Annals of Family Medicine

NOVEMBER 20, 2024

Context: Patients with diabetes who receive structured and integrated care have better control and outcomes; however, care may shift between multiple settings making coordination challenging. Outcome Measures: Number of patients engaged, resulting referrals, Navigator time per patient, and hemoglobin A1c measures across 2-years.

Primary Care 130

Primary Care Diabetes Referral Integrated Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: This work was done in the context of a regional quality improvement (QI) collaborative funded by the Ohio Department of Medicaid (ODM) focused on advancing diabetes equity through cross-sectoral QI infrastructure. We are one of 6 regional QI collaboratives statewide. Setting: Northeast Ohio.

Diabetes 130

Diabetes Community Referral Screening 130

Permanente Medicine

JUNE 3, 2025

I just listened to the one on national cancer care that we’re doing, which was very informative and pretty impressive. The second thing that is different is access to information. When you put in that referral, how do we make sure that that patient walks out with the specialty appointment versus phone tag.

IT 52

IT Patient-Centered Patients Medical 52

GeriPal

SEPTEMBER 7, 2023

And it’s with this information from the geriatric assessment that we can really create interventions, and so that’s something that Alex and I strongly believe that we should move forward with. We have the chemo talks tool posted, so people can go there and click and immediately get the information about this. Mazie: Yes.

Patient-Centered 129

Patient-Centered IT Patients Clinic 129