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Part 1: A functional definition

What integrated behavioral health in primary care needs to look like in action: What to look for "on the ground"

What is integrated behavioral health? A general two-sentence definition:

A practice team of primary care and behavioral health clinicians1 working together with patients and families, using a systematic and cost-effective approach, to provide patient-centered care for a defined population. This care may address mental health and substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.

How is integrated behavioral health done? The defining functions:

The two-sentence definition is a compact, high-level view of integrated behavioral health. But it does not spell out the functions required to achieve it—how is integrated care done in practice? This section outlines those defining functions, first shown at a glance:

At a glance: defining functions of integrated behavioral health (select each segment to learn more)

How integrated behavioral health is done: Defining functions2

Goal: To create a patient-centered care experience and achieve a broad range of outcomes (clinical, functional, quality of life, and resource stewardship), patient-by-patient, that no one provider and patient are likely to achieve on their own.

Functions in place:

The team draws on a range of behavioral health and primary care expertise and role functions to meet the needs of the practice population.

  • The team3 is defined at the level of each patient, and in general for targeted populations,4 including exercise of appropriate cultural and linguistic competence.
  • Teams include a suitable range5 of expertise tailored to particular patients or subpopulations that the practice is responsible for or has chosen to focus on6.
  • Patients, family, or caregivers are invited to take roles on the team up to their comfort and interest in being engaged. 7,8
  • Team members and clear roles are identified to help each patient achieve goals and preferences articulated in a shared treatment plan. Goals and needs may change with the active problems and resources needed.9

Shared operations, workflows, and practice culture support medical clinicians and staff providing patient-centered behavioral health care.

  • Shared workflows, protocols, and office processes that enable and ensure collaboration, including one accessible shared treatment plan for each patient.10
  • A shared practice culture rather than separate and conflicting behavioral health and medical practice cultures.11
  • Shared working environment of physical space and/or virtual "space" that establishes and maintains the relationships, workflows, communication, and shared clinical culture among collaborating team members.12

Formal or on-the-job training to function in this way.

Some form of training or preparation for such clinical roles and relationships, including culture and team building for both medical and behavioral clinicians enable successful integrated behavioral health.13

Common differences in team function encountered between practices can be found in Part 2.

1 Primary care and behavioral health clinicians. The use of the word “clinician” in this short definition is to be read as inclusive of nursing, medical assistant, pharmacy, care management, and others who provide patient care in an integrated primary care team, not only physicians and behavioral health clinicians. A short definition loses its brevity if all possible team members are listed and so “clinician” serves as an umbrella term.

2 Scope of integrated behavioral health. Definition and functions here are for behavioral health integrated in primary care. But very similar definitions and functions can be made for behavioral health in specialty care settings such as in oncology, neurology, cardiology, endocrinology, occupational health, sports medicine, or other specialties.

3 A team has tasks that require interdependent and collaborative efforts.a Outcomes commonly desired from teams include: clinical outcomes superior to "usual care", conservation of expensive physician or other clinician labor, and reduced clinician workload on activities that could be done by others.b Put another way, team outcomes superior to "usual care" involve appropriate use of professionals and staff for patient assistance, diagnostic assessments, and intervention; these should be based on background, training, and skills that lead to maximum clinical and functional benefit while conserving health related resources.

  • A small interdependent team defined at the level of each patient has been referred to as a "clinical microsystem" that forms to meet particular patient and family needs—typically led by a physician or advanced practice provider with some combination of team members in roles such as nursing, care coordination, social work, behavioral health, pharmacy, physical therapy or others. This microsystem changes as the needs of the patient and family shift even as its members often remain embedded in a larger organization or system.c
  • Some team roles or members will likely be the same in a practice and across patients with common needs, while other team roles or individuals will vary with regard to access and dedicated time based on practice population characteristics and desired targeted outcomes.
  • "Team" as used here does not require that all team members are from the same organization or "network". However, for some people, "team" may connote professionals that work in the same organization or unit (e.g., a clinic) rather than those brought in from disparate organizations for a particular patient. The term "collaboration" could be used by those who wish to restrict "team" to members of one clinic or organization.

