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Compass Rose for Generating Community-based Referrals via Epic: Best Practices and Lessons Learned [Social determinants and vulnerable populations]

Annals of Family Medicine

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.

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Evaluation of Universal Food Insecurity Screening in the Primary Care Setting [Social determinants and vulnerable populations]

Annals of Family Medicine

The American Academy of Pediatrics recommends universal screening; however studies have found inconsistencies in screening of FI, documentation of FI, and referral to appropriate resources. Population Studied Families of children ages 0-18yo at an urban pediatric primary care mobile medical clinic serving families in Washington, D.C.

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Optimizing Medical Legal Partnerships for sustainable public funding through the tele-legal model [Mixed methods research]

Annals of Family Medicine

Descriptive analysis utilized primary legal record and secondary electronic health record sources. Setting or Dataset: Clinics: AF Williams Family Medicine, Lowry Internal Medicine; EPIC data; legal records. Nine focus groups were conducted and recorded, using semi-structured interviews.

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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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Adoption, implementation, and impact of a Diabetes Navigator program based in primary care [Diabetes and endocrine disease]

Annals of Family Medicine

A retrospective cohort study design was utilized to assess changes in A1c levels over the course of one year pre-enrollment and one year post-enrollment, comparing enrolled and not enrolled patients; a mixed effects interrupted time series model was employed for analysis.

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Risks and Needs: Lessons Learned from Assessing Patients Willingness to Receive Help for Social Risks in Primary Care [Social determinants and vulnerable populations]

Annals of Family Medicine

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.

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Ambulatory Behavioral Health Referral Patterns in the Setting of Chronic Medical Conditions [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

Early identification and intervention in behavioral aspects of chronic diseases leads to improved function with decreased healthcare utilization, yet we know little about referral patterns for behavioral support of chronic disease. 88% (n= 11,483) of BH referrals were created for the management of a mental health condition.

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