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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. We also assessed patterns of social risks and need for assistance among our patient populations. Of those patients with an episode (i.e.,

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Patient experience with Social Prescribing Program in Ontario, Canada [Social determinants and vulnerable populations]

Annals of Family Medicine

Context Social Prescribing (SP) is an approach to help individuals address their health and social needs wherein a healthcare practitioner refers patients to non-clinal services in the community. Models of SP vary, and the experience of patients across these models is less known.

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How to Improve Care for Patients With Multiple Chronic Conditions

Physician's Weekly

Caring for patients with multiple chronic conditions requires identifying those at risk, clear communication, and coordinated care to improve outcomes. Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles.

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A Call for Engagement Outside of the Exam Room

Physician's Weekly

There is robust data regarding the importance of patient connection and engagement in the hospital and clinic setting. Many of us are taught in medical school and residency the importance of patient communication on improving patient satisfaction scores, quality metrics, and professional fulfillment.

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Multisector Health Equity Coordination in a Midwestern Primary Care Practice, 2022-2023 [Social determinants and vulnerable populations]

Annals of Family Medicine

Multisector coordination is critical for effective screening and referral initiatives. Objective: To assess the function and impact of a new role, a Health Equity Coordinator, on the reach of the social needs screening and referral program. Contact hours included a mix of in-person visits and phone calls.

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Combating Food Insecurity in Minnesota

Minnesota Academy of Family Physicians

A Collaborative Approach Between Health Care Providers and Community Partners Food insecurity affects thousands of Minnesotans, often contributing to chronic health conditions and overall poor health outcomes.

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A feasibility study of the Illuminate 360o approach for monitoring the implementation of a health system innovation [Mixed methods research]

Annals of Family Medicine

Objectives: We explored how to design a system to provide near real-time feedback on context and impacts to inform health system innovations; and how to operationalize data collection across diverse patient populations and providers. Study Design and Analysis: We used a mixed-method complexity-informed methodology.

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