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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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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

On January 7, 2025, SAMHSA announced the award of one-year Certified Community Behavioral Health Clinics (CCBHCs) Demonstration planning grants to 14 states and Washington, D.C., Leverage Technology and Data Implement measurement-based care tools that work across both systems to track patient outcomes and demonstrate effectiveness.

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Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care [Smoking cessation]

Annals of Family Medicine

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. Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Referral to counseling (7.5% Referral to counseling (7.5%

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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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Primary Care Perspectives on Access to Specialty Care in Rural Communities: A Mixed-Method Study [Health care disparities]

Annals of Family Medicine

Rural facilities report challenges and solutions to meet community needs for specialty care. American Medical Association Physician Masterfile Population Studied: Cardiologists, neurologists, oncologists, or pulmonologists; rural health systems leaders. Objective: This study sought to analyze changes in the U.S. Setting/Data Set: U.S./American

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

Annals of Family Medicine

Context: Diabetes management (DM) for patients with Type 2 Diabetes (T2D) can be hindered by non-medical, health-related social needs. family medicine, general internal medicine, endocrinology) affiliated with an academic medical center serving a diverse population in a mid-western metropolitan area.