4 Range of team expertise: a table of examples.

5 Suitable range of expertise. What is "suitable" cannot be specified in advance here because a) it depends on the choice of target conditions, populations, or clinical or other situations, and b) practices are often not in a position to secure all the team members that would be ideal. The purpose of "suitable" here is to require that the practice learn and establish, as well as it can, the range of expertise needed to be helpful to their target populations. It does not require having the "ideal" slate of team members.

6 Typical scope of care that teams must address includes: Chronic illness care, acute care, common physical symptoms associated with stress without serious disease present, acute life stresses, wellness and prevention, health behavior change, and mental health/substance abuse dimensions of the total care of patients.

7 Range of basic roles for patients, family, and caregivers include: 1) being a participant in a healing relationship; 2) providing information on needs, preferences, values, and priorities during shared decision-making, as well as customizing care (family members may need permissions as well as willingness); 3) being the source of control,d and 4) taking an active role or "ownership" of health.

8 Patient engagement has been defined as "actions individuals must take to obtain the greatest benefit from the health care services available to them."e This focuses on the behaviors of individuals that are critical to health outcomes, rather than those of professionals or institutions. Domains include finding safe, decent care from among the alternatives; communication with professionals; organizing and paying for health care; participation in treatment decisions and treatment; promoting health knowledge, health behaviors, and preventive care; and planning for end of life. In this view, "engagement" is an active inquiry and set of behaviors by individuals, not merely "compliance."f

9 Patients need to know who is on the team and why, especially when a BH team member is added. The patient should experience the addition of team members (such as a behavioral health clinician) as value-added for their care. This occurs through, 1) helping the patient understand why their situation and plan needs other professionals to be involved, and 2) the patient seeing current providers endorse the credibility and work of the new clinician(s).

10 Shared workflows: Working from shared workflows, protocols, and office processes goes beyond spatial proximity or "co-location," which does not by itself establish shared workflows. Shared workflows could be regarded as "shared process space" in contrast to "shared physical space".

Co-location does not ensure collaboration. Collaboration has to do with the interactions of clinicians, not their physical location. For example, there can be co-located practices that are not as effective as practices with collaborative arrangements of shared protocols and workflows where some providers are not physically located in the clinic. Shared workflows and protocols could take place among closely collaborating clinics and clinical partners, not only those co-located in the same physical space. Although not a requirement, co-location (shared physical space) is good to have because:

  • It helps clinicians and staff establish relationships with one another.
  • It promotes communication, spontaneous interdependent function, and consultation.
  • It allows patients to observe the interaction and behavior of the team in action.
  • It reduces barriers to patient access and follow-through that result from traveling from one place to another. From the patient perspective, value in shared space comes from not having to go to a different place for part of their care, even if the clinicians are linked by workflows and communication.
  • Telehealth visits may also lower barriers associated with multiple locations, especially after clinicians and patients have developed initial face-to-face relationships.

11 Shared practice culture refers to identity, purpose, and roles as a clinician in the context of interdependency; customs (as expressed in workflows) for communication, interruptions, and confidentiality; a shared picture of what it means to be patient-centered, how you relate to each other's power and influence; and how you engage in clinical systems. Behavioral health in primary care takes on much of the overt style and practice culture of primary care.g Demonstrable commitment to building a shared practice culture (when accompanied by specific plans and timeframes) is an acceptable interim state on the way to actually having a shared practice culture.

12 About shared working environment of physical and/or virtual "space". With widespread use of secure telehealth, e-visits, and virtual team communications, the concept of "spatial arrangement", "shared space" or "co-location" has shifted. New technology (and its acceptance) has meant that team functions that required physical presence in the past no longer do so. The concept has shifted from "shared space" meaning physical space, to a shared working environment that includes well-integrated virtual spaces, including the possibility of a behavioral health or other professional consulting virtually with one or more practices. The technology, its range of secure use, how it is used, and even the language for describing electronically connected teamwork has been rapidly evolving and now includes electronic as well as physical presence to maintain key team functions. Read more about this in part 2, differences between practices.

