- 
                                        
www.ahrq.gov/ncepcr/tools/obesity/obpcp-refs.html
May 01, 2014 - Committee on Quality of Health Care in America, Institute of Medicine. … National health statistics reports; no 27 . … Hyattsville, MD: National Center for Health Statistics. 2010. 
   4.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
March 18, 2008 - However, 
when it is integrated into an organization-wide delivery process, its impact is dramatic. … offers a range of inpatient medical, surgical, pediatric, obstetric, and behavioral health services … integrated systems approach to clinical and nonclinical patient care. … More recently, Mahoney, et al., reported on the results of implanting an integrated information 
technology … Effects of an integrated clinical information system on 
medication safety system in a multi-hospital
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-238-fullreport.pdf
October 01, 2019 - Utilization measures will be 
incomplete if they do not capture behavioral/mental health services provided … under both medical 
benefits and behavioral/mental health carve-outs and would not include services … Measure Topic – care in the most integrated setting: No.  
m. … or facility:** Can compare: (i) practice sites; (ii) medical or other 
professional groups; or (iii) integrated … Further, while mental health 
disorders and emotional/ behavioral issues often develop early in life,
                                     
                                                                    - 
                                        
www.ahrq.gov/ncepcr/care/coordination/atlas/chapter3tab3.html
June 01, 2014 - MPR:  Care coordination activity – assess patient's needs and health status; develop goals. … insurance coverage; and behavioral health care patients. … ; care coordination function – uses health information technology. … NQF:  Framework domain – information systems – the use of standardized, integrated electronic information … Guide to health informatics. 2nd ed.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/primary-care-research-conference-proceedings.pdf
January 01, 2023 - Consider the value of primary care for behavioral health concerns 
post-COVID-19. … The integration with 
behavioral health and public 
health is an important part of 
the holistic nature … • Integrating primary care/behavioral health/public health is necessary to the whole-person 
model … ” 
• Shared vision between primary care, behavioral health, and public health. … • Lessons could be learned from behavioral health integration.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/ncepcr-webinar-person-centered-care.pptx
June 27, 2024 - Highlight examples of primary care research on integration of behavioral health and 
2. … Introduce AHRQ resources that support behavioral health integration.
8
Moderator
Maya Gerstein … mental health, and 12 social care plans 
Unhealthy Behaviors
# health risks	0	1	2	3	4	5	6	0	6	34 … Mental Health p <0.001
*Health Behavior vs. … We also learned that substantially more work is needed to provide those integrated data and care systems
                                     
                                                                    - 
                                        
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence5.html
April 01, 2025 - clinical champions can build intentionality and organizational capacity to sustain change within a health … Sustainable CEs are built by more than just a lead investigator and their research team; they are integrated … Experiential Learning for Leadership Engagement: NYC Health + Hospitals   Simulation is now an integral … Bajaj is Chief Quality Officer at NYC Health + Hospitals/Jacobi/NCB and Clinical Director of Simulation
                                     
                                                                    - 
                                        
www.ahrq.gov/ncepcr/reports/2024-annual-report/future-directions.html
May 01, 2024 - Quality Improvement 
 Healthcare Systems and Infrastructure 
 Digital Healthcare 
 Person-Centered Care 
 Behavioral … Health and Substance Use Disorders 
 Health Equity 
 Primary Care Workforce 
 Public Health and Community … Practitioners Increase Access to Primary Care 
 S9: Using Integrated Social and Medical Risk Data Dashboards … However, there has been less focus on behavioral health (14%), and only a small proportion of grants … with a focus on public health and community integration (7%) and workforce (4%).
                                     
                                                                    - 
                                        
www.ahrq.gov/news/newsletters/e-newsletter/970.html
August 01, 2025 - David Dorr, M.D., M.S., shared his team’s work on a clinical decision support tool integrated with the … electronic health record and patient portal. … in Primary Care: Environmental Scan A new environmental scan from the AHRQ Academy for Integrating Behavioral … Evolution of clinical health information exchanges to population health resources: a case study of the … Aging Ment Health  2025 Jan;29(1):112-20. Epub 2024 Jun 26.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0242-table4.pdf
January 01, 2010 - A model for chronic care envisions a 
structure that integrates health care, patient 
self-management … recommendation 
The USPSTF found adequate evidence that 
multicomponent, moderate- to high-intensity 
behavioral … There is adequate evidence that the harms of 
behavioral interventions are no greater than 
small. … (pp. 8-10) 
III Department of Health and 
Human Services.
                                     
