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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

On January 7, 2025, SAMHSA announced the award of one-year Certified Community Behavioral Health Clinics (CCBHCs) Demonstration planning grants to 14 states and Washington, D.C., Journal of clinical psychology in medical settings , 25 (2), 109–126. References Reiter, J. Dobmeyer, A. C., & Hunter, C.

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Artificial Intelligence in Health Care

Integrated Care News by CFHA

Traylor and colleagues (2025) show that generative‑AI tools can boost health literacy by translating medical jargon into plain language. Reclaiming Time and Attention Primary care professionals may log more than eleven hours a day, over half of it in the electronic health record (Menchaca, 2025). References Menchaca, J.

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Optimizing Medical Legal Partnerships for sustainable public funding through the tele-legal model [Mixed methods research]

Annals of Family Medicine

Context: Medical legal partnerships (MLP) are an effective intervention for social determinants of health, like housing, education, and employment status. Participating clinic sites offered convenience sample frame, patients with legal needs were identified through universal and secondary screening approach.

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Economic analysis of virtual Medical Legal Partnership model [Economic or policy analysis]

Annals of Family Medicine

Context: Despite copious evidence of the positive health impact of Medical legal partnerships (MLP), public funding remains subject to economic arguments seeking return on investment (ROI) from the perspective of public payers. Setting or Dataset: Medicaid Claims, Epic electronic health record.

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Adoption, implementation, and impact of a Diabetes Navigator program based in primary care [Diabetes and endocrine disease]

Annals of Family Medicine

Population Studied: Patients with recent hemoglobin A1c levels of ≥8% were invited to join the Diabetes Navigator program, identified through the electronic health record at two academic primary care clinics. Navigator outreach time parallels that of a standard 15-minute clinic visit, on average.

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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care [Smoking cessation]

Annals of Family Medicine

Setting or Dataset: Electronic health record data from 11 community-based clinics within a safety-net system in the Midwest from 07/01/2021-3/31/2024. Referral to counseling (7.5% overall) and provision of tobacco cessation medications (3.5% Design and Analysis: Observational study.