13 Formal or on-the-job training for the clinical roles and relationships of integrated care is required for successful integrated behavioral health. It is based on the common practical observation that clinicians are often not trained for such collaboration in practice. Specific training is needed at this point in history, but as this collaborative practice spreads, more clinicians will be exposed to it.

Goal: Teams of medical and behavioral health clinicians do psychosocial care14 for total health outcomes15 (or whole-person health16,17), instead of separately evaluated, understood, and treated physical and mental health conditions. The practice team also acts with knowledge of specific social and environmental challenges that affect health in their served communities. 

What you see in place:

Clinicians and staff create care plans that integrate physical and behavioral health (biopsychosocial) factors, rather than addressing physical, behavioral, and social factors as separate unrelated domains. They take responsibility together for the total care, even though they typically have division of labor within the shared care plan.18

The practice team regards patients as members of their shared practice population, not as separate medical or behavioral health populations. Though, the practice might identify a target subset of the whole practice population for integrated behavioral health.19

Clinicians and clinics are engaged with their served communities to understand the specific social context and needs of that population (e.g., patterns of health and illness, social determinants of health, and resources available to clinicians).20,21,22

Common differences encountered between practices can be found in Part 2

14 Francesc B-C, Anthony LS, Ronald ME. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. The Annals of Family Medicine. 2004;2(6):576. https://www.doi.org/10.1370/afm.245. Accessed September 11, 2023.

15 Total health outcomes include both "medical" and "behavioral health outcomes. "Outcomes are defined as the impact of a healthcare service or intervention, and can include events or results in:

  • Patient health status or quality of life.
  • Patient, provider, and population attitudes and behavior.
  • New evidence, research, prevention strategies, treatments, and care models.

For example, patient-reported outcomes (PROs) are one type of outcome that offer a complementary perspective to that of clinician assessments and may provide greater insights into health status, function, symptom burden, adherence, health behaviors, and quality of life".h

16 Whole person health and biopsychosocial care. As defined by the National Institutes for Health (NIH), “whole person health involves looking at the whole person—not just separate organs or body systems—and considering multiple factors that promote either health or disease. It means helping and empowering individuals, families, communities, and populations to improve their health in multiple interconnected biological, behavioral, social, and environmental areas. Instead of treating a specific disease, whole person health focuses on restoring health, promoting resilience, and preventing diseases across a lifespan”. i

A “biopsychosocial” model of health and care is an earlier construct that is somewhat narrower in scope than “whole person health” but is considered synonymous by most clinicians (Thomas et al, 2018) and often used interchangeably.

17 Hayley T, Geoffrey M, Justin R, Megan B. Definition of whole person care in general practice in the English language literature: a systematic review. BMJ Open. 2018;8(12):e023758. https://www.doi.org/10.1136/bmjopen-2018-023758. Accessed September 11, 2023.

18 Definitions of common terms such as mental health, behavioral health, substance use, primary care, and different kinds of integrated care (some version of the “family tree of terms”) to appear in an appendix. 

19 Identifiable subsets of a clinic panel for whom integrated behavioral health is made available, e.g., age group, disease or condition, gender, culture or ethnicity, or other identified subset of the population. This means that a team may focus its integrated behavioral health work on a particular subset of the entire practice panel rather than all patients who come to the clinic.

20 Primary care engagement with communities and public health: The Practical Playbook II: Building Multisector Partnerships That Work. Michener JL, Castrucci BC, Bradley DW, Hunter EL, Thomas CW, Patterson C, et al., editors: Oxford University Press; 2019 01 Jun 2019. https://doi.org/10.1093/med/9780190936013.001.0001. Accessed August 23, 2023.

