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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. Descriptive analysis utilized primary legal record and secondary electronic health record sources. Nine focus groups were conducted and recorded, using semi-structured interviews.

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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. Setting or Dataset: Medicaid Claims, Epic electronic health record.

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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

Population Studied: Patients with recent hemoglobin A1c levels of ≥8% were invited to join the Diabetes Navigator program, identified through the electronic health record at two academic primary care clinics. Results: We identified 176 patients with recent hemoglobin A1c ≥8%.

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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. Referrals were not placed for patients being discharged to another facility or who already had an outside primary care provider.

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Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care [Smoking cessation]

Annals of Family Medicine

Setting or Dataset: Electronic health record data from 11 community-based clinics within a safety-net system in the Midwest from 07/01/2021-3/31/2024. Referral to counseling (7.5% overall) and provision of tobacco cessation medications (3.5% Design and Analysis: Observational study.

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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

Use shared electronic health record (EHR) features to enable smooth referrals and tracking of patient progress between primary care and specialty behavioral health services. Journal of clinical psychology in medical settings , 25 (2), 109–126. Dobmeyer, A. C., & Hunter, C.

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Artificial Intelligence in Health Care

Integrated Care News by CFHA

Traylor and colleagues (2025) show that generative‑AI tools can boost health literacy by translating medical jargon into plain language. Reclaiming Time and Attention Primary care professionals may log more than eleven hours a day, over half of it in the electronic health record (Menchaca, 2025).