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

Objective Assess how a lecture on HT during a 4-week family medicine (FM) clerkship impacts medical student knowledge, skills, and attitudes regarding HT. Screening knowledge was 92% post session, 75% at 3 months, 97% at 6 months, and 75% at 12 months. Study Design Mixed methods prospective quantitative study.

Medical Student 130

Medical Student Education Medical Referral 130

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

Annals of Family Medicine

MARCH 24, 2025

BACKGROUND We evaluated the effectiveness of a structured family-based cardiovascular health promotion intervention model in improving weight management among adults. METHODS We conducted an open label, cluster randomized controlled trial ( ClinicalTrials.gov NCT02771873 ) with families serving as the unit of intervention.

Family 130

Family Families Management 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. Study design and analysis Our approach was informed by the Theoretical Framework of Acceptability.

Screening 130

Screening Patients Referral Family 130

Common Sense Family Doctor

MARCH 15, 2025

Michelle Rockwell and colleagues at the Carilion Clinic in Roanoke, Virginia, performed a sludge audit of their colorectal cancer (CRC) screening services in 2021 and 2022. In contrast, patients who reported no or minimal sludge were more likely to complete screenings and less likely to report distrust in the health system.

Screening 52

Screening Insurance Primary Care Referral 52

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

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

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

Davos Alzheimer’s Collaborative Healthcare System Preparedness (DAC-SP) aims to catalyze global healthcare system transformation, providing Alzheimer’s patients and their families quicker access to life-changing innovations and therapies. clinical consensus, financing mechanisms) and the organization (e.g.,

Primary Care 130

Primary Care Screening Healthcare Finance 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

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

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. Have a good week!

Primary Care 52

Primary Care Appointment Family Medicine DO 52

Vascular Physician

JULY 11, 2021

Raynaud phenomenon is more common in young women and in those with a family history. Evaluation begins with three screening questions: Are your fingers or toes unusually sensitive to cold? This usually includes a sudden onset of cold in digits on hands or toes followed by a three-color change from white to blue to red.

Referral 52

Referral Mental Health Patients Diagnose 52

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. From lab work to screenings, consistent care means catching problems before they escalate.

Primary Care 130

Primary Care Relationship PCP PCP 130

Permanente Medicine

JUNE 3, 2025

I practice family and sports medicine as part of the Southern California Permanente Medical Group here in Fontana, California. WM: Like you, I’m a family physician. When you put in that referral, how do we make sure that that patient walks out with the specialty appointment versus phone tag. You’re all set.

IT 52

IT Patient-Centered Patients Medical 52

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

SEPTEMBER 7, 2023

So my family is from Maui and were impacted by the wildfires, so I really appreciate this. Alex: How is your family doing? My family’s also from Maui. And her dad’s family, the Makekaus family, which is based in Lahaina, and we actually visited their grave sites there, when we were there a few years ago.

Patient-Centered 129

Patient-Centered IT Patients Clinic 129

GeriPal

FEBRUARY 22, 2024

Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here ). We saw that around 60% of people were screening positive for depression in the last month before death. Or is it that I’m just not screening? That’s a lot.

Mental Health 122

Mental Health Patient-Centered Illness Screening 122

GeriPal

JULY 21, 2022

Often the work of the certified driving rehab specialist is to assess the older drivers goals, assess prognosis for driving, and help the family navigate discussions around driving cessation (hmmm…sounds like an approach to family meetings). Were those people self referring, or family members calling you asking? Eric: Yeah.

IT 102

IT Family Families Diagnosis 102

GeriPal

FEBRUARY 6, 2025

How should we screen for cognitive impairment? Who do you think we should be screening and how should we be screening them for these symptoms? Well, so I guess it depends on what you say screening. That screening influences kind of further treatment, actually, probably more importantly, patient outcomes.

Primary Care 95

Primary Care Diagnosis Screening IT 95

GeriPal

JUNE 5, 2025

The obstacles hindering referrals to palliative care services. We also take a dive into these 2 articles that Connie first authored: Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. So we see a lot of problems with symptom management, a lot of family conflict.

Referral 78

Referral Nurse Practitioner Consulting Board-Certified 78

GeriPal

APRIL 6, 2023

It is a screening? That’s why we use the terms assessment and intervention and we think of assessment as a skill of a very advanced skill that chaplains have of doing an in-depth evaluation of a patient or family member, and then the interventions should certainly follow naturally from that. I guess FICA is not as cool as SKY.

IT 99

IT Patient-Centered Families Family 99

GeriPal

FEBRUARY 15, 2024

Eric: Well, what are the odds that two family members focus on a similar topic and do research together? laughter] Alex: We love the family theme. So one of the big pieces of this is that idea of a referral at a second time when they’re less overwhelmed and stressed to figure out what happened. It works really well for us.

Community 114

Community Transportation IT PCP 114

GeriPal

OCTOBER 27, 2022

So if you can think about certain decisions like continuing to screen for certain cancers like colon cancer or breast cancer, or how strict you should control diabetes or blood pressures. We know that a lot of times with cancer screening, you don’t actually get benefits right away and it can cause potential harms right away.

IT 95

IT Clinic Screening Patients 95

GeriPal

MARCH 10, 2022

The Lived Experience of Providing Feeding Assistance to a Family Member with Dementia. Whereas the home with the low rate of feeding tube use involved families in decision making. So we looked at hospital referral regions, and we looked at high- and low- intensity regions. Archives of Internal Medicine 2010. Rehabbed to Death.

Nurse Practitioner 60

Nurse Practitioner Hospital Family Families 60

GeriPal

AUGUST 24, 2023

Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches. But once I got into medicine, I found myself attracted to the field of psychiatry.

Patient-Centered 98

Patient-Centered Patients IT Illness 98

GeriPal

FEBRUARY 24, 2022

We see our patients and our families throughout the illness trajectory into the hospital. It’s hard for your family to know. Juliet: Because even in the ICU, they’ll often have multiple meetings just to try and help a family move along before they can make a decision. It’s part of our family mythology.

Illness 98

Illness Patient-Centered IT Patients 98

GeriPal

JULY 20, 2023

She sought me out to come and tell me a story because about 10 years earlier, she and her family, their loved one was dying in a hospital in Florida and they tried to access palliative care and they couldn’t get the doctor to refer them to palliative care. I think you’re a loving family doing the best you can.”

Telemedicine 73

Telemedicine Telehealth Patient-Centered Board-Certified 73