21 Community engaged healthcare model. Barker SL, Maguire N, Gearing RE, Cheung M, Price D, Narendorf SC, et al. Community-engaged healthcare model for currently under-served individuals involved in the healthcare system. SSM - Population Health. 2021;15:100905. https://doi.org/10.1016/j.ssmph.2021.100905. Accessed August 23, 2023.

22 Community-engaged primary care. Michener J. Community Engagement: A Core Component of Primary Care. Durham, NC: National Academy of Medicine; 2022. https://www.nationalacademies.org/documents/embed/link/LF2255DA3DD1C41C0A42D3BEF0989ACAECE3053A6A9B/file/DECC57A626D99D59E65FD2761D14C434244CC1AFCB93?noSaveAs=1. Accessed August 23, 2023.

Goal: Clinician teams use an explicit and systematic clinical approach embedded in an operational system that enables them to routinely function well.

What you see in place—what it means to have a systematic clinical approach:

A. Methods to identify members of the clinic population who need or may benefit23 from integrated behavioral and medical care and at what level of severity or priority.24 This includes clinical conditions, clinical situations, organization of care and relationships, and need for health behavior change.25

Identification is used operationally to help the clinic focus its efforts or outreach. For example, the practice can identify the pressing problems of individuals or sub-populations, taking into account health disparities or social determinants of health.

B. Patients and families are engaged in identifying their needs and goals for care and the kinds of services and care team members (e.g., care coordinators, interpreters, or community health workers) we would expect to see with integrated care are available. What patients can do to participate in their own care is made clear and patient and family roles appear in the electronic health record, along with the professionals who will work together with the patient,26 as well as which community organizations will be engaged to address overall health in the social context.

C. Patients and clinicians are involved together in decision-making to create an integrated care plan appropriate to patient needs, values, and preferences that is patient-centered and addresses medical diagnoses. This goes beyond engaging patients in their needs and goals for care to explicit involvement in shared decision-making, jointly assessing risks and benefits of alternative therapies with patient values and preferences in view, often using decision aids.27

D. All clinicians recognize when specialists or consultants are needed, whether medical or specialty behavioral health clinicians outside the immediate primary care team. This can also include community-based caregivers or staff who bridge the practice to patients in the community or other parts of the medical system, e.g., community health workers, promotoras,28 or other roles that help patients navigate the system).

E. Use of an explicit, unified, care plan in a shared record that contains assessments and plans for biological/physical, psychological, cultural, social, and organization of care aspects of the patient's health and health care. Scope includes prevention, acute, and chronic/complex care, and key involvements in community resources important to the overall care plan. Care plans include (among other things):

  • Goals of care with assigned team roles—specific goals and team members responsible for achieving those care goals or tasks are identified.
  • Documentation of dialogue on the goals of care and decision-making and why integrated care and a shared record is important; also includes exploration of any patient concerns about shared records or confidentiality.29
  • Patient education about their conditions, treatments, and self-management—uncovering what the patient understands or believes and what they are prepared to do.
  • Medical treatments of all kinds, typically those carried out by primary care clinicians. This includes but is not limited to pharmacologic treatment; for example, a single shared problem list and treatment and medication list, knowing there is no sharp distinction between "medical" and "behavioral" treatments.
  • Behaviorally oriented treatments,30 such as psychological or behavioral intervention, community groups, or other non-pharmacologic behavioral health, substance use treatment or support, or behavioral counseling (e.g., motivational interviewing and behavioral activation).
  • Tailoring of the plan to the patient or family context, considering culture, language, education, vocation, and community—including involvement of community resources to tailor the plan beyond the clinic team.

Implementing a care plan means all involved providers read and work from the care plan; these are shared care plans with ongoing communication among team members.

F. Systematic follow-up and adjustment of treatment plans if patients are not improving as expected. This is the ongoing management of patients based on early identification.

