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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

Population Studied: Three sites, representing 13 urban and rural primary care practices in Minnesota, Wisconsin, and Florida participated in the Compass Rose pilot. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

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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

Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida. Study Design and Analysis: Descriptive analysis of secondary data.

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Effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in practice [Education and training]

Annals of Family Medicine

Objective: To evaluate the effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in clinical practice. Setting: Divisions of Family Medicine and Community Internal Medicine at a large academic medical center in Southeast Minnesota.

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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.