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A Multi-Sector Pilot Design in the Northeast Ohio QI Hub: Engaging Community Based Organizations to Advance Diabetes Equity [Health care disparities]

Annals of Family Medicine

Population Studied: We conducted focus groups, key informant interviews, and in-depth interviews with leaders from ODM, CBOs, and regional health systems, triangulated with thematic review of community health needs assessments. Setting: Northeast Ohio.

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Pilot Testing of the Treatment Burden Screening in Diabetes Tool in Primary Care [Multimorbidity]

Annals of Family Medicine

Context: Nearly all patients with type 2 diabetes have comorbid chronic conditions, adding complexity to self-management. The 13 clinician participants felt comfortable discussing topics (92%), felt the TBSD revealed new information (44%), focused patient conversations (44%), and uncovered issues that don’t typically arise (32%).

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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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How to Improve Care for Patients With Multiple Chronic Conditions

Physician's Weekly

Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles. Even within practices, some staff members may not be aware of which patients require more proactive management due to multiple chronic conditions. Have open gaps in care or medications not filled.

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Using EMR data to describe administrative workload of primary care providers in Nova Scotia, Canada [Secondary data analysis]

Annals of Family Medicine

Context: Primary care providers in Canada face significant workload challenges, including managing prescriptions, referrals, and laboratory tests alongside patient visits. Outcome measures: Average number of prescriptions, referrals, and laboratory tests per encounters among primary care providers in Nova Scotia from 2007 to 2022.

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Multisector Health Equity Coordination in a Midwestern Primary Care Practice, 2022-2023 [Social determinants and vulnerable populations]

Annals of Family Medicine

Multisector coordination is critical for effective screening and referral initiatives. Objective: To assess the function and impact of a new role, a Health Equity Coordinator, on the reach of the social needs screening and referral program.

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The Evolution of Concierge Medicine: What 20 years in the industry have taught me

Concierge Choice Physicians

​By Wayne Lipton Managing Partner, Concierge Choice Physicians ​The Origin Story It was the early 1990s when I embarked on a career in concierge medicine. At one time it seemed concierge medicine was incompatible with a vertically integrated healthcare organization that relies on third party payers and referrals.