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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. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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Cardiovascular risk management of patients with depression in Dutch general practices [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

The majority of patients with depression is treated by their General Practicioner (GP). In the Netherlands GPs are also responsible for cardiovascular risk management (CVRM), for which a guideline is made. Knowing the current CVRM practice of Dutch GPs is needed before any recommendations regarding depressed patients can be made.

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

Annals of Family Medicine

Objective: The overarching objective of the MU is to enhance the delivery of high-quality care to a broader patient population. 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.

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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

Background Team-based care (TBC) has established benefits for patient outcomes. In both cases, TBC can help by providing a collaborative approach to care that can better manage the complex needs of patients. In rural areas, TBC can help address challenges arising from limited access to specialized care.

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Patient and Caregiver Use of Patient Portal Features [Survey research or cross-sectional study]

Annals of Family Medicine

Context: Patient portals (PPs) are online healthcare platforms enabling patients access their electronic health records and offering different features to help patients manage their care such as viewing and entering health information, and permitting asynchronous communication between patients and their providers.

Patients 130
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“The physician–patient encounter is health care’s choke point” -NEJM

A Country Doctor Writes

Its basic argument was that it isn’t sustainable to only see patients one by one in traditional doctor visits. I thought of it the other day when I put together a presentation about Galileo’s way of interacting with patients. The physician–patient encounter is health care’s choke point.

Patients 130
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Clinical outcomes of administering an ePROM of barriers to adherence to ART to people with HIV through a patient portal [Clinical research (other)]

Annals of Family Medicine

We used the patient portal (Opal) to administer the I-Score, a 7-item electronic patient-reported outcome measure (ePROM) of barriers to ART adherence. Objective: To describe patient and service-related outcomes of the I-Score intervention and outline adherence barrier management by physicians. 10 to T3=2.3/10),

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