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Risks and Needs: Lessons Learned from Assessing Patients Willingness to Receive Help for Social Risks in Primary Care [Social determinants and vulnerable populations]

Annals of Family Medicine

Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida. Setting or Dataset: Secondary data on social needs screening and referral generated through Epic.

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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. The most common type of support requested related to transportation needs (42%), followed by assistance related to food insecurity (25%), utilities (12%), and housing (9%).

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Addressing diabetes management in the context of social needs: a qualitative study of primary care providers [Diabetes and endocrine disease]

Annals of Family Medicine

Objective: To describe how primary care clinics have considered social needs in DM, and identify opportunities to support primary care clinics. family medicine, general internal medicine, endocrinology) affiliated with an academic medical center serving a diverse population in a mid-western metropolitan area.

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MN Legislative Session 2025: MAFP Priorities Remain in Play

Minnesota Academy of Family Physicians

These include health care, jobs and labor, K-12 education, energy, higher education, taxes, transportation and bonding. Sticking points remaining include reinsurance, paid family and medical leave and whether undocumented residents can qualify for MinnesotaCare. We are hopeful they will be included in a final agreement.

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Integrated care for adults with complex needs: opportunities of case management in primary care to improve equity [Health care disparities]

Annals of Family Medicine

Setting/Population studied/Intervention: A case management program (CMP) for people with complex needs was implemented in four primary care clinics of an urban area. However, partnerships between primary care clinics and community-based organizations would deserve consideration in further research.

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Relationship between Social Risks and Diabetes Metrics in a Large US Health System [Social determinants and vulnerable populations]

Annals of Family Medicine

Primary care settings may be an appropriate environment to address social risk factors, however much is not known about the characteristics of patient reported social risk among patients with diabetes in a general primary care setting. Context Type 2 diabetes impacts 11.3%

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Relationship between Social Risks and Colorectal Cancer Screening/Surveillance in a Large US Health System [Social determinants and vulnerable populations]

Annals of Family Medicine

Implementation of electronic health record SDOH questionnaires is more common in health care institutions and allows for individual-level assessment of social risk in a primary care setting. Significant differences may exist among screening and surveillance populations.

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