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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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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

Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida. Outcome Measures: social risk factors, whether patients wanted assistance with their risk factors, and measures related to connection to community resources.

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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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Comparing impact of a holistic patient centered navigation model to an online navigation service on health care utilization [Population health and epidemiology]

Annals of Family Medicine

Context Social prescribing has been linked to better access, improved health and wellbeing, and decreased health care utilization (HCU). Population Primary care providers in 12 Ottawa and Sudbury (Ontario, Canada) practices referred their patients with health or social needs to access needed SP services.

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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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Project ECHO Rheumatology - Rationale and Results from a Multi-Method Study to Capture Impact [Musculoskeletal and rheumatology]

Annals of Family Medicine

Context Project ECHO (Extension for Community Healthcare Outcomes) is a virtually-delivered health professions education model, designed to improve patient care by enhancing primary care capacity in specialty topics. Conclusion The burden of rheumatic disease is rising.

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Evaluation of Primary Care Provider Utilization by Asthma Patients after the Implementation of Coach McLungsSM [Child and adolescent health]

Annals of Family Medicine

Patients with the worst outcomes often lack continuity of primary care and receive care at emergency departments during exacerbations. Improved asthma outcomes are associated with effective communication between patients and providers, such as using shared decision-making. to 0.08, p=0.44), 5% to 2% ([95%]CI -0.03