Annals of Family Medicine

NOVEMBER 20, 2024

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.

Primary Care 130

Primary Care Referral Electronics Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

SUD screening is not universally done in primary care (PC). In our institution, screenings are completed for patients ≥15 years during well visits; those not presenting for well visits and under 15 may represent missed opportunities. A score ≥2 constitutes a positive screen for possible substance misuse.

Primary Care 130

Primary Care Screening Referral Wellness Visit 130

Integrated Care News by CFHA

MAY 1, 2025

When used intentionally, AI can help us: draft progress notes or referral letters, suggest evidence‑based interventions or psycho‑educational handouts, and organize task lists, reminders and teaching materials so we can focus on patients and learners. How are you integrating AI into your clinical, teaching or supervisory work?

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Common Sense Family Doctor

MARCH 15, 2025

Michelle Rockwell and colleagues at the Carilion Clinic in Roanoke, Virginia, performed a sludge audit of their colorectal cancer (CRC) screening services in 2021 and 2022. In contrast, patients who reported no or minimal sludge were more likely to complete screenings and less likely to report distrust in the health system.

Screening 52

Screening Insurance Primary Care Referral 52

Annals of Family Medicine

NOVEMBER 20, 2024

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives.

Primary Care 130

Primary Care Referral Screening Patient-Centered 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: To explore participants’ barriers to and facilitators of engagement in a multilevel, cross-sector clinical trial designed to address social needs and improve health-related outcomes for individuals with T2D experiencing food insecurity. Setting: Ambulatory clinics (e.g., their 3-month endpoint visit).

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

Annals of Family Medicine

MAY 27, 2025

METHODS We used agile implementation principles to integrate a DCA tool into routine workflows across 7 primary care clinics. A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment.

Primary Care 130

Primary Care Screening Referral Clinic 130

Minnesota Academy of Family Physicians

FEBRUARY 20, 2025

Through food pharmacies, food insecurity screenings and innovative community partnerships, health care providers are ensuring patients get the nourishment they need to thrive. Encourage Healthy Eating Through Vouchers: Many clinics and systems have voucher programs in place to help supplement food for patients.

Family Physician 52

Family Physician Community Family Families 52

Annals of Family Medicine

NOVEMBER 20, 2024

A recent review of national diabetes treatment guidelines recommended adjustments to DM to reduce financial strain (eg, selecting lower cost medications), as well as directly intervening in response to an identified social need (eg, referral to a community-based service). Setting: Ambulatory clinics (e.g.,

Primary Care 130

Primary Care Diabetes Management Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

clinical consensus, financing mechanisms) and the organization (e.g., referral networks, technology infrastructure) to drive the transformation needed to facilitate early detection for cognitive impairment in primary care.

Primary Care 130

Primary Care Screening Healthcare Finance 130

Physician's Weekly

JUNE 13, 2025

There is robust data regarding the importance of patient connection and engagement in the hospital and clinic setting. This can be done by maintaining a directory of community resources and making referrals during patient visits. Connect patients with local resources such as food banks, housing assistance, and mental health services.

Chronic Disease Management 52

Chronic Disease Management Community Chronic Disease Education 52

The Physicians Foundation

AUGUST 15, 2024

Founder and CEO of Cherry Hill Free Clinic (CHFC), Chief Medical Officer at Camden Coalition and Medical Director for Community Health at Virtua Health, as the recipient of the Dr. Buz Cooper Award for Addressing Drivers of Health. “The Jubril Oyeyemi, M.D., president of The Physicians Foundation. I am deeply honored to receive the Dr.

Primary Care 40

Primary Care Community Chronic Disease Management Education 40

Blood, Sweat, and Tears

MAY 24, 2022

She would peer out at the gate of the clinic and start predicting what cases we would see. So you came to the clinic after you went out to get yourself damaged? Sister N pointed to the screen with a blood pressure reading of 180/110. But I was glad no one needed referral. “Yazi Moosa, today feels like trauma.

