Annals of Family Medicine

NOVEMBER 20, 2024

Context: In May 2023, Mayo Clinic implemented a revised screening tool to assess social determinants of health (SDOH) for its patients. Objective: To assess the impact of a question on need for assistance with social risk factors identified through routine screening. Study Design and Analysis: Descriptive analysis of secondary data.

Primary Care 130

Primary Care Referral Routine Screenings Patients 130

Annals of Family Medicine

NOVEMBER 20, 2024

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

Primary Care 130

Primary Care Medical Behavioral Health Services Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Outcome Measures: Assessment of tobacco use; Among patients with current tobacco use, provision of advice to quit, referral to tobacco cessation counseling and tobacco cessation medication orders. Referral to counseling (7.5% The difference was the largest for no SDOH risk (61%) vs. SDOH risk 3+ (51%), OR, 95% CI (1.5,

Primary Care 130

Primary Care Referral Electronics Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

SUD screening is not universally done in primary care (PC). In our institution, screenings are completed for patients ≥15 years during well visits; those not presenting for well visits and under 15 may represent missed opportunities. A score ≥2 constitutes a positive screen for possible substance misuse.

Primary Care 130

Primary Care Screening Referral Wellness Visit 130

Integrated Care News by CFHA

MAY 1, 2025

When used intentionally, AI can help us: draft progress notes or referral letters, suggest evidence‑based interventions or psycho‑educational handouts, and organize task lists, reminders and teaching materials so we can focus on patients and learners. Annals of Family Medicine , 23(1), 5–6. JAMA , 329(16), 1333–1336.

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Recognizing that health-related social needs drive health inequities, healthcare settings are increasingly beginning to screen and refer patients for social needs. Yet, many patients who screen positive for social needs decline to be referred to resources or do not have their needs resolved.

Primary Care 130

Primary Care Screening Patients Referral 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

Annals of Family Medicine

NOVEMBER 20, 2024

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives.

Primary Care 130

Primary Care Referral Screening Patient-Centered 130

Annals of Family Medicine

NOVEMBER 20, 2024

A recent review of national diabetes treatment guidelines recommended adjustments to DM to reduce financial strain (eg, selecting lower cost medications), as well as directly intervening in response to an identified social need (eg, referral to a community-based service). Setting: Ambulatory clinics (e.g.,

Primary Care 130

Primary Care Diabetes Management Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

family medicine, general internal medicine, endocrinology) at an urban academic medical center in the Midwest. Population Studied: Adults (≥18 years) who receive care at an affiliated clinic, screen positive for food insecurity, have a T2D diagnosis, and an A1c level > 7.5%. Setting: Ambulatory clinics (e.g.,

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

Noreta Family Medicine

MARCH 26, 2025

At Noreta Family Medicine, we offer hour-long appointments, allowing time to build a meaningful doctor-patient relationship and creating a space where patients can openly express their concerns and receive the attention they deserve. “ patients have easy access to their family doctor. patients feel heard and valued.

Primary Care 52

Primary Care Appointment DO Family Medicine 52

Annals of Family Medicine

MAY 27, 2025

A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment. DCA screening was completed in 1,808 (10.8%) of 16,708 eligible visits. Screening workflows were tailored to each clinic.

Primary Care 130

Primary Care Screening Referral Clinic 130

Minnesota Academy of Family Physicians

FEBRUARY 20, 2025

Through food pharmacies, food insecurity screenings and innovative community partnerships, health care providers are ensuring patients get the nourishment they need to thrive. The Minnesota Academy of Family Physicians (MAFP) adopted a resolution (policy guidance) in 2024 related to addressing food insecurity in Minnesota.

Family Physician 52

Family Physician Community Family Families 52

Annals of Family Medicine

NOVEMBER 20, 2024

referral networks, technology infrastructure) to drive the transformation needed to facilitate early detection for cognitive impairment in primary care. Results The CFIR-based implementation evaluation highlighted the importance of alignment between contextual factors at the system level (e.g.,

Primary Care 130

Primary Care Screening Healthcare Finance 130

Annals of Family Medicine

MARCH 24, 2025

Families were randomly assigned via computer-generated numbers to receive either the comprehensive package of interventions or enhanced usual care in a 1:1 ratio.

Family 130

Family Families Management Referral 130

Edge Family Medicine

APRIL 10, 2025

At Edge Family Medicine , we believe that one of the most powerful tools in healthcare isn’t technology — it’s trust. At Edge Family Medicine , we prioritize relationship-based care that supports your wellness every step of the way. Over time, they become familiar with your health history, lifestyle, and concerns.

Primary Care 130

Primary Care Relationship PCP PCP 130

GeriPal

JANUARY 18, 2024

After discussing screening options for substance use disorder, we go on to talk about both the treatments for it and the issues that arise. So, we are not screening for substance use in cancer care, so we don’t get good estimates among people with cancer, which is really how we would prefer to ask the question. Katie: Yeah.

Illness 136

Illness Patient-Centered Screening Clinic 136

GeriPal

APRIL 6, 2023

It is a screening? LaVera: I trained at UCSF in family medicine. And so then it would be nice to have those other than the chaplains, be aware of the spiritual component and then just ask some basic screening questions. And the screening questions would just allow you to know that. What’s involved in this?

IT 99

IT Patient-Centered Family Families 99