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Pilot Testing of the Treatment Burden Screening in Diabetes Tool in Primary Care [Multimorbidity]

Annals of Family Medicine

Context: Nearly all patients with type 2 diabetes have comorbid chronic conditions, adding complexity to self-management. A tool to more efficiently relay points of patient-perceived treatment burden during a primary care visit may lead to more patient-centered care plans and improved outcomes.

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Risks and Needs: Lessons Learned from Assessing Patients Willingness to Receive Help for Social Risks in Primary Care [Social determinants and vulnerable populations]

Annals of Family Medicine

Context: In May 2023, Mayo Clinic implemented a revised screening tool to assess social determinants of health (SDOH) for its patients. Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Study Design and Analysis: Descriptive analysis of secondary data.

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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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Flipping the Script: A Design thinking Approach to Enhancing Interprofessional Collaboration in Primary Care [Research capacity building]

Annals of Family Medicine

The challenges faced stem from the uncertainty and complexity of redefining professional roles and scopes of practice, as well as the skills needed to effectively work together and coordinate patient care as a cohesive team. Setting: One multidisciplinary primary care team in the province of Quebec, Canada.

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Developing actionable strategies to implement evidence-based breast cancer follow-up in primary care using codesign [Dissemination and implementation research]

Annals of Family Medicine

Objective: Describe codesign methods to implement actionable strategies for breast cancer survivorship follow-up care. The resulting intervention was a care quality improvement project that engaged practice champions (n=18) from 6 primary care practices in bi-weekly virtual facilitation and monthly learning collaboratives over 3 months.

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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.