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Changes in patterns and referrals of Nova Scotians seeking mental health care through 2-1-1 Referral Service [Health care services, delivery, and financing]

Annals of Family Medicine

Context 2-1-1 is a designated phone help line in Canada and the US that provides referrals for individuals to local government and community-based services for a wide variety of needs, including social, health care, and mental health services. 2-1-1 Nova Scotia has operated since 2013 as a nonprofit that offers 24/7 assistance.

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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

The workflows for use of the tool, including enrollment criteria, patient outreach, and use of the Findhelp platform for community-based referrals were standardized; however, each pilot site had different staff members responsible for using the tool.

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A Multi-Sector Pilot Design in the Northeast Ohio QI Hub: Engaging Community Based Organizations to Advance Diabetes Equity [Health care disparities]

Annals of Family Medicine

Instrument: The discussion guide included questions on 1) identifying shared social care priorities across the three groups, and 2) describing best practices, facilitators, and barriers around screening and referral for social needs learned from existing and past collaborative models.

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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

Intervention: The Navigator, a diabetes-trained medical scribe, contacted patients by phone to inform them about the Stanford Diabetes Care Program (SDCP) and engaged them in shared decision-making for necessary referrals. Results: We identified 176 patients with recent hemoglobin A1c ≥8%.

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Ambulatory Behavioral Health Referral Patterns in the Setting of Chronic Medical Conditions [Behavioral, psychosocial, and mental illness]

Annals of Family Medicine

Early identification and intervention in behavioral aspects of chronic diseases leads to improved function with decreased healthcare utilization, yet we know little about referral patterns for behavioral support of chronic disease. 88% (n= 11,483) of BH referrals were created for the management of a mental health condition.

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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

Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. 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.

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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

Referrals were not placed for patients being discharged to another facility or who already had an outside primary care provider. A referral order was created in the hospital system’s electronic health record to the "Hospital Discharge Clinic," and referrals were placed for urgent (7-day) or routine (14-day) TCM appointments.