Annals of Family Medicine

NOVEMBER 20, 2024

Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization. A Compass Rose episode was automatically generated in the patient’s medical record in Epic if patients indicated that they had at least one of the four social risk factors on the screening tool.

Referral 130

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: We conducted focus groups, key informant interviews, and in-depth interviews with leaders from ODM, CBOs, and regional health systems, triangulated with thematic review of community health needs assessments.

Community 130

Community Diabetes Referral Screening 130

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. Objective: To assess the impact of a question on need for assistance with social risk factors identified through routine screening. Study Design and Analysis: Descriptive analysis of secondary data.

Primary Care 130

Primary Care Referral Routine Screenings Patients 130

Annals of Family Medicine

NOVEMBER 20, 2024

A recent review of national diabetes treatment guidelines recommended adjustments to DM to reduce financial strain (eg, selecting lower cost medications), as well as directly intervening in response to an identified social need (eg, referral to a community-based service).

Primary Care 130

Primary Care Diabetes Management Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: Adults (≥18 years) who receive care at an affiliated clinic, screen positive for food insecurity, have a T2D diagnosis, and an A1c level > 7.5%. Transportation and scheduling challenges also hindered engagement. All participants are referred to receive free produce ("standard of care").

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

GeriPal

FEBRUARY 15, 2024

So Carmen and Katie developed an EMS Community Partnership program. They created a seamless link between this Community Partnership program and 911 calls for falls. Eric and I enjoyed talking with Carmen and Katie about this innovative and common sense approach to addressing falls in the community. What can we do as a community?

Community 115

Community Transportation IT PCP 115

GeriPal

JUNE 5, 2025

The obstacles hindering referrals to palliative care services. We also take a dive into these 2 articles that Connie first authored: Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. And what does that referral process look like? So that part we know and I.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78