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Implementation of Combined PCBH and CCBHC Models: Key Considerations

Integrated Care News by CFHA

A recent inquiry within the CFHA community sought recommendations on implementing the Primary Care Behavioral Health (P CBH) model at a Federally Qualified Health Center (FQHC) that had received CCBHC Demonstration. Ensure that you engage in culture-building across the FQHC to maintain the primary care focus.

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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. Evidence‑informed care was literally at his fingertips. For AI in Primary Care, Start With the Problem. Administrative overload fuels burnout and pushes us away from our patients.

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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

Context: Patients with diabetes who receive structured and integrated care have better control and outcomes; however, care may shift between multiple settings making coordination challenging. Outcome Measures: Number of patients engaged, resulting referrals, Navigator time per patient, and hemoglobin A1c measures across 2-years.

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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. Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Referral to counseling (7.5%

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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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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. Intervention: A team was created with an attending physician, care coordinators, and front office staff.

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Using EMR data to describe administrative workload of primary care providers in Nova Scotia, Canada [Secondary data analysis]

Annals of Family Medicine

Context: Primary care providers in Canada face significant workload challenges, including managing prescriptions, referrals, and laboratory tests alongside patient visits. This study aims to analyze electronic medical record (EMR) data to understand these workload dynamics. referrals, and 6.6 (2.8)