  • Use of population-based EHR reports or registries for systematic follow-up with individual patients, and monitoring the status of populations tracked in the registry.
  • Outreach to patients who do not follow up.
  • Regular monitoring of treatment response, side effects, and how treatments fit the patient's life, goals, and priorities. Identify and monitor indicators that improvement has begun or that the care plan is not working, along with who on the team is most likely to notice the change first and who should be informed that the care plan needs changing.
  • Adjust care plan quickly (and with shared decision-making31) for patients who are not improving; whose care does not fit their goals or life; who are not engaged; who are not responding to initial treatments; or who are experiencing troublesome treatment side effects, complications, or other adverse events. Revise the plan or move it to a more intensive level.
  • Establish and support relapse prevention plans for when patients are substantially improved.

Common differences encountered between practices can be found in Part 2

23 Identification as an integrated behavioral health function is primarily aimed at distinguishing those who specifically need integrated behavioral and medical care at a particular level of intensity or priority. However, understand that population-level identification takes place in the larger context of all care such as universal screening or medical screening, and not only individuals requiring integrated behavioral health.

24 Identification is for case-finding, for behavioral health integration is a broader concept than universal screening for conditions. For example, the need for treatment of mental health/substance use conditions, behavioral factors (or mental health conditions) embedded in chronic illness care, common physical symptoms or complaints not attributed to disease processes, health behavior change, social interferences with care, and how the organization of care or clinician-patient relationships may complicate or interfere with care.

25 Identification of individuals whose care plans require blended behavioral health and medical expertise. A table containing common examples can be found in the original 2013 Lexicon.

26 Engaging patients also includes exploring what patients can do to participate in their own care, such as being a prepared communicator, tracking their own progress, and other patient engagement behaviors.e,f Engaging patients also means clarifying the reasons for inclusion of the behavioral health clinician on the team and the use of a shared record—exploring its benefits and risks as seen by both patient and provider.

27 Shared decision-making has emerged as a systematic discipline with its own literature, roles, goals, tools, and protocols.j,k,l Definitions and requirements have become clearly articulated.m

28 Promotora: a community member who receives training to provide basic health education in the community without being a professional health care worker. Promotores de salud, also known as promotoras, is the Spanish term for “community health workers”.n

29 Dialogue with patient on information sharing and confidentiality. Clinicians should prepare for the possibility that a patient may not initially want a shared record. Primary care involves sharing of information, but the clinician has a responsibility to initiate dialogue with the patient that explains why a shared record is important and to listen to patient concerns and negotiate a resolution. This could be applicable to privacy issues for HIV, STDs, reproductive health, mental health and other conditions and life situations.

The general principle is that the patient came to the primary care clinic to get health care, which in this practice is integrated and therefore charted for the team to view (and potentially others if the patient releases information). The patient does not have to enter a fully integrated primary care clinic; this may not be the choice for everyone. And of course, every patient has a right to refuse providers outside the practice having access to their medical information.

30 Evidence-based: Medical, psychological, and counseling treatments or techniques are to be supported by research evidence as much as possible, knowing this is a constantly unfolding story with different levels and kinds of support for different things. Clinicians should be able at any time to point at support and rationale for what they are doing.

31 Shared decision making: Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-7. https://www.doi.org/10.1007/s11606-012-2077-6. Accessed August 23, 2023.

Organizational support functions that make integrated behavioral health sustainable on a meaningful scale

Goal: The practice is sufficiently engaged with its served communities or populations that care can be planned with respect to the specific population or community context and needs. The community or clinic population understands the benefits of integrated behavioral health care and expects it.

What you see in place:

  • Clinician or other practice leaders maintain connections with served communities or populations to understand their characteristic health, illness, and care-seeking challenges.
  • Practices or systems help their patients recognize the personal benefits of integrated behavioral health so they know they can seek care for a wide range of issues and concerns, including with personal, behavioral, and psychological concerns.

Common differences encountered between practices can be found in Part 2 

Goal: Vision, leadership, incentives, operations, and business model are aligned in support of integrated behavioral health so it is coherent and can be sustained.

What you see in place:

Aligned purposes, incentives, leadership, and program supervision within the practice.

