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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. Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida.

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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.,

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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. Objective: To describe how primary care clinics have considered social needs in DM, and identify opportunities to support primary care clinics.

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Integrated care for adults with complex needs: opportunities of case management in primary care to improve equity [Health care disparities]

Annals of Family Medicine

Setting/Population studied/Intervention: A case management program (CMP) for people with complex needs was implemented in four primary care clinics of an urban area. However, partnerships between primary care clinics and community-based organizations would deserve consideration in further research.

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Association between patient reported social risks and HOUSES index: A rural-urban comparison [Social determinants and vulnerable populations]

Annals of Family Medicine

Integration of patient reported social risk questionnaires in electronic health records allows for assessment of individual-level SES, but this data is frequently missing. A housing asset-based measure of SES (HOUSES) can provide individual-level SES without need for patient questionnaires. vs 3.4%, transportation risk 3.3%

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Relationship between Social Risks and Diabetes Metrics in a Large US Health System [Social determinants and vulnerable populations]

Annals of Family Medicine

Primary care settings may be an appropriate environment to address social risk factors, however much is not known about the characteristics of patient reported social risk among patients with diabetes in a general primary care setting. Context Type 2 diabetes impacts 11.3%

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Relationship between Social Risks and Colorectal Cancer Screening/Surveillance in a Large US Health System [Social determinants and vulnerable populations]

Annals of Family Medicine

Implementation of electronic health record SDOH questionnaires is more common in health care institutions and allows for individual-level assessment of social risk in a primary care setting. Significant differences may exist among screening and surveillance populations.

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