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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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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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Patient experience with Social Prescribing Program in Ontario, Canada [Social determinants and vulnerable populations]

Annals of Family Medicine

Context Social Prescribing (SP) is an approach to help individuals address their health and social needs wherein a healthcare practitioner refers patients to non-clinal services in the community. Models of SP vary, and the experience of patients across these models is less known.

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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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Factors associated with patients' experience of access to their primary health care clinic: a multilevel analysis [Health care services, delivery, and financing]

Annals of Family Medicine

Context: Understanding patients’ experience accessing primary health care (PHC) is necessary in order to move toward better service organization and more equitable PHC access. A total of 122,397 patients and 999 family physicians, 107 nurse practitioners and 411 administrative staff nested into 104 clinics answered the survey.

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Patient experiences navigating US healthcare with long-COVID - Part 3 of 3 [COVID-19]

Annals of Family Medicine

Context: For many patients with long-COVID, primary care is the first point of interaction with the healthcare system. However, beyond expressions of disempowerment, the patient’s perspective regarding the quality of long-COVID care is lacking. Patients described two areas of experiences.