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1

Health, Great Britain Department of. Supporting people with long term conditions: An NHS and social care model to support local innovation and integration. London: Department of Health, 2005.

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2

Chamberlain, Patricia. Treating chronic juvenile offenders: Advances made through the Oregon multidimensional treatment foster care model. Washington: American Psychological Association, 2003. http://dx.doi.org/10.1037/10596-000.

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3

Families, illness, and disability: An integrative treatment model. New York: BasicBooks, 1994.

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4

Does the Collaborative Model Improve Care for Chronic Heart Failure? Lippincott Williams & Wilkins, 2005. http://dx.doi.org/10.7249/rp1173.

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5

Crabtree, Mary Katherine. SELF-EFFICACY AND SOCIAL SUPPORT AS PREDICTORS OF DIABETIC SELF-CARE (HEALTH BELIEFS, BEHAVIOR, CHRONIC ILLNESS, SOCIAL LEARNING THEORY, MODEL TESTING). 1986.

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6

Treating Chronic Juvenile Offenders: Advances Made Through the Oregon Multidimensional Treatment Foster Care Model (Law and Public Policy: Psychology and the Social Sciences). American Psychological Association (APA), 2003.

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7

Upadhyay, Ashish, Lesley A. Inker, and Andrew S. Levey. Chronic kidney disease. Edited by David J. Goldsmith. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0094.

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The conceptual model, definition, and classification of chronic kidney disease (CKD) were first described in the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines in 2002 and have had a major impact on patient care and research. Since this publication there has been an increased recognition that the cause of CKD influences progression and complications. In addition, epidemiologic reports from diverse populations have consistently shown graded relations between higher albuminuria and adverse kidney outcomes and complications, in addition to, and independent of, low GFR. Given these new understanding in risk relationships, Kidney Disease Improving Global Outcomes (KDIGO) updated the original guidelines in 2012. The updated guidelines retain the KDOQI definition of CKD, but recommend classifying CKD by the cause, level of GFR, and level of urinary albumin to creatinine ratio. Specialized nephrology care is recommended for severe reduction in GFR or high albuminuria, uncertain diagnosis, or difficult to manage complications.
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8

Alberto, June Eloise. A TEST OF A MODEL OF THE RELATIONSHIPS BETWEEN TIME ORIENTATION, PERCEPTION OF THREAT, HOPE, AND SELF-CARE BEHAVIOR OF PERSONS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (PULMONARY DISEASE). 1990.

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9

McCarron, Robert M., Amir Ramezani, Ian Koebner, Samir J. Sheth, and Jessica Palka. Integrated Chronic Pain and Psychiatric Management. Edited by Robert E. Feinstein, Joseph V. Connelly, and Marilyn S. Feinstein. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190276201.003.0023.

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Both physical pain and psychiatric disorders are widely prevalent, and collectively they account for the most frequently presenting complaints in the primary care setting. These conditions are a complex challenge for both the patient and provider, with frequent high use of medical services and increased morbidity. The Integrated Behavioral Pain Medicine (IBPM) treatment model incorporates a multidisciplinary, biopsychosocial, team-based approach for patients who have chronic and largely treatment-refractory pain. IBPM uses an integrated care team of providers and coordinators, who collectively work with the chronic pain patient to individualize a pain management plan, which may include pharmacologic management, cognitive-behavioral therapy, trauma-focused therapy, biofeedback, mindfulness, acupuncture, nutrition, behavioral weight and sleep management, and physical therapy. Ideally, primary care providers will refer patients to an IBPM model of care, but if the treatment model is not available in a specific area, a piecemeal approach with partial use of services is recommended.
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10

Alder, Catherine A., Mary Guerriero Austrom, Michael A. LaMantia, and Malaz A. Boustani. Aging Brain Care. Edited by Robert E. Feinstein, Joseph V. Connelly, and Marilyn S. Feinstein. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190276201.003.0008.

