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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.,

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. The final question asked patients, who have at least one risk factor, if they would like assistance with their need(s). Study Design and Analysis: Descriptive analysis of secondary data.

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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. Population Studied: Purposive sample of care team members (eg, physicians, social workers, diabetes educators, dietitians, community health workers).

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Health-Related Social Needs Increase and Persist following Onset of COVID-19 Pandemic [Social determinants and vulnerable populations]

Annals of Family Medicine

Context: Health-related social needs (HRSN), such as housing, food, and transportation, play a major role in overall patient health and well-being. The Coronavirus-19 (COVID-19) pandemic amplified HRSN disparities, adding stress to social support systems. Logistic regression model- binary indicator for a positive screen.

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You don’t need X-Rays in a child with bronchiolitis, croup, asthma, or first time wheezing

PEMBlog

This is a blog post and a podcast episode designed to disseminate the important work of Choosing Wisely , an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

Asthma 52
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EMS Intervention to Reduce Falls: Carmen Quatman and Katie Quatman-Yates

GeriPal

The insight started when Carmen, an orthopedic surgeon-researcher, and Katie, a physical therapist- researcher participated in ride-alongs with EMS providers to patient’s homes. Going into patient’s homes was eye opening. So Carmen and Katie developed an EMS Community Partnership program. Word of mouth spread rapidly.

Community 114
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The Physicians Foundation Continues Efforts to Tackle Chronic Disease—America’s Leading Cause of Death—by Addressing Drivers of Health

The Physicians Foundation

The Physicians Foundation announces the 2025 recipient of the Drivers of Health (DOH) Fellowship Program, urges physicians to screen patients for DOH BOSTON, May 21, 2025 – Today, The Physicians Foundation reinforces its efforts to help physicians address drivers of health (DOH) to improve a person’s overall health.