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. Setting or Dataset: We used data from Epic on social needs screening and Compass Rose utilization.

Referral 130

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

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. Outcome Measures Percent eligible families that completed a food insecurity screening. 24% who were FI in 2022 became not FI in 2023.

Primary Care 130

Primary Care Screening Referral 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. Objective: To assess the impact of a question on need for assistance with social risk factors identified through routine screening. 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

Objective: Evaluate the economic impact of receiving tele-legal services from Medicaid’s perspective with regard to a) fee- for service (FFS) total cost of care; b) FFS cost of primary care; c) utilization for FFS primary care; d) utilization for FFS and capitated behavioral health (BH) and BH emergency department encounters.

Primary Care 130

Primary Care Medical Behavioral Health Services Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

A recent review of national diabetes treatment guidelines recommended adjustments to DM to reduce financial strain (eg, selecting lower cost medications), as well as directly intervening in response to an identified social need (eg, referral to a community-based service).

Primary Care 130

Primary Care Diabetes Management Provider 130

Minnesota Academy of Family Physicians

FEBRUARY 20, 2025

Recognizing the critical connection between access to nutritious food and health, health care systems across Minnesota are taking innovative steps to address food insecurity. Food Insecurity Screenings: Hennepin Health Care has integrated the Hunger Vital Signs tool into routine screenings to identify and support at-risk patients.

Family Physician 52

Family Physician Community Family Families 52

GeriPal

FEBRUARY 15, 2024

So what we found is up to 30% of people would call 911 again for a fall, and of those calls, some people became very high-utilizers and so they would call 911 over and over again. I think once someone becomes kind of a high-utilizer, it’s a slippery slope. I had no idea that people were calling 911 that much sometimes.

Community 116

Community Transportation IT PCP 116