Annals of Family Medicine

NOVEMBER 20, 2024

Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach. Intervention/Instrument: Legal-needs screening tool. Descriptive analysis utilized primary legal record and secondary electronic health record sources.

Medical 130

Medical Referral Screening Internal Medicine 130

Annals of Family Medicine

NOVEMBER 20, 2024

At baseline, 79% of students had no previous training on HT, 94% felt it was important to receive this training, 68% reported knowing the health consequences of HT, 51% could identify red flags, 22% knew how to screen, and 16% knew referral resources.

Medical Student 130

Medical Student Education Medical Referral 130

Annals of Family Medicine

NOVEMBER 20, 2024

Outcome Measures: Assessment of tobacco use; Among patients with current tobacco use, provision of advice to quit, referral to tobacco cessation counseling and tobacco cessation medication orders. Referral to counseling (7.5% The difference was the largest for no SDOH risk (61%) vs. SDOH risk 3+ (51%), OR, 95% CI (1.5,

Primary Care 130

Primary Care Referral Electronics Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

Intervention/Instrument: Legal-needs screening tool. Clinics: AF Williams Family Medicine, Lowry Internal Medicine. Population Studied: Attributed patients of participating clinics; clinic staff; Colorado state agency staff.

Primary Care 130

Primary Care Medical Behavioral Health Services Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

SUD screening is not universally done in primary care (PC). In our institution, screenings are completed for patients ≥15 years during well visits; those not presenting for well visits and under 15 may represent missed opportunities. A score ≥2 constitutes a positive screen for possible substance misuse.

Primary Care 130

Primary Care Screening Referral Wellness Visit 130

Common Sense Family Doctor

MARCH 15, 2025

Michelle Rockwell and colleagues at the Carilion Clinic in Roanoke, Virginia, performed a sludge audit of their colorectal cancer (CRC) screening services in 2021 and 2022. In contrast, patients who reported no or minimal sludge were more likely to complete screenings and less likely to report distrust in the health system.

Screening 52

Screening Insurance Primary Care Referral 52

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Recognizing that health-related social needs drive health inequities, healthcare settings are increasingly beginning to screen and refer patients for social needs. Yet, many patients who screen positive for social needs decline to be referred to resources or do not have their needs resolved.

Primary Care 130

Primary Care Screening Patients Referral 130

Integrated Care News by CFHA

MAY 1, 2025

When used intentionally, AI can help us: draft progress notes or referral letters, suggest evidence‑based interventions or psycho‑educational handouts, and organize task lists, reminders and teaching materials so we can focus on patients and learners. Administrative overload fuels burnout and pushes us away from our patients. Traylor, D.

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Annals of Family Medicine

NOVEMBER 20, 2024

Electronic risk assessment and communication may enhance screening and prevention, but patient perspectives are understudied. Elevated-risk individuals in Arms 2/3 were referred to genetics/screening services. Context Few affected by hereditary cancer syndromes know their cancer risk.

Screening 130

Screening Patients Referral Families 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: The rise in social needs screening in primary care settings has led to questions about program design and implementation strategies. Multisector coordination is critical for effective screening and referral initiatives.

Primary Care 130

Primary Care Referral Screening Patient-Centered 130

Annals of Family Medicine

MAY 27, 2025

A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment. DCA screening was completed in 1,808 (10.8%) of 16,708 eligible visits. Screening workflows were tailored to each clinic.

Primary Care 130

Primary Care Screening Referral Clinic 130

Medical Xpress

FEBRUARY 8, 2023

In a first-of-its-kind study, researchers at RCSI University of Medicine and Health Sciences have found that a school-based screen for mental health problems, combined with a referral system, can be effective at improving and protecting the mental health of adolescents.

Mental Health 75

Mental Health Screening Referral IT 75

Annals of Family Medicine

NOVEMBER 20, 2024

referral networks, technology infrastructure) to drive the transformation needed to facilitate early detection for cognitive impairment in primary care. Results The CFIR-based implementation evaluation highlighted the importance of alignment between contextual factors at the system level (e.g.,

Primary Care 130

Primary Care Screening Healthcare Finance 130

Minnesota Academy of Family Physicians

FEBRUARY 20, 2025

Through food pharmacies, food insecurity screenings and innovative community partnerships, health care providers are ensuring patients get the nourishment they need to thrive. 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 Families Family 52

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

Physician's Weekly

JUNE 13, 2025

Physicians may participate in more traditional community engagement venues such as community health fairs or organizing screenings, providing educational workshops on nutrition exercise and disease prevention or helping facilitate small group chronic disease management.

Chronic Disease Management 52

Chronic Disease Management Community Chronic Disease Education 52

Annals of Family Medicine

MARCH 24, 2025

Nonphysician health workers delivered the comprehensive package of interventions, which included annual screening for cardiovascular risk factors, structured lifestyle modification sessions, referral to a primary health care facility for individuals with established risk factors, and active follow-up to evaluate self-care adherence.

Families 130

Families Family Management Referral 130

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: Adults (≥18 years) who receive care at an affiliated clinic, screen positive for food insecurity, have a T2D diagnosis, and an A1c level > 7.5%. All participants are referred to receive free produce ("standard of care").

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

Noreta Family Medicine

MARCH 26, 2025

We are dedicated to staying connected with our patients, ensuring they are up-to-date with follow-up appointments, preventive screenings, referrals, medication refills, and any other care needs. At Noreta, we believe that care doesn’t stop when you walk out the door. You know DPC is working when ….patients

Primary Care 52

Primary Care Appointment Family Medicine DO 52

Vascular Physician

APRIL 22, 2024

Benefits of Vascular Ultrasound Undergoing a vascular ultrasound can provide a variety of benefits to individuals who have been diagnosed with a vascular condition or who are interested in using it as a screening tool. Some of these benefits include: Detecting blood clots in the deep veins of the body, such as the legs, (DVT).

