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

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

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

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 115

Community Transportation IT PCP 115

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. Like, yeah, utilization of hospice has increased pretty well. Eric 21:49 Yeah.

Nurse Practitioner 78

Nurse Practitioner Referral Consulting Board-Certified 78