Integrated Care News by CFHA

MAY 1, 2025

Evidence‑informed care was literally at his fingertips. When used intentionally, AI can help us: draft progress notes or referral letters, suggest evidence‑based interventions or psycho‑educational handouts, and organize task lists, reminders and teaching materials so we can focus on patients and learners. JAMA , 329(16), 1333–1336.

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives.

Primary Care 130

Primary Care Referral Screening Patient-Centered 130

Minnesota Academy of Family Physicians

FEBRUARY 20, 2025

Through food pharmacies, food insecurity screenings and innovative community partnerships, health care providers are ensuring patients get the nourishment they need to thrive. Food Insecurity Screenings: Hennepin Health Care has integrated the Hunger Vital Signs tool into routine screenings to identify and support at-risk patients.

Family Physician 52

Family Physician Community Family Families 52

Physician's Weekly

JUNE 13, 2025

Community engagement allows physicians to broadly and collectively educate patients on important health topics, empowering them to make informed decisions about their health. This can be done by maintaining a directory of community resources and making referrals during patient visits.

Chronic Disease Management 52

Chronic Disease Management Community Chronic Disease Education 52

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: Adults (≥18 years) who receive care at an affiliated clinic, screen positive for food insecurity, have a T2D diagnosis, and an A1c level > 7.5%. All participants are referred to receive free produce ("standard of care").

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

The Physicians Foundation

AUGUST 15, 2024

The clinic offers referrals to specialists, conducts free cancer screenings, provides medication vouchers and engages in extensive public health education efforts. For more information about The Physicians Foundation’s Leadership Award Program, please visit physiciansfoundation.org/leadership-award-program.

Primary Care 40

Primary Care Community Chronic Disease Management Education 40

Edge Family Medicine

APRIL 10, 2025

From lab work to screenings, consistent care means catching problems before they escalate. Coordinated Specialist Referrals Your PCP is your guide through the larger healthcare system. If you need a specialist, they can make informed referrals and help you navigate next steps — ensuring continuity and clarity.

Primary Care 130

Primary Care Relationship PCP PCP 130

Permanente Medicine

JUNE 3, 2025

I just listened to the one on national cancer care that we’re doing, which was very informative and pretty impressive. The second thing that is different is access to information. When you put in that referral, how do we make sure that that patient walks out with the specialty appointment versus phone tag.

IT 52

IT Patient-Centered Patients Medical 52

GeriPal

JANUARY 18, 2024

After discussing screening options for substance use disorder, we go on to talk about both the treatments for it and the issues that arise. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Katie: Yeah. I have so many thoughts.

Illness 137

Illness Patient-Centered Screening Clinic 137

GeriPal

SEPTEMBER 7, 2023

And it’s with this information from the geriatric assessment that we can really create interventions, and so that’s something that Alex and I strongly believe that we should move forward with. There’s really no added extra resource or time that the coordinators really need to put to doing the screening, themselves.

Patient-Centered 130

Patient-Centered IT Patients Clinic 130

GeriPal

FEBRUARY 22, 2024

Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here ). It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. That’s a lot.

Mental Health 123

Mental Health Patient-Centered Illness Screening 123

GeriPal

JUNE 5, 2025

The obstacles hindering referrals to palliative care services. We also take a dive into these 2 articles that Connie first authored: Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. And what does that referral process look like? So that part we know and I.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78

GeriPal

FEBRUARY 15, 2024

It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. I mean, we work at a different part of the health system a lot of times, although we have acute care therapists who do the same thing, but the gap in information flow is similar.

Community 116

Community Transportation IT PCP 116

GeriPal

JULY 21, 2022

Is there a screening tool that we can use, or just questions that you ask older adults around driving safety? We and many others have tried to come up with a short, validated screening tool. I can get you guys that information. And then they can transfer that information to the specialist. “How are things going?”

IT 102

IT Families Family Diagnosis 102

GeriPal

OCTOBER 27, 2022

But we know from previous studies that a lot of older adults actually want this information, but might not feel comfortable bringing it up. So if you can think about certain decisions like continuing to screen for certain cancers like colon cancer or breast cancer, or how strict you should control diabetes or blood pressures.

IT 95

IT Clinic Screening Patients 95

GeriPal

APRIL 6, 2023

Alex Practice-PC Program Information: UCSF’s Practice-PC program is now accepting applications for the 2023-2024 year. It is a screening? And so then it would be nice to have those other than the chaplains, be aware of the spiritual component and then just ask some basic screening questions. I guess FICA is not as cool as SKY.

IT 99

IT Patient-Centered Families Family 99

GeriPal

MARCH 10, 2022

So we looked at hospital referral regions, and we looked at high- and low- intensity regions. Ruth: Very strong odor, devoid of furniture, broken screens … Eric: So it was the physical environment and … Ruth: Physical environment. ” Caroline: So we have done a multi-pronged approach using some of that information.

Nurse Practitioner 60

Nurse Practitioner Hospital Families Family 60

GeriPal

AUGUST 24, 2023

Our early studies were looking at things like, desire for death, and syndromal depression, and screening for depression and anxiety, and will to live. So I mean, I had referrals from as far as Canadian Arctic North, of people who were interested in doing dignity therapy. ‘I want everything.'”

Patient-Centered 98

Patient-Centered Patients IT Illness 98

GeriPal

FEBRUARY 24, 2022

And that kind of prognostic information can be just as valuable, really, to patients and their families planning as time-based information. Get the hospice referral. ” But I think what I’m trying to model is that we got some really valuable information, even though we have no decision. Those kinds of things.

Illness 98

Illness Patient-Centered IT Patients 98

GeriPal

JULY 20, 2023

So recognizing that the public health emergency was going to be declared over and all those temporary waivers were going to expire, the DEA actually put out a request for information about should it go back to life as it was, or should they potentially have some new rules or new flexibilities? What state are they in? Go ahead Eric.

Telemedicine 73

Telemedicine Telehealth Patient-Centered Board-Certified 73