Annals of Family Medicine

NOVEMBER 20, 2024

Study Design and Analysis: We used information gathered from site visits and team meetings to understand how Compass Rose was being utilized across sites. Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization.

Referral 130

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Intervention/Instrument: The intervention includes a short survey to determine patients’ needs with respect to transportation, food insecurity, financial difficulty related to utility payments, and housing.

Primary Care 130

Primary Care Referral Routine Screenings Patients 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