Integrated Care News by CFHA

MARCH 21, 2025

Leverage Technology and Data Implement measurement-based care tools that work across both systems to track patient outcomes and demonstrate effectiveness. Use shared electronic health record (EHR) features to enable smooth referrals and tracking of patient progress between primary care and specialty behavioral health services.

Behavioral Health Services 130

Behavioral Health Services Primary Care Integrated Care Mental Health 130

Canadian Family Physician

MAY 14, 2025

Objective To determine the major themes among clinical questions asked to addiction medicine specialists sent by primary care providers (PCPs) via the Champlain Building Access to Specialists through the eConsultation (BASE™) electronic consultation (eConsult) service and the PCP-perceived benefits of this service.

Primary Care 52

Primary Care Consulting Electronics Provider 52

Physician's Weekly

JUNE 25, 2025

Caring for patients with multiple chronic conditions requires identifying those at risk, clear communication, and coordinated care to improve outcomes. Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles.

Chronic Condition 52

Chronic Condition Patients Management Primary Care Physician 52

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. 0.9SD) encounters per patient since 2007.

Primary Care 130

Primary Care Referral Provider Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective(s): This research explores patient navigation between primary care and specialty care to facilitate treatment completion in a health care system. Intervention: Patient navigation program to specialist treatment from primary care with additional referral to behavioral health services. Among new patients, 58.9%

Behavioral Health Services 130

Behavioral Health Services Primary Care Patients Healthcare 130

Annals of Family Medicine

NOVEMBER 20, 2024

Electronic risk assessment and communication may enhance screening and prevention, but patient perspectives are understudied. Patient coinvestigators and clinicians were involved in all research steps. Context Few affected by hereditary cancer syndromes know their cancer risk.

Screening 130

Screening Patients Referral Family 130

Dr. Zaar

JUNE 1, 2025

Check Experience With Type 2 Diabetes Patients Not all endocrinologists or general practitioners have extensive experience with Type 2 diabetes. Ask: How many Type 2 diabetes patients do they treat each month? Are they patient and open to your questions? Firsthand referrals often lead to trusted and patient-focused providers.

Diabetes 52

Diabetes Board-Certified Management Internal Medicine 52

The Clinical Problem Solvers

MARCH 14, 2025

They are often the first interface for patients experiencing mental health crises, not academic medical centers. There are a growing number of Child Psychiatric Access Programs, including one in Massachusetts, which provide quick access to psychiatric consultation and facilitates referrals for accessing ongoing behavioral health care.

Mental Health 52

Mental Health Community Patient-Centered Hospital 52

Permanente Medicine

JUNE 3, 2025

They candidly discuss the unique challenges and opportunities health care organizations face in meeting patient expectations. Today we are talking about the patient care experience specifically here at Kaiser Permanente, but also in general. For me specifically, it’s how do we make a patient feel. AM: Thank you so much.

IT 52

IT Patient-Centered Patients Medical 52

GeriPal

SEPTEMBER 7, 2023

Does it improve outcomes that patients, caregivers, and clinicians care about? hint: 80% can be done in advance by patients or caregivers) Why is it that some oncologists are resistant to conducting a geriatric assessment, yet have no problem ordering tests that cost thousands of dollars? Welcome back, William. William: Thanks so much.

Patient-Centered 130

Patient-Centered IT Patients Clinic 130

GeriPal

JUNE 9, 2022

Should eligibility and access be determined by clinician referral? If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged? Patients have all sorts of problems. And while they identified thousands of patients and enrolled. By diagnosis?

Consulting 100

Consulting Patient-Centered Diagnosis IT 100

GeriPal

JULY 21, 2022

Initially, it was just because there weren’t really answers for my patients. We’re going to go into how to talk to patients about this, because Emmy, you’ve done some research on it. Because to me, the cognitive concerns are the ones that the patient is not likely to self identify. Eric: Yeah. Is it common?

Families 102

Families IT Family Diagnosis 102

GeriPal

APRIL 6, 2023

Today we have a star-studded lineup, including Lexy Torke of Indiana University, who discusses her RCT of a chaplaincy intervention for surrogates of patients in the ICU , published in JPSM and plenary presentation at AAHPM/HPNA. These studies are important. So, learn as many as you can and what they’re all about.

IT 99

IT Patient-Centered Families Family 99

GeriPal

SEPTEMBER 19, 2024

Give too much, it may cause harm (even if the higher dose had no significant side effects, it would require patients to take a lot of unnecessary additional pills as well as increase the cost.) So, what is the effective dose of palliative care? Give too little – it may not work. Jennifer 04:25 I can take that on. Eric 05:32 Yeah.

Patient-Centered 120

Patient-Centered IT Patients Hospital 120

GeriPal

JULY 6, 2023

It’s that first place that you start where it may not be the AAAs job, but we’ve organized where they have to have the partnerships and they know who the players are and they know who to make a referral to. And that referral can be done in real time, a soft handoff. I think most states have them. Eric: Wait, county 911?

Community 89

Community Nurse Practitioner Provider IT 89

GeriPal

MARCH 27, 2025

Only 5% of intervention patients received the facilitator-led component of the intervention (there were other components, facilitator-led was the most engaged component). I’m hearing dementia patients or patients with dementia. Eric 09:15 And then who were the patients just with dementia or were they. Is that right?

Primary Care 80

Primary Care IT Clinic Illness 80

GeriPal

FEBRUARY 24, 2022

We see our patients and our families throughout the illness trajectory into the hospital. And maybe we should have more patient-centered conversations. We want to do meaningful work and so we want to know that the conversations we have impact patient care. And I kind of think our patients are on this longer journey, right?

Illness 98

Illness Patient-Centered IT Patients 98

GeriPal

JULY 20, 2023

Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic. Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others.

Telemedicine 73

Telemedicine Telehealth Patient-Centered Board-Certified 73