Integrated behavioral health, to the extent new to a practice, requires realignment of purposes, incentives, philosophy, and systems—a shared vision for integrated behavioral health across people of the practice in context of the served communities. Top leaders are aligned around the benefits and maintain the "how to do it" functions (above) as a prominent feature of the practice vision.32 They mentor and supervise accordingly, tracking progress and making program changes to become as effective as envisioned.

Operational systems and management that consistently and reliably33 supports all the "how it is done" functions of integrated behavioral health.

This includes alignment of operational systems; office processes; electronic information tools, including EHRs; community engagement processes; and office management practices in support of those functions. Integrated behavioral health is built thoroughly into operations, not only into clinical methods.34

A sustainable business model (financial model) that supports the consistent delivery of integrated behavioral and medical services in a practice or clinic system.

All the required "how to do it" functions of integrated behavioral health are linked to some means of sustainable financial support. This is not prescriptive of a particular model of reimbursement, coding, bundling, or any other financial model involving practices, payers, or other sources of financing. But the goal is an integrated practice with its functions sustained financially.35

Common differences encountered between practices can be found in Part 2

32 Leadership. A particular practice within a large organization may be ready to integrate behavioral health care, but different clinics within that same organization may be at different points of readiness. These practices are not likely fully independent of the larger organization, which may affect how far a particular practice can go in making the changes required.

33 Office processes "consistently and reliably" support integrated care. Institutionalizing highly consistent and reliable office processes that routinely support the functions of integrated behavioral health is for most practices a developmental path, rather than something established all at once. If not yet fully consistent or reliable, what you see in place is the aspiration plus gradual improvement.

34 Operational and management support for functions may often require local clinic leaders to engage higher level organizational leaders for specifics that enable implementation. Even with everyone embracing the vision of integrated behavioral health, it is not always apparent what specific policies or processes are required to support the functions. It can be an iterative process between local implementers and higher-level organizational leaders.

35 A sustainable business model. At this time in history, dominant business models are often regarded as not sustainable of integrated behavioral health or primary care in general. The section on levels of the developmental path is a way of looking at the level of business model support for integrated behavioral health and how sustainability might be defined along with examples of payment or non-payment revenue that might be in the mix.

Goal: The practice quickly learns from experience and changes what it is doing; internal evidence is used to improve the practice. As a result, patients get higher quality, safer, more efficient care, and health care delivery organizations become better places to work.

What you see in place:

Routine collection and use of practice-based data to improve outcomes and the clinic system.

To change what the practice is doing and quickly learn from experience, which is to say act as a Learning Health System "in which internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice."36

Practice-based data is collected as a standard part of clinic operations at the practice or is reported back to the practice from a central administration or other source. This includes quality improvement or program evaluation data.37

Other data on total cost of care, hospital, pharmacy, readmissions, emergency services, referral, health disparities, health equity, or social determinants of health may or may not be generated or reported back to the practice, as well.38

Periodic examination and internal reporting of outcomes.

Internal reporting at the provider and program level that engages the practice in making program design changes accordingly.

Outcomes reported at the patient level and practice or panel level. Outcomes of interest include clinical, patient experience (satisfaction, access,39 and goal attainment40), and clinician experience, as included in the "quadruple aim."41

Common differences encountered between practices can be found in Part 2 

36 Learning Health System. Agency for Healthcare Research and Quality (AHRQ). About Learning Health Systems. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2019. https://www.ahrq.gov/learning-health-systems/about.html. Accessed August 23, 2023.

37 Practice-based data. Quality improvement, program evaluation, or other data is collected ideally in a form amenable to publication, but the essential function is the practice learns and changes in response to data it routinely collects.

38 Collection of uniform demographic data such as race/ethnicity and language as outlined in the Affordable Care Act Section 4302. The law requires that data collection standards for these measures be used, to the extent practicable, in all national population health surveys, but they could also be adapted by practices for their own local demographic profiles.

