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Artificial Intelligence in Health Care

Integrated Care News by CFHA

Traylor and colleagues (2025) show that generative‑AI tools can boost health literacy by translating medical jargon into plain language. Evidence‑informed care was literally at his fingertips. For AI in Primary Care, Start With the Problem. Annals of Family Medicine , 23(1), 5–6. References Menchaca, J.

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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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Effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in practice [Education and training]

Annals of Family Medicine

Objective: To evaluate the effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in clinical practice. Setting: Divisions of Family Medicine and Community Internal Medicine at a large academic medical center in Southeast Minnesota.

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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

Population Studied: Three sites, representing 13 urban and rural primary care practices in Minnesota, Wisconsin, and Florida participated in the Compass Rose pilot. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Population Studied: Inpatients were referred if they were being discharged from the Family Medicine service to home.

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Economic analysis of virtual Medical Legal Partnership model [Economic or policy analysis]

Annals of Family Medicine

Context: Despite copious evidence of the positive health impact of Medical legal partnerships (MLP), public funding remains subject to economic arguments seeking return on investment (ROI) from the perspective of public payers. Clinics: AF Williams Family Medicine, Lowry Internal Medicine.

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Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care [Smoking cessation]

Annals of Family Medicine

Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Outcome Measures: Assessment of tobacco use; Among patients with current tobacco use, provision of advice to quit, referral to tobacco cessation counseling and tobacco cessation medication orders.