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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. A Compass Rose episode was automatically generated in the patient’s medical record in Epic if patients indicated that they had at least one of the four social risk factors on the screening tool.

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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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Optimizing Medical Legal Partnerships for sustainable public funding through the tele-legal model [Mixed methods research]

Annals of Family Medicine

Context: Medical legal partnerships (MLP) are an effective intervention for social determinants of health, like housing, education, and employment status. Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach.

Medical 130
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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

Few medical schools include this topic in their curriculum, and it is not standardized in undergraduate medical education. Objective Assess how a lecture on HT during a 4-week family medicine (FM) clerkship impacts medical student knowledge, skills, and attitudes regarding HT. Population Studied FM clerkship students.

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

Annals of Family Medicine

Context: In Ontario, multiple organizations operate under a ‘boutique’ medicine model where patients pay a block or annual fee to access primary care services. Little is known about the characteristics of physicians and patients participating in boutique clinic practice models. Study Design and Analysis.

Clinic 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

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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Economic analysis of virtual Medical Legal Partnership model [Economic or policy analysis]

Annals of Family Medicine

Context: Despite copious evidence of the positive health impact of Medical legal partnerships (MLP), public funding remains subject to economic arguments seeking return on investment (ROI) from the perspective of public payers. Population Studied: Attributed patients of participating clinics; clinic staff; Colorado state agency staff.