Referral 52

Referral Community Patients Specialization 52

GeriPal

JANUARY 18, 2024

After discussing screening options for substance use disorder, we go on to talk about both the treatments for it and the issues that arise. So, we are not screening for substance use in cancer care, so we don’t get good estimates among people with cancer, which is really how we would prefer to ask the question. Katie: Yeah.

Illness 137

Illness Patient-Centered Screening Clinic 137

GeriPal

SEPTEMBER 7, 2023

Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their guidelines for care of older adults to state that all older adults receiving systemic therapy (including chemo, immuno, targeted, hormonal therapy) should receive geriatric assessment guided care. Mazie, welcome to GeriPal. William: Sure.

Patient-Centered 130

Patient-Centered IT Patients Clinic 130

GeriPal

FEBRUARY 22, 2024

Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here ). We saw that around 60% of people were screening positive for depression in the last month before death. Or is it that I’m just not screening? That’s a lot.

Mental Health 123

Mental Health Patient-Centered Illness Screening 123

GeriPal

FEBRUARY 6, 2025

How should we screen for cognitive impairment? So let’s just say you have a healthy 55 year old or 65 year old in your clinic. Who do you think we should be screening and how should we be screening them for these symptoms? Well, so I guess it depends on what you say screening. Nate 05:29 Ooh.

Primary Care 97

Primary Care Diagnosis Screening IT 97

GeriPal

JUNE 5, 2025

The obstacles hindering referrals to palliative care services. We also take a dive into these 2 articles that Connie first authored: Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. And what does that referral process look like? So that part we know and I.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78

GeriPal

JULY 21, 2022

I don’t practice clinically in outpatient settings, and often the folks I’m seeing are there for other kinds of issues. Eric: Let’s say I have a panel of older adults that I’m seeing, or a palliative care outpatient clinic. We and many others have tried to come up with a short, validated screening tool.

Families 102

Families IT Family Diagnosis 102

GeriPal

OCTOBER 27, 2022

As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful. As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making.

IT 95

IT Clinic Screening Patients 95

GeriPal

FEBRUARY 15, 2024

We require, especially if they’re coming to us, we’re often making them come to our clinics if they’re going to get treatment, and we’re relying upon what they report to us, and are they going to tell us, “Oh, my steps are uneven and actually my railing’s all rickety and I’ve got boxes everywhere”?

Community 116

Community Transportation IT PCP 116

GeriPal

APRIL 6, 2023

It is a screening? Okay, I don’t necessarily want to stay clinical, but I really love that spiritual work and what’s the closest profession. We compared the raw scores on those measures, but we also were interested in making sure that the differences were clinically meaningful. I guess FICA is not as cool as SKY.

IT 99

IT Patient-Centered Families Family 99

GeriPal

AUGUST 24, 2023

Our early studies were looking at things like, desire for death, and syndromal depression, and screening for depression and anxiety, and will to live. And so the importance of the picture and the epiphany that really came many years later, I published a paper in the Journal of Clinical Oncology called Dignity in the Eye of the Beholder.

Patient-Centered 98

Patient-Centered Patients IT Illness 98

GeriPal

MARCH 10, 2022

Now when I say variation, I’m not talking about small little clinically questionable variations. Ruth: I do have to also say that it’s important to remember that feeding tube use and hospital transfers for people with advanced dementia has no demonstrated clinical benefit. Joan: A lot of my work comes out of my clinical practice.

Nurse Practitioner 60

Nurse Practitioner Hospital Families Family 60

GeriPal

FEBRUARY 24, 2022

Should we focus on something else, both from a clinical and a research perspective? Get the hospice referral. So I’m just going to share on my screen. And this seems like it’s part of this larger debate around… And some of our listeners may not know there is this debate going on around advance care planning.

Illness 98

Illness Patient-Centered IT Patients 98

GeriPal

JULY 20, 2023

Joe: Well, the proposed rule changes would’ve included, for example, that you have to have a face-to-face encounter with a patient in order to prescribe over telemedicine, or you have to have received a referral from someone who did have a face-to-face, and they also would’ve had to be DEA certified. What state are they in?

Telemedicine 73

Telemedicine Telehealth Patient-Centered Board-Certified 73