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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

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. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

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Evaluating the Impact of a Longitudinal Clerkship Lecture on Medical Students Knowledge and Response to Human Trafficking [Education and training]

Annals of Family Medicine

Few medical schools include this topic in their curriculum, and it is not standardized in undergraduate medical education. Objective Assess how a lecture on HT during a 4-week family medicine (FM) clerkship impacts medical student knowledge, skills, and attitudes regarding HT.

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Optimizing Medical Legal Partnerships for sustainable public funding through the tele-legal model [Mixed methods research]

Annals of Family Medicine

Context: Medical legal partnerships (MLP) are an effective intervention for social determinants of health, like housing, education, and employment status. Setting or Dataset: Clinics: AF Williams Family Medicine, Lowry Internal Medicine; EPIC data; legal records. Intervention/Instrument: Legal-needs screening tool.

Medical 130
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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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Practice patterns of Ontario physicians working in 'boutique' medical clinics [Economic or policy analysis]

Annals of Family Medicine

Results: Significant differences were seen in patient demographics, fees, and referral patterns amongst boutique clinic practices compared to Toronto Central LHIN and Ontario physicians. There was a higher rate of referrals to dermatology, surgery, and family practice from boutique clinics.

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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

Intervention: The Navigator, a diabetes-trained medical scribe, contacted patients by phone to inform them about the Stanford Diabetes Care Program (SDCP) and engaged them in shared decision-making for necessary referrals. Navigators attempted to call 96 patients and reached 64 patients (67% response rate).