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

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

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

Annals of Family Medicine

NOVEMBER 20, 2024

Intervention: Randomized controlled trial testing the effect of 2 distinct interventions on A1c for adults (≥18 years) who screen positive for food insecurity, have a T2D diagnosis, and an A1c level > 7.5%: a 6-week culinary and nutrition education class and community referrals to address unmet social needs.

Primary Care 130

Primary Care Diabetes Management Provider 130

Physician's Weekly

JUNE 22, 2025

High social risk burden in adults with IBD drives emergency care use and medication gaps—spotlighting the urgent need for social screening in clinical practice. A greater social risk burden was linked to increased odds of unplanned healthcare utilization (severe vs none: OR, 3.5 [1.2-10.2])

Healthcare 52

Healthcare Transportation IT Insurance 52

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

The Physicians Foundation

MAY 20, 2025

The Physicians Foundation announces the 2025 recipient of the Drivers of Health (DOH) Fellowship Program, urges physicians to screen patients for DOH BOSTON, May 21, 2025 – Today, The Physicians Foundation reinforces its efforts to help physicians address drivers of health (DOH) to improve a person’s overall health.

Chronic Disease 40

Chronic Disease Screening Transportation Patient-Centered 40