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Background Integrated care is the coordination of general and behavioral health and is a highly promising and practical approach to improving healthcare delivery and patient outcomes. While there is growing interest and investment in integrated care implementation internationally, there are no formal guidelines for integrated care implementation applicable to diverse healthcare systems. Furthermore, there is a complex interplay of factors at multiple levels of influence that are necessary for successful implementation of integrated care in health systems. Methods Guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons et al., 2011), a multiple case study design was used to address two research objectives: 1) To highlight current integrated care implementation efforts through seven international case studies that target a range of healthcare systems, patient populations and implementation strategies and outcomes, and 2) To synthesize the shared and unique challenges and successes across studies using the EPIS framework. Results The seven reported case studies represent integrated care implementation efforts from five countries and continents (United States, United Kingdom, Vietnam, Israel, and Nigeria), target a range of clinical populations and care settings, and span all phases of the EPIS framework. Qualitative synthesis of these case studies illuminated common outer context, inner context, bridging and innovation factors that were key drivers of implementation. Conclusions We propose an agenda that outlines priority goals and related strategies to advance integrated care implementation research. These goals relate to: 1) the role of funding at multiple levels of implementation, 2) meaningful collaboration with stakeholders across phases of implementation and 3) clear communication to stakeholders about integrated care implementation. Trial registration Not applicable.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In ‘I: framing family medicine—history, values, and perspectives’, the authors address the following themes: ‘Notes on Storylines of Family Medicine’, ‘Family medicine—the generalist specialty’, ‘Family medicine’s achievements—a glass half full assessment’, ‘Family medicine’s next 50 years—toward filling our glasses’, ‘Four enduring truths of family medicine’, ‘Names matter’, ‘Family medicine at its core’ and ‘The ecology of medical care.’ May readers find much food for thought in these essays.

Objectives Low back pain (LBP) is the number one cause of disability world-wide. It is also the most expensive area in healthcare. Patient-centered innovations are needed. This paper uses medical storytelling to illustrate the common problems that often lead to unnecessary suffering for patients, and costs to society. We present innovative solutions, including narrative interventions. Methods We use medical storytelling to present a scenario in which hypothetical twin patients with identical LBP episodes enter the healthcare system, with one twin managed in an appropriate manner, and the other inappropriately. Results One twin becomes a chronic LBP sufferer, while the other experiences quick resolution, despite identical conditions. Recommendations are made to de-implement inappropriate action and to implement a more productive approach. Conclusions Many patients with LBP descend into chronic pain. This is rarely inevitable based on clinical factors. Much of chronic LBP results from how the condition is handled within the healthcare system. Medical narrative may be one innovation to illustrate the problem of current LBP management, recommend solutions and foster changes in clinical behavior. Practical implications The starkly different outcomes for each identical twin are illustrated. Recommendations are made for reframing the situation to de-implement the inappropriate and to implement a more appropriate approach.

Hospital closures have become commonplace in the United States but remain controversial. Memorial Hospital of Rhode Island was a 294-bed hospital in a disadvantaged community that closed in 2018 amid falling patient volume and rising costs. Immersion/crystallization method of qualitative analysis was employed in reviewing semi-structured interviews, public testimony, and public documents. Themes that emerged were organized into discrete narrative typographies, represented by illustrative quotations. Three main narratives of the hospital's closure arose: 1.) financial inevitability; 2.) corporate mismanagement; and 3.) systems realignment. Overlapping and discrepant narratives of the closure demonstrated the complicated role of hospitals within communities and health systems. Acknowledgment of both the hospital's financial straits and the negative impacts of closure on a marginalized community demonstrate the malalignment of economic incentives and the public good in the state's health care system. This case study may offer lessons for other communities facing or experiencing hospital closure.

Objectives: Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices. Methods: Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team. Results: Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers’ and staff’s emotional exhaustion and depersonalization increased slightly over the course of the intervention from baseline to follow-up, and personal accomplishment decreased slightly. Providers and staff expressed appreciation for the patient-centered medical home as an ideal model, variously implemented some important patient-centered medical home components, increased their understanding of patient-centered medical home as more than specific isolated parts, and recognized their evolving work roles in the medical home. However, frustration with implementation barriers and the added work burden they associated with patient-centered medical home persisted. Conclusion: Patient-centered medical home transformation is disruptive to practices, requiring enduring commitment of leadership and personnel at every level, yet the model continues to hold out promise for improved delivery of patient-centered primary care.

