Integrated Care News by CFHA

MARCH 21, 2025

Enhance Care Coordination Across Both Models Establish workflows that integrate care coordination efforts between PCBH teams and CCBHC case managers to ensure smooth transitions between brief interventions in primary care and longer-term behavioral health services when necessary. Dobmeyer, A. C., & Hunter, C.

Behavioral Health Services 390

Behavioral Health Services Primary Care Integrated Care Mental Health 390

Annals of Family Medicine

NOVEMBER 20, 2024

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. The pre-intervention no-show rate of TCM appointments at Wellstar MCG Health was 44% per month.

Appointment 130

Appointment Hospital Management DO 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Primary care providers in Canada face significant workload challenges, including managing prescriptions, referrals, and laboratory tests alongside patient visits. This study aims to analyze electronic medical record (EMR) data to understand these workload dynamics. referrals, and 6.6 (2.8)

Primary Care 130

Primary Care Referral Provider Electronics 130

Dr. Zaar

JUNE 1, 2025

Managing Type 2 diabetes requires more than just medication—it demands a long-term partnership with a skilled healthcare provider who understands your individual needs. Choosing the right diabetes doctor can make a major difference in how effectively your condition is managed, your quality of life, and your long-term health outcomes.

Diabetes 52

Diabetes Board-Certified Management Internal Medicine 52

Physician's Weekly

JUNE 25, 2025

Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles. Even within practices, some staff members may not be aware of which patients require more proactive management due to multiple chronic conditions. Have open gaps in care or medications not filled.

Chronic Condition 52

Chronic Condition Patients Management Primary Care Physician 52

GeriPal

SEPTEMBER 7, 2023

So I will say that it’s challenging, because we don’t have, unlike City of Hope, we don’t have a big team like they do of geriatricians and palliative care physicians, who can screen these older adults or help with management. So pretty soon, I hope, we’ll be able to do this all electronically by anyone who wants to.

Patient-Centered 130

Patient-Centered IT Patients Clinic 130

GeriPal

JULY 21, 2022

Emmy: But we know that physiologic changes with aging, like decreasing night vision and so forth, as well as medications, as well as medical conditions, can all affect whether you can drive. My general answer is that driving is usually not considered medically necessary. They’re really not. Emmy: Generally not.

Families 102

Families IT Family Diagnosis 102