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While fragmented care is a problem across the entire health care delivery system, it is especially problematic for vulnerable older adults with dementia and late-life depression. Most older adults have multiple chronic conditions. Cognitive impairment and mood disorders complicate the management of these comorbid conditions by interfering with the patient’s ability to monitor and report symptoms and comply with the care plan. To reduce fragmentation and promote integrated care, each medical provider must adopt a more holistic view of health care, recognizing the importance of communication and collaboration among all providers and the potential impact of any one action on the patient’s overall health. The Aging Brain Care (ABC) model provides a structure for integrating evidence-based interventions for dementia and depression into the primary care environment. By extending the delivery of care beyond the clinic, ABC offers patient-centered services aimed at coordinating care across multiple providers, settings, and community resources.
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11

Sullivan, Mark D. Patient-Centered Care or Patient-Centered Health? Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780195386585.003.0002.

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The history of proposals for patient-centered medicine begins with Michael Balint’s proposal for patient-centered medicine as an alternative to illness-centered medicine. This has been weakened in more recent calls for patient-centered care from clinicians, foundations, and professional organizations. It is argued that patient-centeredness consists of both taking the patient’s perspective and activating the patient. Taking the patient’s perspective involves communication skills and may involve developing a “shared mind” with the patient. Two programs for activating patients are contrasted, 1) the Expert Patient program based on the Chronic Disease Self-Management Program of Lorig and Holman and 2) the Patient-Centered Medical Home based on the Chronic Care Model developed by Wagner and colleagues. Patient empowerment involves activating patients on their own behalf and in service of their own goals. A truly patient-centered chronic care model aims not only for patient empowerment, but also for patient capability to pursue health and other vital goals.
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12

Feinstein, Marilyn S., and Robert E. Feinstein. Health Coaching in Integrated Care. Edited by Robert E. Feinstein, Joseph V. Connelly, and Marilyn S. Feinstein. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190276201.003.0025.

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Health care in the United States is in transition. Facilitating individual patient and population-based lifestyle change is critical for creating a healthier country. Fostering prevention, promoting lifestyle change, and dealing with the high incidence and prevalence of chronic disease is within the purview of health coaching, a new health discipline. This chapter describes the emergence, theories and methodologies, and efficacy of health coaching. We describe health coaching in practice, as primary care and integrated care environments begin to incorporate health coaching within multidisciplinary health care teams. Five major coaching approaches are discussed: the transtheoretical model (stages of change), motivational interviewing, solution-focused coaching, cognitive-behavioral coaching, and mindfulness-based stress reduction. An example of a brief coaching session is presented.
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13

Phillips, Jane L., Annmarie Hosie, and Patricia M. Davidson. Palliative care in the nursing home. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656097.003.0014.

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Internationally, ageing, technological advances, evolving patterns of disease and disability, and changes in family structures have resulted in nursing homes becoming the final residence for many frailer older people. Much of the on-site assistance with activities of daily living in nursing homes is predominately provided by an unregulated or minimally trained carer workforce with registered nurse supervision, while professional nursing and medical care is provided either by on-site or visiting doctors, nurses, and allied health professionals from external services. This chapter details the palliative care needs of older people living in nursing homes and the challenges and opportunities to deliver better end-of-life care to this population, and proposes utilizing the Chronic Care Model as a framework for delivering the elements of a palliative approach to improve care outcomes for residents and their families.
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14

Handzo, George, and Christina Puchalski. The role of the chaplain in palliative care. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656097.003.0045.

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Spirituality has been shown to be a key factor in how people understand illness and how they cope with suffering. It is especially important for people who have serious or chronic illness. Standards for palliative care include spiritual care as a required domain of palliative care. Models and recommendations have been developed to facilitate interprofessional spiritual care where all members of the team attend to the spiritual issues of patients with the professional chaplain being the expert in spiritual care in a generalist specialist model of care. Palliative care teams should have a professional chaplain with training in palliative care assigned. This chaplain functions as the spiritual care lead and the spiritual care specialist on the team.
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15

Feinstein, Robert, Joseph Connelly, and Marilyn Feinstein, eds. Integrating Behavioral Health and Primary Care. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190276201.001.0001.

