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Implementation of a novel linkage of primary care electronic medical record data with hospital data in South Eastern Ontario [Big data]

Annals of Family Medicine

Context: Currently, primary care data, community data, and hospital data are not linked in Ontario, resulting in a disconnect in continuity of care. We demonstrated the capacity to implement data-drive QI approaches to support patient care across health care sectors using the novel merged datasets.

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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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Primary Care Utilization in Native American Communities: Challenges and Opportunities [Health care disparities]

Annals of Family Medicine

It is paramount to understand the barriers faced by the AI/AN community to better serve their medical needs. The impact of long-standing inadequate access to basic healthcare coupled with generational trauma has contributed to community distrust of western medicine. Population Studied: AI/AN patients residing in the USA.

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The Midwest Trans Health Education Network: Increasing Access to Gender Affirming Care Through Virtual Training Cohorts [Education and training]

Annals of Family Medicine

Context Gender affirming medical care is associated with long term benefits for transgender and non-binary patients but access to such care does not meet the current need. This mismatch is worsened in rural communities. Setting or Dataset A pretestposttest survey design was utilized to assess the intervention.

Education 130
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Impact of an Intensive Primary Care Service on Health Services Utilization in a High-Utilizer Patient Population [Health care services, delivery, and financing]

Annals of Family Medicine

Context: High-utilizer patient populations reflect poor health for those patients and high resource use for health systems. Few studies of high-utilization patient programs found improvements in the intervention groups compared to controls. Setting: Safety net hospital/clinic system in Fort Worth, Texas.

Utilities 130
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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. 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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Personalized medicine in a community health system: the Endeavor Health experience [Dissemination and implementation research]

Annals of Family Medicine

Successful implementation required the development of a scalable family history collection tool, the Genetic and Wellness Assessment (GWA) and Breast Health Assessment (BHA) tools; integrated pharmacogenomics programming; educational programming; electronic medical record integration; and robust clinical decision support tools.

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