Annals of Family Medicine

NOVEMBER 20, 2024

Instrument: The discussion guide included questions on 1) identifying shared social care priorities across the three groups, and 2) describing best practices, facilitators, and barriers around screening and referral for social needs learned from existing and past collaborative models.

Community 130

Community Diabetes Referral Screening 130

Annals of Family Medicine

NOVEMBER 20, 2024

Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach. Descriptive analysis utilized primary legal record and secondary electronic health record sources. Intervention/Instrument: Legal-needs screening tool.

Medical 130

Medical Referral Screening Internal Medicine 130

Annals of Family Medicine

NOVEMBER 20, 2024

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. Results: Among 119,926 patients, 40% did not have SDOH assessed; 31% had 3 or more social needs identified during screening, 11% had 2, 7% had 1, and 11% had no social needs.

Primary Care 130

Primary Care Referral Electronics Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

Setting or Dataset: Medicaid Claims, Epic electronic health record. Intervention/Instrument: Legal-needs screening tool. Clinics: AF Williams Family Medicine, Lowry Internal Medicine. Population Studied: Attributed patients of participating clinics; clinic staff; Colorado state agency staff.

Primary Care 130

Primary Care Medical Behavioral Health Services Utilities 130

Integrated Care News by CFHA

MAY 1, 2025

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). Beyond the Screen: The Impact of Generative Artificial Intelligence on Patient Learning and the Patient‑Physician Relationship. JAMA , 329(16), 1333–1336. Traylor, D.

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Annals of Family Medicine

NOVEMBER 20, 2024

Electronic risk assessment and communication may enhance screening and prevention, but patient perspectives are understudied. Elevated-risk individuals in Arms 2/3 were referred to genetics/screening services. Context Few affected by hereditary cancer syndromes know their cancer risk.

Screening 130

Screening Patients Referral Family 130

Permanente Medicine

JUNE 3, 2025

When you put in that referral, how do we make sure that that patient walks out with the specialty appointment versus phone tag. Let’s get this important cancer screening test done. They’ll also pen the rheumatology referral. We’ve been enhancing that and we share that with the other markets. I love that.

IT 52

IT Patient-Centered Patients Medical 52