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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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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. To date, there are less than a handful of economic analyses for MLP in the published literature.

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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. Descriptive analysis utilized primary legal record and secondary electronic health record sources. Nine focus groups were conducted and recorded, using semi-structured interviews.

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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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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. Study Design: Secondary data analysis of patient demographic, referral, and encounter-level data extracted from site eMR (Epic). 8% (n= 1,146) were ordered for medical condition management.

Referral 130
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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. Population Studied Families of children ages 0-18yo at an urban pediatric primary care mobile medical clinic serving families in Washington, D.C.

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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. Setting: Ambulatory clinics (e.g.,