IT 52

IT Diagnose Specialization Healthcare 52

The Physicians Foundation

AUGUST 15, 2024

The clinic offers referrals to specialists, conducts free cancer screenings, provides medication vouchers and engages in extensive public health education efforts. His dedication to this cause should serve as an inspiration to the entire medical community.”

Primary Care 40

Primary Care Community Chronic Disease Management Education 40

Vascular Physician

JULY 11, 2021

Evaluation begins with three screening questions: Are your fingers or toes unusually sensitive to cold? If the symptoms are extremely debilitating, or cause ulceration of the tips of fingers or toes, pharmacological therapy and referral to a rheumatologist to look for autoimmune disease causes may also be considered.

Referral 52

Referral Mental Health Patients Diagnose 52

Blood, Sweat, and Tears

MAY 24, 2022

Sister N pointed to the screen with a blood pressure reading of 180/110. But I was glad no one needed referral. The phone rang, a referral from a clinic so I left to take the call. What if theres gangrene” Sister N’s direct tone was direct and stern. “Bheka iBP yakho baba. When last have you checked your BP?

Referral 52

Referral Community Patients Specialization 52

Edge Family Medicine

APRIL 10, 2025

From lab work to screenings, consistent care means catching problems before they escalate. Coordinated Specialist Referrals Your PCP is your guide through the larger healthcare system. If you need a specialist, they can make informed referrals and help you navigate next steps — ensuring continuity and clarity.

Primary Care 130

Primary Care Relationship PCP PCP 130

Permanente Medicine

JUNE 3, 2025

When you put in that referral, how do we make sure that that patient walks out with the specialty appointment versus phone tag. Let’s get this important cancer screening test done. They’ll also pen the rheumatology referral. We’ve been enhancing that and we share that with the other markets. I love that.

IT 52

IT Patient-Centered Patients Medical 52

GeriPal

JANUARY 18, 2024

After discussing screening options for substance use disorder, we go on to talk about both the treatments for it and the issues that arise. So, we are not screening for substance use in cancer care, so we don’t get good estimates among people with cancer, which is really how we would prefer to ask the question. Katie: Yeah.

Illness 136

Illness Patient-Centered Screening Clinic 136

GeriPal

FEBRUARY 22, 2024

Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here ). We saw that around 60% of people were screening positive for depression in the last month before death. Or is it that I’m just not screening? That’s a lot.

Mental Health 122

Mental Health Patient-Centered Illness Screening 122

GeriPal

FEBRUARY 6, 2025

How should we screen for cognitive impairment? Who do you think we should be screening and how should we be screening them for these symptoms? Well, so I guess it depends on what you say screening. That screening influences kind of further treatment, actually, probably more importantly, patient outcomes.

Primary Care 96

Primary Care Diagnosis Screening IT 96

GeriPal

SEPTEMBER 7, 2023

Because a lot of my colleagues, who are like transplant coordinators for example, are asking, “Can you help us better screened for which older adults would be fit enough to go for transplant? There’s really no added extra resource or time that the coordinators really need to put to doing the screening, themselves.

Patient-Centered 129

Patient-Centered IT Patients Clinic 129

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. And what does that referral process look like? So that part we know and I.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78

GeriPal

JULY 21, 2022

Is there a screening tool that we can use, or just questions that you ask older adults around driving safety? We and many others have tried to come up with a short, validated screening tool. ” So a lot of times it’s a referral back to their primary care, to a specialist-. “How are things going?”

IT 102

IT Family Families Diagnosis 102

GeriPal

FEBRUARY 15, 2024

So one of the big pieces of this is that idea of a referral at a second time when they’re less overwhelmed and stressed to figure out what happened. In addition to the grab bars, we have also helped train the EMS professionals in different lenses about screening. We do that in medicine all the time. Katie: I was going to jump in.

Community 115

Community Transportation IT PCP 115

GeriPal

OCTOBER 27, 2022

So if you can think about certain decisions like continuing to screen for certain cancers like colon cancer or breast cancer, or how strict you should control diabetes or blood pressures. We know that a lot of times with cancer screening, you don’t actually get benefits right away and it can cause potential harms right away.

IT 95

IT Clinic Screening Patients 95

GeriPal

APRIL 6, 2023

It is a screening? And so then it would be nice to have those other than the chaplains, be aware of the spiritual component and then just ask some basic screening questions. And the screening questions would just allow you to know that. Who does the assessments, who does screening? I guess FICA is not as cool as SKY.

IT 99

IT Patient-Centered Family Families 99

GeriPal

AUGUST 24, 2023

Our early studies were looking at things like, desire for death, and syndromal depression, and screening for depression and anxiety, and will to live. So I mean, I had referrals from as far as Canadian Arctic North, of people who were interested in doing dignity therapy.

Patient-Centered 98

Patient-Centered Patients IT Illness 98

GeriPal

MARCH 10, 2022

So we looked at hospital referral regions, and we looked at high- and low- intensity regions. Ruth: Very strong odor, devoid of furniture, broken screens … Eric: So it was the physical environment and … Ruth: Physical environment. But what we wanted to do was to control for regional … what’s that called?

Nurse Practitioner 60

Nurse Practitioner Hospital Family Families 60

GeriPal

FEBRUARY 24, 2022

Get the hospice referral. So I’m just going to share on my screen. So you need to do them in order. And I think a lot of times when we get consulted, we’re asked for the outcome, right? We want to get the DNR, right? So I created a Venn diagram for a JAGS editorial about a forthcoming article.

Illness 98

Illness Patient-Centered IT Patients 98