Annals of Family Medicine

NOVEMBER 20, 2024

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

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

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.

Primary Care 130

Primary Care Referral Routine Screenings Patients 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Diabetes management (DM) for patients with Type 2 Diabetes (T2D) can be hindered by non-medical, health-related social needs. Some providers felt that even with medication assistance programs and utilizing less expensive medications, medications and testing supplies remain a financial burden to their diabetic patients.

Primary Care 130

Primary Care Diabetes Management Provider 130

GeriPal

FEBRUARY 15, 2024

The insight started when Carmen, an orthopedic surgeon-researcher, and Katie, a physical therapist- researcher participated in ride-alongs with EMS providers to patient’s homes. Going into patient’s homes was eye opening. It was eyeopening to see patients in their own home. And so that really triggered my interest.

Community 114

Community Transportation IT PCP 114

GeriPal

JUNE 5, 2025

The obstacles hindering referrals to palliative care services. We also take a dive into these 2 articles that Connie first authored: Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. Practical strategies to overcome these barriers and enhance care. Thank you so much.

Referral 78

Referral Nurse Practitioner Consulting Board-Certified 78

GeriPal

JULY 6, 2023

This includes transportation, driver’s license, parks, volunteerism, housing, and of course health and human services. It’s that first place that you start where it may not be the AAAs job, but we’ve organized where they have to have the partnerships and they know who the players are and they know who to make a referral to.

Community 89

Community Nurse Practitioner Provider IT 89