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Adoption, implementation, and impact of a Diabetes Navigator program based in primary care [Diabetes and endocrine disease]

Annals of Family Medicine

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.

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Pilot Testing of the Treatment Burden Screening in Diabetes Tool in Primary Care [Multimorbidity]

Annals of Family Medicine

Context: Nearly all patients with type 2 diabetes have comorbid chronic conditions, adding complexity to self-management. A tool to more efficiently relay points of patient-perceived treatment burden during a primary care visit may lead to more patient-centered care plans and improved outcomes.

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Clinician perception of the relationship between mental health, health-related social needs, and diabetes outcomes [Diabetes and endocrine disease]

Annals of Family Medicine

Context: Health-promoting behaviors are crucial for good outcomes in diabetes. However, mental health conditions and health-related social needs (HRSNs) can complicate patients’ success. Consequently, clinicians may avoid these stigmatized topics and provide general recommendations that can’t be followed by patients.

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Implementation Evaluation of a Community Health Worker Program for Patients with Type 2 Diabetes or Hypertension [Dissemination and implementation research]

Annals of Family Medicine

Context Disparities in type 2 diabetes mellitus (T2D) and hypertension (HTN) control are well-described. Community health worker (CHW) interventions show promising outcomes for T2D and HTN control particularly among low income and historically marginalized patients. Population Studied Adult patients with T2D and/or HTN.

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“The physician–patient encounter is health care’s choke point” -NEJM

A Country Doctor Writes

Its basic argument was that it isn’t sustainable to only see patients one by one in traditional doctor visits. I thought of it the other day when I put together a presentation about Galileo’s way of interacting with patients. The physician–patient encounter is health care’s choke point.

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Reliability and Validity of a Comprehensiveness of Care Measure in Primary Care, A Case Study of the PRIME Registry [Research methodology and instrument development]

Annals of Family Medicine

nurse practitioners and physician assistants), as well as validity of the measure and its association with poorly controlled diabetes (e.g. Study Design and Analysis: A retrospective cohort of providers and its patient panel for two performance years, 2019 and 2022. Hemoglobin A1C > 9.0 as a case study).

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Development and Testing of an Interoperable e-care Plan for Person-Centered Care Planning for Multiple Chronic Conditions [Multimorbidity]

Annals of Family Medicine

Because people with MCC typically see multiple providers in multiple care settings often using different EHRs, critical information is difficult to obtain, leading to fragmented care, clinician and patient burden, and suboptimal outcomes. The apps also collect patient reported data on goals, social needs, and functional status.