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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. Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization.

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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

A retrospective cohort study design was utilized to assess changes in A1c levels over the course of one year pre-enrollment and one year post-enrollment, comparing enrolled and not enrolled patients; a mixed effects interrupted time series model was employed for analysis.

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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.

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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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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.

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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.

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Combating Food Insecurity in Minnesota

Minnesota Academy of Family Physicians

Streamline Referrals: Utilize technology like the Hunger Vital Signs tool and the Minnesota Food Helpline to connect patients directly to mobile food units, emergency food programs or Supplemental Nutrition Assistance Program (SNAP) enrollment services. Park Nicollet Health Services combines nutrition education with SNAP referrals.