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. Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization.

Referral 130

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Intervention/Instrument: The intervention includes a short survey to determine patients’ needs with respect to transportation, food insecurity, financial difficulty related to utility payments, and housing.

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

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. Like, yeah, utilization of hospice has increased pretty well. Eric 21:49 Yeah.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78

GeriPal

JULY 6, 2023

Alex: We’ve got a lot to talk about…what states are doing and cities are doing to support older adults in the community. But, what you need is a community-based game there. The long-term care is being actually provided in the community at a much higher rate than what the formal system provides. You go back home.

Community 89

Community Nurse Practitioner Provider IT 89