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.
Value-Based Primary Care during COVID-19 @ Oak Street Health
Oak Street Health, a network of 56 value-based primary care centers serving nearly 80,000 adults on Medicare, developed a remote care program allowing them to…
Innovators
- Griffin Myers, MD, MBA, FACEP
- Geoffrey Price, MBA
- Mike Pykosz, JD
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…