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

Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Population Studied: 13 urban and rural primary care practices located across Mayo Clinic sites in Minnesota, Wisconsin, and Florida.

Primary Care 130

Primary Care Referral Routine Screenings Patients 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). Outcome Measure: Themes that emerged from interviews.

Primary Care 130

Primary Care Diabetes Management Provider 130

GeriPal

FEBRUARY 15, 2024

They weren’t hurt, they didn’t need transport, and we were seeing the same people over and over again. But what was really interesting is the transport to the hospital was actually going down in their system. I think once someone becomes kind of a high-utilizer, it’s a slippery slope. What do you think of that?”

Community 114

Community Transportation IT PCP 114

GeriPal

JUNE 5, 2025

The obstacles hindering referrals to palliative care services. Practical strategies to overcome these barriers and enhance care. 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.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78