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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. Population Studied: Three sites, representing 13 urban and rural primary care practices in Minnesota, Wisconsin, and Florida participated in the Compass Rose pilot. Of those patients with an episode (i.e.,

Referral 130
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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. Study Design and Analysis: Descriptive analysis of secondary data.

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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%

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Three Practices, Three Stories: best practices and unique approaches to substance use screening in rural primary care [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

Context: Primary care (PC) practices that implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) can identify, reduce, and prevent problematic alcohol use that otherwise could go undetected. While screening and brief counseling in PC is considered best practice, it is not standard practice.

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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., CCBHCs focus on comprehensive behavioral health services, ensuring 24/7 crisis care, care coordination, and a broader continuum of behavioral health treatment.

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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. Rural health system leaders described 5 methods to provide rural specialty access: community-based, visiting, referrals to larger towns, telehealth, and management by primary care with specialist support.

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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

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. Contact hours included a mix of in-person visits and phone calls.