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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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Advancing Primary Care through a Model Unit for Innovative Practice Enhancement [Practice management and organization]

Annals of Family Medicine

Setting or Dataset: Data includes secondary data gathered through Epic electronic medical records system as well as primary data collected from physicians, APPs, and staff working in the MU. Results: We observed an increase in telehealth visits from 4% to 9% and uptake of ambient documentation by 9 of 10 providers during a pilot period.

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Utilization of Treatment for Chlamydia and Gonorrhea in the Primary Care Setting Using the American Family Cohort [Infectious diseases (not respiratory tract)]

Annals of Family Medicine

Setting or Dataset: Electronic health records from the PRIME Registry, years 2018-2022. The electronic health records are stored in the American Family Cohort, the largest national United States primary care database. Efforts are needed to develop management plans for better quality of STI-related care and health equity.

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Describing Differences Across Place and Provider in Canadian Team-Based Care Settings Using Electronic Health Records [Health care informatics]

Annals of Family Medicine

In both cases, TBC can help by providing a collaborative approach to care that can better manage the complex needs of patients. We also observed that family physicians and nurses tend to use more clinically-oriented codes, while mental health care providers and therapists use more codes related to social determinants of health.

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Factors Associated with Documenting Social Determinants of Health in Electronic Health Records by Family Physicians [Social determinants and vulnerable populations]

Annals of Family Medicine

Understanding SDOH documentation in electronic health records (EHRs) is crucial for care management to improve patient outcomes and mitigate health inequities. Context: Social determinants of health (SDOH) significantly impact health outcomes more than medical care alone, yet their integration into decision-making is inconsistent.

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Maryland's Primary Care Program: incremental progress or breakthrough?

The Health Policy Exchange

Our residency, formerly a collaboration with Providence Hospital, is now known as the Medstar Health/Georgetown-Washington Hospital Center Family Medicine Residency Program. What hasn't changed is that our family medicine residents remain excited about health policy and advocacy. I stepped down as director of the Robert L.

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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

Central tenets of primary care are essential to the delivery of effective MCC care: person & family-centered, comprehensive, equitable, team-based, collaborative, coordinated and integrated. Results of testing and evaluation will be presented.