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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

Context: Patients with diabetes who receive structured and integrated care have better control and outcomes; however, care may shift between multiple settings making coordination challenging. Outcome Measures: Number of patients engaged, resulting referrals, Navigator time per patient, and hemoglobin A1c measures across 2-years.

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Developing actionable strategies to implement evidence-based breast cancer follow-up in primary care using codesign [Dissemination and implementation research]

Annals of Family Medicine

Objective: Describe codesign methods to implement actionable strategies for breast cancer survivorship follow-up care. The resulting intervention was a care quality improvement project that engaged practice champions (n=18) from 6 primary care practices in bi-weekly virtual facilitation and monthly learning collaboratives over 3 months.

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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. Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Referral to counseling (7.5%

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Test-Retest Reliability of Electronic Handgrip Dynamometry and Accelerometry Measured Muscle Function in Older Adults [Musculoskeletal and rheumatology]

Annals of Family Medicine

Measures of handgrip strength are collected in primary care settings as a vital sign for the prevention of health conditions related to low muscle strength. Objective: We sought to determine the test-retest reliability of electronic handgrip dynamometry and accelerometry measured muscle function in older adults.

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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

Referrals were not placed for patients being discharged to another facility or who already had an outside primary care provider. Intervention: A team was created with an attending physician, care coordinators, and front office staff.

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Economic analysis of virtual Medical Legal Partnership model [Economic or policy analysis]

Annals of Family Medicine

Objective: Evaluate the economic impact of receiving tele-legal services from Medicaid’s perspective with regard to a) fee- for service (FFS) total cost of care; b) FFS cost of primary care; c) utilization for FFS primary care; d) utilization for FFS and capitated behavioral health (BH) and BH emergency department encounters.

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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

A recent inquiry within the CFHA community sought recommendations on implementing the Primary Care Behavioral Health (P CBH) model at a Federally Qualified Health Center (FQHC) that had received CCBHC Demonstration. Ensure that you engage in culture-building across the FQHC to maintain the primary care focus.