                                                                    - 
                                        
www.ahrq.gov/ncepcr/research-transform-primary-care/transform/synthesis-report/appa.html
October 01, 2015 - Center Network 
 Federally Qualified Health Centers in the Institute for Family Health Network 
 14 … MD, PhD, MPH; Transforming Primary Care: Evaluating the Spread of Group Health Medical Home 
 Group Health … owned and operated clinics 
 26 
 Integrated health system (nonprofit, consumer-governed) 
 Practices … care homes by the Minnesota Department of Health 
 132 
 75% of the health care homes were part of large … improvement, and onsite or otherwise integrated behavioral health 
 All PCR clinics achieved the highest
                                     
                                                                    - 
                                        
www.ahrq.gov/ncepcr/reports/grants-transform/key-characteristics.html
March 01, 2017 - Center Network 
 Federally Qualified Health Centers in the Institute for Family Health Network 
 14 … MD, PhD, MPH; Transforming Primary Care: Evaluating the Spread of Group Health Medical Home 
 Group Health … owned and operated clinics 
 26 
 Integrated health system (nonprofit, consumer-governed) 
 Practices … care homes by the Minnesota Department of Health 
 132 
 75% of the health care homes were part of large … improvement, and onsite or otherwise integrated behavioral health 
 All PCR clinics achieved the highest
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_6-coaching-speaker-notes.pdf
July 01, 2023 - Quality and the Johns Hopkins University Contract 
Number HHSP233201500020I in collaboration with the Health … Resources and Services Administration and the Alliance for Innovation 
on Maternal Health. 
16 
26
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_6-coaching-speaker-notes.pdf
July 01, 2023 - Quality and the Johns Hopkins University Contract 
Number HHSP233201500020I in collaboration with the Health … Resources and Services Administration and the Alliance for Innovation 
on Maternal Health. 
16 
26
                                     
                                                                    - 
                                        
www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool4.html
May 01, 2014 - Sample Punch Card 
 
 
 
 
 
 
 
 Our practice is interested in the health habits of patient as part … Section 1: Health and Health Behaviors 
 1.  … Would you say that in general your health is: 
 
 
 
 ___  1  Poor 
 ___  2  Fair 
 ___  3  Good 
 __ … ___  1 
 ___  2 
 ___  3 
 ___  4 
 
 
 
 Section 4: Primary Care and Health Behavior Change 
 13.  … about the risks of overweight and obesity. 
___  5  Assess patients' willingness to make weight related health
                                     
                                                                    - 
                                        
www.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.html
July 01, 2021 - Integration of behavioral health and primary care. … Behavioral health care. 
 Health care for special populations served by federal programs. … Integration of behavioral health and primary care. … Integrated primary and behavioral health care. … insurance coverage, costs and spending (including value-based care), behavioral health, and care for
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/pccp4p-learningcollab.pdf
September 01, 2025 - • Identifying and meeting training needs across integrated teams is necessary for communication and … MCCs are defined as the co-
occurrence of two or more chronic physical, mental, or behavioral health … (integrated care for older people) approach was shared as a useful resource.20   
 
Findings 
Following … • Patient empowerment through problem solving treatment and behavioral activation can support 
persons … Integrated care for older people (ICOPE): guidance for person-centred assessment and 
pathways in primary
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/innovative-use-pcr-091423.pdf
September 14, 2023 - Department of Health and 
Human Services or the Agency for Healthcare Research 
and Quality.
2
Welcome … interventions need to 
be:     
► Personalized
► Integrated into care              
► Developed … reinforcement learning 
algorithm 
► Target individual’s specific motivators
34
DIAMANTE App
35
COM-B Behavioral … Secondary caregivers 
• School nurse
• Home health nurse
3. … Presentation 2
	Acknowledgement
	DIAMANTE Reinforcement Learning Intervention
	DIAMANTE App
	COM-B Behavioral
                                     
                                                                    - 
                                        
www.ahrq.gov/ncepcr/tools/obesity/obpcp-why.html
May 01, 2014 - 2010 the Oregon Rural Practice-based Research Network (ORPRN) received funding from the Agency for Health … Care Research and Quality for research into "Integrated Primary Care Practices and Community-based Programs … Over a 2-year period we worked with eight primary care practices and community-based health coalitions … Design, implement, and evaluate a participatory process using practice facilitation and community-health
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/publications2/files/ncepcr-at-a-glance-2024-annual.pdf
January 01, 2024 - Digital Healthcare 
and Practice and Quality Improvement while a much smaller proportion focused on Behavioral … Health, 
Public Health and Community Integration, and Primary Care Workforce. … Healthcare
Practice and Quality Improvement
Person-Centered Care
Healthcare Systems/Infrastructure
Health … Equity
Behavioral Health
Public Health and Community Integration
 Primary Care Workforce
48% (60