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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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An Open Letter to Robert F. Kennedy, Jr. On Why Integrated Care Should Be a Cornerstone of the HHS Agenda

Integrated Care News by CFHA

At the Collaborative Family Healthcare Association (CFHA), we see your agenda aligning with ours in powerful ways. It moves away from fragmented systems, provides alternatives to medication-only treatment paths, and leads patients to practical pathways for healing—whether for anxiety, diabetes management, depression, or addiction.

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The Impact of Integrated Care on Healthcare Utilization and Costs: Evidence from the Kansas Health Homes Medicaid Program [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

Context: Individuals with complex conditions—those with multiple physical, mental, or behavioral health conditions--require numerous health and social services that are not effectively co-delivered by the current healthcare system. Additionally, we found a statistically significant reduction in PMPM Kansas Medicaid costs.

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Implementation of a novel linkage of primary care electronic medical record data with hospital data in South Eastern Ontario [Big data]

Annals of Family Medicine

Context: Currently, primary care data, community data, and hospital data are not linked in Ontario, resulting in a disconnect in continuity of care. 1072 patients with COPD were identified within the merged dataset, 50% of whom visited the ED within two years. Following patient review by clinician, 77 patients were deemed eligible.

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Agentic AI In Healthcare

The Medical Futurist

This trend is likely to equally impact healthcare leaders, and they will have to manage a new type of collaboration. They are quite specific in their abilities and, in healthcare, can serve as assistants who summarise the latest medical research and provide advice for additional reading. We consider such collaborations in this article.

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“The physician–patient encounter is health care’s choke point” -NEJM

A Country Doctor Writes

Its basic argument was that it isn’t sustainable to only see patients one by one in traditional doctor visits. I thought of it the other day when I put together a presentation about Galileo’s way of interacting with patients. 1) Healthcare is not at all customer centered.

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From Numbers to Names: How Concierge Care is Redefining the Doctor-Patient Experience

Concierge Choice Physicians

For medical professionals and those working in healthcare, the article was grim. Time constraints and pressure on physicians, leading to a decay in the doctor-patient relationship, have eroded trust. Physicians, particularly primary or family care doctors, value the doctor-patient relationship too. But what can be done?

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