medicine Group (U-FMG) Intervention Upon referral from their family doctor, patients attend a group course on nutrition and metabolic health.

DO 130
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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.