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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

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
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A Multi-Sector Pilot Design in the Northeast Ohio QI Hub: Engaging Community Based Organizations to Advance Diabetes Equity [Health care disparities]

Annals of Family Medicine

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
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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. 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.

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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. ITS model- proportion of individuals who screened positive for at least one HRSN, aggregated by week. Logistic regression model- binary indicator for a positive screen.

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Why are So Many Teens and 20-Somethings Today Anxiety-Ridden?

Doctor Rachel

I don’t know how it seems to be going in your home or the town or city you live in, but I am seeing an epidemic of anxious, stressed out teens, in my office and in my community. have lost much of our communal connection. And I am not alone. since the 1940’s. 25% of teens in the U.S. Specifically, Western countries, like the U.S.,

Screening 130
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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

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).

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Barriers to and Facilitators of Participant Engagement in a Multi-level Intervention for Type 2 Diabetes and Food Insecurity [Clinical trial]

Annals of Family Medicine

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. Outcome Measures: Themes regarding barriers to and facilitators of engagement.

Diabetes 130