Remove Medical Remove Patients Remove Referral Remove Utilities
article thumbnail

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. We also assessed patterns of social risks and need for assistance among our patient populations. Of those patients with an episode (i.e.,

Referral 130
article thumbnail

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
Insiders

Sign Up for our Newsletter

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

article thumbnail

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.

article thumbnail

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.

article thumbnail

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.

article thumbnail

Ambulatory Behavioral Health Referral Patterns in the Setting of Chronic Medical Conditions [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

Context: Patients with chronic medical conditions (CCs) and behavioral comorbidities have lower quality of life and increased healthcare expenses. Our work builds a foundation for cost-effective workflows to support patients with multimorbidity. 8% (n= 1,146) were ordered for medical condition management.

Referral 130
article thumbnail

Addressing diabetes management in the context of social needs: a qualitative study of primary care providers [Diabetes and endocrine disease]

Annals of Family Medicine

Context: Diabetes management (DM) for patients with Type 2 Diabetes (T2D) can be hindered by non-medical, health-related social needs. family medicine, general internal medicine, endocrinology) affiliated with an academic medical center serving a diverse population in a mid-western metropolitan area.