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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. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

Referral 130
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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.

Community 130
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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

Intervention: The Navigator, a diabetes-trained medical scribe, contacted patients by phone to inform them about the Stanford Diabetes Care Program (SDCP) and engaged them in shared decision-making for necessary referrals. Results: We identified 176 patients with recent hemoglobin A1c ≥8%.

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Evaluating the Impact of a Longitudinal Clerkship Lecture on Medical Students Knowledge and Response to Human Trafficking [Education and training]

Annals of Family Medicine

Training students to provide care and respond using a trauma informed approach can help ensure our healthcare sites are places of healing and not re-traumatization. Knowledge of referral resources was 89% post session, 61% at 3 months, 78% at 6 months, and 61% at 12 months.

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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
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Practice patterns of Ontario physicians working in 'boutique' medical clinics [Economic or policy analysis]

Annals of Family Medicine

Three boutique clinics in Ontario were identified using publicly available information. Results: Significant differences were seen in patient demographics, fees, and referral patterns amongst boutique clinic practices compared to Toronto Central LHIN and Ontario physicians.

Clinic 130
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Flipping the Script: A Design thinking Approach to Enhancing Interprofessional Collaboration in Primary Care [Research capacity building]

Annals of Family Medicine

We developed an approach to assist healthcare professionals in developing a tool aimed to informing about each team member areas of expertise and optimal care trajectories. The first section lists one health condition per page and explains how and when each health professional can be involved, and the referral process.