Remove Information Remove Patients Remove Referral Remove Utilities
article thumbnail

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. We also assessed patterns of social risks and need for assistance among our patient populations. Of those patients with an episode (i.e.,

Referral 130
article thumbnail

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

Annals of Family Medicine

Context: Patients with diabetes who receive structured and integrated care have better control and outcomes; however, care may shift between multiple settings making coordination challenging. Outcome Measures: Number of patients engaged, resulting referrals, Navigator time per patient, and hemoglobin A1c measures across 2-years.

Insiders

Sign Up for our Newsletter

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

article thumbnail

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

Annals of Family Medicine

Objective: 1) Test the virtual model of MLP to achieve more favorable economies of scale 2) Develop a policy-informed lexicon for MLP to inform model development, D&I research, and improve data sharing across models to ultimately advance sustainable state-based funding for MLP. Intervention/Instrument: Legal-needs screening tool.

Medical 130
article thumbnail

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

Annals of Family Medicine

Context: Patients with chronic medical conditions (CCs) and behavioral comorbidities have lower quality of life and increased healthcare expenses. Our work builds a foundation for cost-effective workflows to support patients with multimorbidity. Among the completed encounters, the average days from referral to encounter was 27.2.

Referral 130
article thumbnail

A feasibility study of the Illuminate 360o approach for monitoring the implementation of a health system innovation [Mixed methods research]

Annals of Family Medicine

Objectives: We explored how to design a system to provide near real-time feedback on context and impacts to inform health system innovations; and how to operationalize data collection across diverse patient populations and providers. Study Design and Analysis: We used a mixed-method complexity-informed methodology.

Referral 130
article thumbnail

Offering genetic testing at the point of care may increase uptake

Medical Xpress

Genetic testing for hereditary cancers, such as breast, colon, pancreatic, and ovarian cancer, helps at-risk individuals understand their familial risk for these diseases and make informed decisions about next steps in care.

article thumbnail

Combating Food Insecurity in Minnesota

Minnesota Academy of Family Physicians

Through food pharmacies, food insecurity screenings and innovative community partnerships, health care providers are ensuring patients get the nourishment they need to thrive. Family physicians play a pivotal role in combating food insecurity, serving as trusted advocates for their patients and connecting them to essential food resources.