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

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. Of those patients with an episode (i.e.,

Referral 130

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: To describe how primary care clinics have considered social needs in DM, and identify opportunities to support primary care clinics. Population Studied: Purposive sample of care team members (eg, physicians, social workers, diabetes educators, dietitians, community health workers).

Primary Care 130

Primary Care Diabetes Management Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Health-related social needs (HRSN), such as housing, food, and transportation, play a major role in overall patient health and well-being. ITS model- proportion of individuals who screened positive for at least one HRSN, aggregated by week. Logistic regression model- binary indicator for a positive screen.

Transportation 130

Transportation Screening Individual Primary Care 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

Kathleen 14:03 I mean, back to Cari’s, you know, what Cari was talking about, about financial barriers to palliative care services in the nursing home setting. Eric 14:32 So there’s financial disincentives for interdisciplinary palliative care teams. Like, yeah, utilization of hospice has increased pretty well.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78