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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. Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida.

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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

Population Studied: Three sites, representing 13 urban and rural primary care practices in Minnesota, Wisconsin, and Florida participated in the Compass Rose pilot. Outcome Measures: We assessed patterns of social risk factors across our patient population as well as the extent to which patients wanted assistance from the clinic.

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Addressing diabetes management in the context of social needs: a qualitative study of primary care providers [Diabetes and endocrine disease]

Annals of Family Medicine

Objective: To describe how primary care clinics have considered social needs in DM, and identify opportunities to support primary care clinics. Setting: Ambulatory clinics (e.g.,

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Integrated care for adults with complex needs: opportunities of case management in primary care to improve equity [Health care disparities]

Annals of Family Medicine

Setting/Population studied/Intervention: A case management program (CMP) for people with complex needs was implemented in four primary care clinics of an urban area. However, partnerships between primary care clinics and community-based organizations would deserve consideration in further research.

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Relationship between Social Risks and Diabetes Metrics in a Large US Health System [Social determinants and vulnerable populations]

Annals of Family Medicine

Primary care settings may be an appropriate environment to address social risk factors, however much is not known about the characteristics of patient reported social risk among patients with diabetes in a general primary care setting. Context Type 2 diabetes impacts 11.3%

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Transitions to non-driving: Internal factors that influence coping in older drivers [Social determinants and vulnerable populations]

Annals of Family Medicine

Primary care clinicians can support older drivers in decisions about driving by prioritizing emotional wellbeing and out-of-home mobility through the transition to non-driving. Outcome Measure: Self-reported use of any alternative transportation in the past three months (e.g. at follow up intervals (6, 12, 18, and 24 months).

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Association between patient reported social risks and HOUSES index: A rural-urban comparison [Social determinants and vulnerable populations]

Annals of Family Medicine

vs 3.4%, transportation risk 3.3% Conclusions SES as measured by HOUSES index is the predominant driver of patient-reported social risk among both urban and rural populations in this primary care population. Further evaluation is needed to apply use of social risk questionnaires and HOUSES index in primary care settings.