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This book describes real-world examples and practical approaches for integrating behavioral and physical health services in primary care and some specialty medical environments. Integrated care models are patient-centered; delivered by teams of medical professionals, utilize care coordination, and a population-based approach. This book is comfortably accessible to students, residents, faculty, and all mental health professionals, primary care and medical specialists who are working in ambulatory/office-based practices. We examine the integrated care literature and recommend applying collaborative care and other existing models of integrated care based on the existing evidence-based research. When there is no literature supporting a specific approach, our experts offer their ideas and take an aspirational approach about how to manage and treat specific behavioral disorder or problems. We assume the use of a fully integrated team staffing model while also recognizing this an ideal that may need modification based on local resources and practice cultures. The full integrated team includes a primary care or specialist provider(s), front desk staff, medical assistant(s), nurse(s), nurse practitioners, behavioral health specialist(s), health coaches, consulting psychiatrist, and care coordinator(s)/manager(s). The book has four sections: Part 1: Models of Integrated Care provides an overview of the principles and the framework of integrated care focusing on five highly successful integrated practices. We also discuss team-based care, financing, tele-behavioral health, and use of mental health assessments and outcome measures. Part 2: Integrative Care for Psychiatry and Primary Care is a review of existing and proposed models of integrated care for common psychiatric disorders. Our continuity approach emphasizes problem identification, differential diagnosis, brief treatment, and yearlong critical pathways with tables and figures detailing “how to” effectively deliver mental health care and manage substance misuse in an integrated care environment. Part 3: Integrated Care for Medical Sub-Specialties & Behavioral Medicine Conditions in Primary Care focuses on two models of integrating behavioral health care: (1) integrating wellness with behavioral health and (2) integrating psychiatry and neurology. Other chapters are “Women’s Mental Health Across the Reproductive Lifespan,” “Assessing and Treating Sexual Problems in an Integrated Care Environment,” “Integrated Chronic Pain and Psychiatric Management,” and “Death and Dying: Integrated Teams.” Part 4: Psychosocial Treatments in Integrated Care describes brief office-based counseling and psychosocial treatment approaches including: health coaching, crisis intervention, family, and group interventions. All of these brief treatment approaches are patient–centered, tailored to be used effectively integrated care settings and as an important contribution to population management.
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16

Sullivan, Mark D. On the Role of Health Behavior in 21st-Century Health. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780195386585.003.0007.

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Patient health behavior is crucially important in the care of chronic disease. Medication adherence and lifestyle health behaviors both make major contributions to individual and population health. Clinical interventions to improve adherence and lifestyle are contrasted with their natural determinants. The Chronic Care Model shifts our attention from promoting patient obedience to developing skills for self-management of chronic illness. We need to ask whether treatment of chronic illness, like diabetes, should be accomplished through or around patient. Two recent diabetes treatment trials, ACCORD and TEAMCARE, provide contrasting approaches to the nature of therapeutic action. The Diabetes Prevention Project demonstrated that it is possible to prevent the development of diabetes through exercise and diet or medication. Adherence to treatment appears to improve health outcomes, even if the treatment is inactive, through the “healthy adherer effect.” This suggests that an active approach to health may have intrinsic benefits.
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17

Sullivan MD, PhD, Mark. From Patient to Agent. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780195386585.001.0001.

