Community Patients Referral Utilities 
Annals of Family Medicine
NOVEMBER 20, 2024
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.,
Annals of Family Medicine
NOVEMBER 20, 2024
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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Minnesota Academy of Family Physicians
FEBRUARY 20, 2025
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.
Annals of Family Medicine
NOVEMBER 20, 2024
Context: Diabetes management (DM) for patients with Type 2 Diabetes (T2D) can be hindered by non-medical, health-related social needs. Population Studied: Purposive sample of care team members (eg, physicians, social workers, diabetes educators, dietitians, community health workers).
Annals of Family Medicine
NOVEMBER 20, 2024
Setting or Dataset: eConsult cases closed in 2021 from the Champlain region in Eastern Ontario for PLWD living in the community and in long-term care (LTC). Population Studied: Our sample included 97 cases from PLWD in the community and 53 cases from LTC. Specialists responded to all cases in a median of less than 1.2
Logansport Memorial Hospital
MARCH 4, 2024
Together with the Pain Management Group (PMG), Logansport Memorial is dedicated to providing high-quality care right here in our community. We are grateful for the invitation to be a part of the Logansport Medical Community,” shared Mark Ozimek, PMG’s President. A referral from a provider is not required but is recommended.
Annals of Family Medicine
NOVEMBER 20, 2024
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. Setting: Alberta, Canada from May 2022 to October 2023.
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