BACKGROUND: Hospital closures have become commonplace in the United States but remain controversial. Memorial Hospital of Rhode Island was a 294-bed hospital in a disadvantaged community that closed in 2018 amid falling patient volume and rising costs. METHODS: Immersion/crystallization method of qualitative analysis was employed in reviewing semi-structured interviews, public testimony, and public documents. Themes that emerged were organized into discrete narrative typographies, represented by illustrative quotations. RESULTS: Three main narratives of the hospital's closure arose: 1.) financial inevitability; 2.) corporate mismanagement; and 3.) systems realignment. CONCLUSIONS: Overlapping and discrepant narratives of the closure demonstrated the complicated role of hospitals within communities and health systems. Acknowledgment of both the hospital's financial straits and the negative impacts of closure on a marginalized community demonstrate the malalignment of economic incentives and the public good in the state's health care system. This case study may offer lessons for other communities facing or experiencing hospital closure.

Secrets and issues of confidentiality are critical concerns in doctor-patient communication and fundamental aspects of every medical encounter. Nevertheless, the nature, content, prevalence, impact, and consequences of secrets in medicine have largely been unexplored. This study investigates the role of secrets in primary care. It describes the intuitive strategies used by primary care physicians to cope with secrets, provides a categorization system, and suggests a conceptual model. Focus groups of primary care physicians were the principal data collection method employed. Transcripts from 8 focus groups were analyzed using an \"immersion-crystallization\" framework involving cycles of concentrated textual review of data. Insights from this iterative process and from the literature were employed in the construction of contextual types, content categories, processes, and models. Sixty-one family physicians and general practitioners in Israel with a wide variety of seniority, ethnic, religious, and immigration backgrounds. Locations in the north, south, and center of Israel. Analysis revealed insights about definitions, prevalence, process, and content of secrets in primary care. The main content findings centered on categories of secrets such as propensity to secrecy, toxicity of secrets, and the special nature of secrets in family medicine. The main process findings regarded the life cycle of secrets and doctors' coping strategies. Based on our findings and a review of the literature, a conceptual model of secrets in primary care is proposed. The importance and impact of secrets are significant part of daily medical practice. Further research is needed to enhance physicians' effective and ethical handling of secrets and secrecy in practice.

Primary care in Rhode Island is in crisis. The dearth of primary care providers is already affecting access to services and the situation is likely to worsen unless major steps are taken. There are inadequate numbers of trainees in primary care medical residencies, nurse practitioner (NP) and physician assistant (PA) training programs who plan to practice primary care in our state. The Care Transformation Collaborative of RI (CTC-RI) has assembled a broadly representative task force of physicians, NPs, PAs, and others to build a strong and robust primary care delivery system across the state that recruits, trains, retains, and sustains primary care providers. Study Methods and Design: Program directors from all primary care medical residencies, NP, and PA programs were asked to provide data on their programs, including the number of new trainees per year, total enrollment, and information on recent year graduates, including the total number, the number entering primary care, and the number entering primary care who plan to practice in RI. Of the 106 graduates from primary care residencies in RI in academic year 2002-23, only 15 (14%) planned to provide primary care in Rhode Island. Similarly, of the 144 NP and PA graduates in primary care programs, only 48 (33%) planned to provide primary care in the state. Given the high rate of primary care provider burnout, reduction in patient care hours, and retirement, primary care access will be further eroded unless major steps are taken. The CTC-RI Task Force on Primary Care Provider Workforce has produced a strategic roadmap to address these issues.

Abstract The Medicare Annual Wellness Visit (AWV) involves a personalized risk assessment and prevention plan to help prevent disease and disability among older adults. Though studies have shown that AWV uptake is suboptimal, little is known about the perspectives and experiences of patients completing it. Family medicine physicians are conducting AWVs at a Rhode Island pilot teaching clinic participating in the GWEP's Age-Friendly Health Systems Initiative. To evaluate perspectives of the clinic's under-resourced patients, 20 qualitative telephone interviews were conducted following their AWV. Interview recordings were analyzed for content and themes. Few patients recognized the term 'Annual Wellness Visit' or recognized it was significantly different from other visits: \"I noticed it was a bit different, but not that different. I'm usually not covered for a visit like that by Medicare.\" Mental health, mobility and medications were discussed at most of the AWVs. Some patients noticed that a physician did the medication review instead of the nurse. Patients had varying experiences of how advance directives were discussed, and some thought it unnecessary since a family member knows their preferences. A few patients were dissatisfied that their physician did not focus on their chronic or acute health problems. However, most patients \"trusted\" their physicians to do \"whatever is necessary\" for them, and were glad to have had the AWV because \"instead of talking about being sick all the time, talking about how to stay well\". Recommendations for patient education to improve understanding and the experience of the AWV will be offered.