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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

A recent inquiry within the CFHA community sought recommendations on implementing the Primary Care Behavioral Health (P CBH) model at a Federally Qualified Health Center (FQHC) that had received CCBHC Demonstration. Ensure that you engage in culture-building across the FQHC to maintain the primary care focus.

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Artificial Intelligence in Health Care

Integrated Care News by CFHA

That small win reminded me that artificial intelligence is already shaping the way our patients (and our families) search for health advice. Three reasons why learning Artificial Intelligence in health care may be a responsibility and not an option: 1. Evidence‑informed care was literally at his fingertips.

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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

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.

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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

We also assessed patterns of social risks and need for assistance among our patient populations. Population Studied: Three sites, representing 13 urban and rural primary care practices in Minnesota, Wisconsin, and Florida participated in the Compass Rose pilot. Of those patients with an episode (i.e.,

Referral 130
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Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care [Smoking cessation]

Annals of Family Medicine

Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Outcome Measures: Assessment of tobacco use; Among patients with current tobacco use, provision of advice to quit, referral to tobacco cessation counseling and tobacco cessation medication orders.

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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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Evaluation of Universal Food Insecurity Screening in the Primary Care Setting [Social determinants and vulnerable populations]

Annals of Family Medicine

The American Academy of Pediatrics recommends universal screening; however studies have found inconsistencies in screening of FI, documentation of FI, and referral to appropriate resources. Comparison of FI for paired patients in 2022 and 2023. Enrollment and referrals in food assistance programs.