39 For minority or underserved populations it may be necessary to look at information such as improved engagement with the practice, rates of follow-through, or actual availability of services in the population.o

40 Alignment of reported outcomes and patient goals. To have the best value for patients, outcomes reported can be services they want to receive.

41 Quadruple aim. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-6. https://www.doi.org/10.1370/afm.1713. Accessed August 23, 2023.

a Bodenheimer T. Building Teams in Primary Care: 15 Case Studies. Oakland, CA: California HealthCare Foundation; 2007. https://www.chcf.org/wp-content/uploads/2017/12/PDF-BuildingTeamsInPrimaryCareCaseStudies.pdf. Accessed August 23, 2023.

b Bodenheimer T, Willard R. The Building Blocks of High-Performing Primary Care: Lessons from the Field. Oakland, CA: California HealthCare Foundation; 2012. https://www.chcf.org/wp-content/uploads/2017/12/PDF-BuildingBlocksPrimaryCare.pdf. Accessed August 23, 2023.

c Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457-61. https://www.doi.org/10.1370/afm.731. Accessed August 23, 2023.

d Institute for Healthcare Improvement. IHI Patient-Centered Care Charter. Boston, MA: Institute for Healthcare Improvement; 2005. http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/EmergingContent/PatientCenteredCareCharter.html.

e Institute for Healthcare Improvement. Clinical Microsystem Assessment Tool. Boston, MA: Institute for Healthcare Improvement 2009. https://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx

f Center for Advancing Health. A New Definition of Patient Engagement: What Is Engagement and Why Is It Important? Washington, D.C.: Center for Advancing Health; 2010. http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf

g Gruman J, Rovner MH, French ME, Jeffress D, Sofaer S, Shaller D, et al. From patient education to patient engagement: implications for the field of patient education. Patient Educ Couns. 2010;78(3):350-6. https://www.doi.org/10.1016/j.pec.2010.02.002. Accessed August 23, 2023.

h McDaniel SH, Campbell TL, Seaburn DB. Principles for collaboration between health and mental health providers in primary care. Family Systems Medicine. 1995;13(3-4):283-98. https://www.doi.org/10.1037/h0089075. Accessed August 23, 2023.

i Agency for Healthcare Research and Quality (AHRQ). Topic: Outcomes. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2023. https://www.ahrq.gov/topics/outcomes.html. Accessed August 23, 2023.

j National Center for Complementary and Integrative Health. Whole Person Health: What You Need To Know. Bethesda, MD: National Institutes of Health; 2021. https://www.nccih.nih.gov/health/whole-person-health-what-you-need-to-know. Accessed September 12, 2023.

k Burkhard C, Doster K, McIntyre H. Shared decision making in health care delivery: Background information and policy options for New Hampshire. Hanover, NH: Dartmouth College; 2011. https://rockefeller.dartmouth.edu/report/shared-decision-making-health-care-delivery. Accessed August 23, 2023.

l Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291(19):2359-66. https://www.doi.org/10.1001/jama.291.19.2359.  Accessed August 23, 2023.

m Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-92. https://www.doi.org/10.1016/s0277-9536(96)00221-3. Accessed August 23, 2023.

n Moumjid N, Gafni A, Brémond A, Carrère MO. Shared decision making in the medical encounter: are we all talking about the same thing? Med Decis Making. 2007;27(5):539-46. https://www.doi.org/10.1177/0272989x07306779. Accessed August 23, 2023.

o Office of Health Equity (OHE). Promotores de Salud/Community Health Workers. Atlanta, GA: Centers for Disease Control and Prevention (CDC); 2019. https://www.cdc.gov/minorityhealth/promotores/index.html. Accessed August 23, 2023.

p Office of Minority Health (OMH). HHS Action Plan to Reduce Racial and Ethnic Health Disparities. Washington, DC: U.S Department of Health and Human Services (HHS); 2011. https://www.govinfo.gov/content/pkg/GOVPUB-HE-PURL-gpo64706/pdf/GOVPUB-HE-PURL-gpo64706.pdf. Accessed August 23, 2023.