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

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

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.

Transportation 130

Transportation Screening Individual Primary Care 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

The Physicians Foundation

MAY 20, 2025

The Physicians Foundation announces the 2025 recipient of the Drivers of Health (DOH) Fellowship Program, urges physicians to screen patients for DOH BOSTON, May 21, 2025 – Today, The Physicians Foundation reinforces its efforts to help physicians address drivers of health (DOH) to improve a person’s overall health.

Chronic Disease 40

Chronic Disease Screening Transportation Patient-Centered 40

GeriPal

JUNE 5, 2025

Eric 17:06 Think like almost 50% of nursing home decedents utilize hospice, and that number has grown over the last two decades. Like, yeah, utilization of hospice has increased pretty well. Like an AI robot goes in the room with the screen and that links to the human palliative care provider and is also the companion.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78