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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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Compass Rose for Generating Community-based Referrals via Epic: Best Practices and Lessons Learned [Social determinants and vulnerable populations]

Annals of Family Medicine

Population Studied: Three sites, representing 13 urban and rural primary care practices in Minnesota, Wisconsin, and Florida participated in the Compass Rose pilot. We had lower referral completions than expected because of the difficulty connecting with patients asynchronously.

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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

Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Outcome Measures: Assessment of tobacco use; Among patients with current tobacco use, provision of advice to quit, referral to tobacco cessation counseling and tobacco cessation medication orders.

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Effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in practice [Education and training]

Annals of Family Medicine

Objective: To evaluate the effect of brief dermoscopy training on primary care providers' diagnostic accuracy on a test and in clinical practice. Setting: Divisions of Family Medicine and Community Internal Medicine at a large academic medical center in Southeast Minnesota.

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Evaluation of Universal Food Insecurity Screening in the Primary Care Setting [Social determinants and vulnerable populations]

Annals of Family Medicine

The American Academy of Pediatrics recommends universal screening; however studies have found inconsistencies in screening of FI, documentation of FI, and referral to appropriate resources. Population Studied Families of children ages 0-18yo at an urban pediatric primary care mobile medical clinic serving families in Washington, D.C.