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Development and Testing of an Interoperable e-care Plan for Person-Centered Care Planning for Multiple Chronic Conditions [Multimorbidity]

Annals of Family Medicine

Background: Multiple chronic conditions (MCC) the most common condition seen in practice are present in 33% of adults and 80% of individuals age > 65. The emergence of FIHR enables the development of interoperable apps to facilitate comprehensive, shared care planning. Results of testing and evaluation will be presented.

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A Multisite CFIR Study of Readiness to Implement Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) [Dissemination and implementation research]

Annals of Family Medicine

Population Studied: Primary care team members involved in high blood pressure management. Intervention: COACH — a patient-facing decision support tool integrated into the electronic record. Consideration of the care team workflows (i.e.,

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Validation of the "Proactive" self-assessment tool for older people to identify their own risk of functional decline [Screening, prevention, and health promotion]

Annals of Family Medicine

Population studied: Individuals aged 65 years and older recruited in primary care clinics or senior residences. A single participant with severe loss of autonomy found Proactive less useful as it did not provide him with any new information. Setting: Community-based.

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Health Care Homes Certification: Advancing Primary Care in MN

Minnesota Academy of Family Physicians

Minnesota’s Health Care Homes (HCH) certification program is transforming primary care by recognizing clinics that prioritize patient-centered, team-based care. This free and voluntary program offers significant benefits to clinics, health care professionals and patients across the state.

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Gathering Family Perspectives on Integrated Care

Integrated Care News by CFHA

The four core functions of primary care—the 4Cs (first contact, comprehensiveness, coordination, and continuity)—are fundamental to achieving high-quality care. Given the complex interplay among these functions, gathering patient perspectives on those core functions seems key to effectively operationalizing and measuring them.

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On a Mission: A Nurse’s Quest to Identify Hereditary Cancer Risk in All Patients

Myriad Genetics

Enhancing Hereditary Cancer Screening at NMC Every day, every patient. Chelsea has spent the better part of a decade developing and implementing a program that ensures everyone who walks through the doors of her department at the Northwestern Medical Center (NMC) in St. Helping patients identify whether they are at high risk is care.

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Governor’s 2025-26 May Revision Proposes Major Cuts to Healthcare and Undermines Medi-Cal Expansion Commitments

California Academy of Family Physicians (CAFP)

Key Health Care Budget Proposals: Proposed Medi-Cal Cuts and Enrollment Changes Medi-Cal, California’s Medicaid program, is typically funded through a partnership between the state and the federal government. State-only Medi-Cal has allowed California to expand access to health care for populations excluded by federal policy.