Annals of Family Medicine

NOVEMBER 20, 2024

Instrument: The discussion guide included questions on 1) identifying shared social care priorities across the three groups, and 2) describing best practices, facilitators, and barriers around screening and referral for social needs learned from existing and past collaborative models.

Community 130

Community Diabetes Referral Screening 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Diabetes management (DM) for patients with Type 2 Diabetes (T2D) can be hindered by non-medical, health-related social needs. Conclusions: Common barriers to providing DM in the context of social needs focused on limitations related to addressing the social needs themselves rather than adjusting diabetes management strategy.

Primary Care 130

Primary Care Diabetes Management Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Adults with T2D often face unmet social needs, such as food insecurity, compounding the challenges associated with their engagement in disease management interventions. Results: Social and economic factors, such as housing instability and limited income, presented significant barriers to management of T2D and intervention engagement.

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

PEMBlog

MAY 20, 2025

Yes, and so thinking about these imaging modalities, I keep coming back to the fact that most of the time when we’re ordering one, it’s because we’re thinking about what’s next from a management standpoint for the patient. Another recommendation that I have is regarding transport calls.

Families 102

Families Family Hospital Patient-Centered 102

GeriPal

JUNE 12, 2025

And sort of a few years ago, we would sometimes see referrals a bit later than we would have liked. We are Seeing referrals at an earlier time point, especially at a point that I feel that I can really help a patient. Is it normally the oncologist who’s making the referrals to you or do they come from people outside of oncology?

Patient-Centered 102

Patient-Centered Referral Patients IT 102

GeriPal

FEBRUARY 15, 2024

They weren’t hurt, they didn’t need transport, and we were seeing the same people over and over again. But what was really interesting is the transport to the hospital was actually going down in their system. Same thing with kind of medication management. What do you think of that?” Eric: Oh, no.

Community 114

Community Transportation IT PCP 114

GeriPal

JANUARY 30, 2025

And I would say we weren’t doing training on symptom management, for example. And then there was a lot of stuff on coping and symptom management. We would make referrals to psycho oncology. I would make referrals to Joe as well as part of the team. Lynn 15:55 Well, it’s a good. And well skilled. So it matters.

Telehealth 105

Telehealth Patient-Centered IT Patients 105