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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

Study Design and Analysis: We used information gathered from site visits and team meetings to understand how Compass Rose was being utilized across sites. Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization.

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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

A retrospective cohort study design was utilized to assess changes in A1c levels over the course of one year pre-enrollment and one year post-enrollment, comparing enrolled and not enrolled patients; a mixed effects interrupted time series model was employed for analysis.

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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. Setting or Dataset: Secondary data on social needs screening and referral generated through Epic.

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

Annals of Family Medicine

Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach. Descriptive analysis utilized primary legal record and secondary electronic health record sources. Conclusions: Best practices for virtual model require on-site clinical champions.

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

Annals of Family Medicine

Objective: Evaluate the economic impact of receiving tele-legal services from Medicaid’s perspective with regard to a) fee- for service (FFS) total cost of care; b) FFS cost of primary care; c) utilization for FFS primary care; d) utilization for FFS and capitated behavioral health (BH) and BH emergency department encounters.

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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. Population Studied Families of children ages 0-18yo at an urban pediatric primary care mobile medical clinic serving families in Washington, D.C.

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Developing actionable strategies to implement evidence-based breast cancer follow-up in primary care using codesign [Dissemination and implementation research]

Annals of Family Medicine

Population Studied: Primary care clinics. Feedback from champions was elicited to improve report accuracy and support tool utility. Other suggestions included clinical documentation guidance to align with broader health system goals (e.g., Setting: Large integrated health system. prevention metrics and revenue generation).