Our recipes are primers that will help you explore and implement care strategies to benefit your providers, patients, and practice. You can search for the available recipes by keywords, or browse using the filters below.

Improving Social Determinants of Health Assessments @ Boston Children’s Hospital Primary Care Network

This project with the Pediatric Physicians’ Organization at Children’s (PPOC) utilized a social  health needs assessment screening tool to improve primary care providers’ capacity to…

Innovators

  • Jane Bittner, MPH, CPH
  • Nicole Pelletier, MPH
  • Emily Trudell Correa, MPH, MS
  • Jonathan Hatoun, MD, MPH, MS
  • Sara Donahue, DrPH
  • Louis Vernacchio, MD, MSc

Creating Value for Communities by Investing in Housing @ LA County Department of Health

In 2012, LA County Department of Health Services addressed homelessness and associated poor health outcomes via a multi-pronged, comprehensive housing program called Housing for Health…

Innovators

  • Reshma Gupta, MD, MSHPM
  • Mark Ghaly, MD, MPH
  • Cheri Todoroff
  • Soma Wali, MD

Building Community Linkages to Address SDOH via eConsults @ Public Health System Los Angeles County Department of Health

This project utilized analysis of eConsults from a metropolitan county-level public services agency and its affiliated health centers to a community-based health and social services…

Innovators

  • Tony Kuo, MD, MSHS
  • Noel Barragan, MPH, MBA
  • Amelia DeFosset, MPH
  • Janina Morrison, MD, MPH

Improving Diabetes Care via Medical Assistants and Community Health Workers @ Northern California Community Health Centers

This project at a group of community health centers implemented a new medical assistant and community health worker-led diabetes care management program to study differential…

Innovators

  • Hector P. Rodriguez, MD, MPH
  • Mark W. Friedberg, MD
  • Arturo Vargas-Bustamante, PhD, MA, MPP
  • Xiao Chen, PhD
  • Ana E. Martinez, MPH
  • Dylan H. Roby, PhD

Improving Transition Care via EHR Hospital Use Data @ Northwestern Medicine Group Transitional Care Clinic

The Northwestern Medicine Group Transitional Care clinic (NMG-TC) seeks to reduce preventable re-hospitalization by implementing a model of intensive case management and integrated behavioral/medical healthcare…

Innovators

  • Joe Feinglass PhD
  • Celeste A. Mallama PhD MPH
  • Angela Rogers MPH, APN-CNP
  • Caroline Teter PA
  • Courtney Hurt LCSW
  • Christine Schaeffer MD

Improving Medication-Assisted Treatment for Opioid Use Disorder via Integrated Behavioral Health @ Rural FQHC in Oregon

Masters and doctoral level mental health clinicians are integrated onto primary health care teams to address the biopsychosocial needs of patients in medication assisted treatment…

Innovators

  • Rebecca E. Cantone, MD
  • Nicholas Gideonse, MD
  • Joan Fleishman, PsyD
  • Brian Garvey, MD, MPH

Employing Community Health Workers (CHWs) to Improve Population Health via the IMPaCT Model @ Penn Center for Community Health Workers

The IMPaCT (Individualized Management of Patient-Centered Targets) model is a standardized, scalable, evidence-based Community Health Worker (CHW) intervention proven to improve chronic disease control, quality…

Innovators

  • Shreya Kangovi, MD, MS
  • Scott Tornek, MBA
  • Olenga Anabui, MBA, MPH
  • Jill Feldstein, MPA
  • Tamala Carter

Integration of a Social Needs Assessment @ Northeast Ohio Medical University’s Student Outreach Free Clinic (SOAR)

This project sought to integrate a cost-effective social needs assessment into Northeast Ohio Medical University’s SOAR Free Clinic.

Innovators

  • Akanksha Dadlani MPH

Adoption of Social Determinants of Health EHR Tools by Community Health Centers in the Pacific Northwest

This pilot study assessed the feasibility of implementing EHR tools for collecting, reviewing, and acting on patient-reported social determinants of health in three community health…

Alleviating Food Insecurity via “Feed1st” Food Pantries @ The University of Chicago

Feed1st is a research and service program designed to alleviate food insecurity among patients

Innovators

  • Stacy Tessler Lindau, MD, MAPP
  • Megan DePumpo, AM