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In the 21st century, the primary challenge for health care is chronic illness. To meet this challenge, we need to think anew about the role of the patient in health and health care. There have been widespread calls for patient-centered care, but this model of care does not question deeply enough the goals of health care, the nature of the clinical problem, and the definition of health itself. We must instead pursue patient-centered health, which is a health perceived and produced by patients. We should not only respect, but promote patient autonomy as an essential component of this health. Objective health measures cannot capture the burden of chronic illness, so we need to draw on the patient's perspective to help define the clinical problem. We require a new definition of health as the capacity for meaningful action. It is recognized that patients play a central role in chronic illness care, but the concept of health behavior retards innovation. We seek not just an activated patient, but an autonomous patient who sets and pursues her own vital goals. To fully enlist patients, we must bridge the gap between impersonal disease processes and personal processes. This requires understanding how the roots of patient autonomy lie in the biological autonomy that allows organisms to carve their biological niche. It is time for us to recognize the patient as the primary customer for health care and the primary producer of health. Patient agency is both the primary means and primary end of health care.
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18

Marvasti, Farshad Fani. The Role of Family and Community in Integrative Preventive Medicine. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190241254.003.0006.

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The role of family and community in integrative preventive medicine (IPM) is to leverage primary care as the chief means for disseminating and implementing a new integrative model of prevention. Thus IPM provides a shift from acute to chronic disease treatment and prevention with the goal of morbidity compression to extend the period of disease-free high-quality life. This shift results in a new focus for family and community medicine. Integrative preventive medicine realigns primary care with primary prevention, from reactive “sick” acute care to proactive preventive “health” care. It recreates “routine” physical exams as opportunities for primary prevention and patient health education. It empowers physicians to go beyond simply screening for secondary prevention and waiting for a disease to be diagnosed in favor of proactively engaging patients with an evidence-based lifestyle regimen to prevent the onset of disease and maintain optimal health for as long as possible.
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19

Zabrecky, George. The Role of Chiropractic in Mind–Body Health. Edited by Anthony J. Bazzan and Daniel A. Monti. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190690557.003.0009.

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The chiropractic approach is based on the principles that diseases, both psychiatric and medical, are caused by disturbances in the nervous system and that such disturbances are often related to musculoskeletal problems. Thus chiropractic therapies utilize an integrative approach to health and well-being that includes various spinal manipulations as well as an integrative approach to the patient. Chiropractic therapies are most well known for the management of chronic and acute pain, which frequently can be accompanied by anxiety and depression symptoms. There is little direct evidence that chiropractic care improves mental health outside of the benefits related to pain alleviation. However, based on the overall chiropractic model, chiropractic therapy can potentially benefit a wide variety of psychological symptoms, but more research is needed. This chapter reviews the principles of chiropractic care, particularly in the context of psychiatric conditions, and provides information for future clinical and research programs.
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20

Hill, Douglas L., and Chris Feudnter. Hope in the Midst of Terminal Illness. Edited by Matthew W. Gallagher and Shane J. Lopez. Oxford University Press, 2017. http://dx.doi.org/10.1093/oxfordhb/9780199399314.013.19.

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Although palliative and hospice care services are increasingly available, many adults and children still die without this kind of support or receive it only in the last few days of life, as many patients, family members, and clinicians equate the initiation of these services with loss of hope. This chapter presents a model of how hopeful patterns of thinking and a balance of positive and negative affect may facilitate a regoaling process in which individuals transition from cure-seeking goals to other personally meaningful goals that are attainable at the end of life or while living with a serious chronic illness. Understanding different forms of hopeful thinking, goals, and self-concepts among dying patients and their families can help clinicians provide support through this difficult experience and achieve better quality of life and symptom management for patients and better quality of life and long-term adjustment for family members.
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21

Sullivan, Mark D. Health as the Capacity for Action. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780195386585.003.0006.

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Objective definitions of health and disease are favored because they promise a value-free measure of health problems and health care needs. But objective health does not simply cause the subjective experience of health. Self-rated health predicts mortality, disability, and hospitalizations for up to a decade after controlling for objective measures of health. Objective tissue abnormalities cannot be discovered to be pathological without reference to the experiences of patients acting in their natural environment. Patients adapt to chronic illness and its functional deficits over time with real improvements in their quality of life. Problems like pain and depression do not distort quality of life assessments, but are at their core. Since neither objective nor subjective models of health are valid, we must derive a different model: health as capacity for action. Any adequate approach to health must foster the patient’s sense of agency, her capacity to achieve her vital goals.
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