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A central concern that TL theory approaches but does not fully address is the process whereby an individual generates a more adequate meaning perspective after shedding an outmoded one. This article complements TL theory's account with a phenomenological description of the dangers and opportunities encountered on that quest. It employs the concept of liminality to articulate the transitional process that occurs when one has lost the familiar reference points that enabled one to feel at home. It begins to map the journey from disorientation to integration. Between those endpoints lies the liminal zone. Because there is little if any structure in that realm--hence the experience of groundlessness--agency is relatively unfettered in its search for new meaning perspectives. Originary thought that transcends the conventional ways of operating becomes possible. This is culturally significant as our current frameworks lack the potency to respond to the multiple challenges we are facing.

NAPCRG celebrated 50 years of leadership and service at its 2022 meeting. A varied team of primary care investigators, clinicians, learners, patients, and community members reflected on the organization's past, present, and future. Started in 1972 by a small group of general practice researchers in the United States, Canada, and the United Kingdom, NAPCRG has evolved into an international, interprofessional, interdisciplinary, and intergenerational group devoted to improving health and health care through primary care research. NAPCRG provides a nurturing home to researchers and teams working in partnership with individuals, families, and communities. The organization builds upon enduring values to create partnerships, advance research methods, and nurture a community of contributors. NAPCRG has made foundational contributions, including identifying the need for primary care research to inform primary care practice, practice-based research networks, qualitative and mixed-methods research, community-based participatory research, patient safety, practice transformation, and partnerships with patients and communities. Landmark documents have helped define classification systems for primary care, responsible research with communities, the central role of primary care in health care systems, opportunities to revitalize generalist practice, and shared strategies to build the future of family medicine. The future of health and health care depends upon strengthening primary care and primary care research with stronger support, infrastructure, training, and workforce. New technologies offer opportunities to advance research, enhance care, and improve outcomes. Stronger partnerships can empower primary care research with patients and communities and increase commitments to diversity and quality care for all. NAPCRG offers a home for all partners in this work. Key words: primary care; family practice; general practice; research; organizations; NAPCRG; interdisciplinary research; community-based participatory research, INTRODUCTION NAPCRG celebrated its first 50 years at its 2022 annual meeting. A varied group of members reflected on the organization and its place in family medicine and primary care [...]

Mezirow's theory of transformative learning presupposes agency. Agency is the means by which the limitations of an inadequate meaning perspective are transcended. It is the creative activity necessitated by an encounter with a disorienting dilemma. This implies that transformation cannot be achieved "from within" the existent meaning perspective. It can only be exercised from "outside" that constellation of constructs. This depends on the person dissociating from that perspective in order to enter a groundless state where originary thought is possible. In that state, they have access to an impersonal consciousness. That impersonal consciousness, which constructed the problematic meaning perspective, is now utilized for designing a more adequate one. These processes are accompanied by associated affects. For example, anxiety is the affect associated with groundlessness whereas depression with the lack of agency. I suggest that agency arises when the situation demands it and falls away after the dilemma has been addressed.

Barriers to the spread of integrated behavioral health and primary care continue to limit progress on meeting critical needs for mental health and substance use disorder services. The recent Bipartisan Policy Center Report (2021) provides key policy recommendations to address these barriers and accelerate the adoption of integrated behavioral health in Medicaid and Medicare. Having bipartisan support presents a policy window of opportunity to advance integrated behavioral health through advocacy for implementation of these recommendations, parallel changes to occur in employer-based and other commercial insurance plans, and development of operationalized standards for core service delivery elements., During the nearly 50 years since the articulation of the biopsychosocial model as the desired way to provide health care (Engel, 1977), evidence has continued to mount indicating that there [...]

In this paper we look into the conditions in which dialogue could be utilized to facilitate transformative learning and reflection. We explore the notion of a safe and accepting learning environment from the relational and phenomenological viewpoint, and analyze what it actually means and how it may be developed. We understand facilitating conditions as an inseparable aspect of the learning process similarly to the way a greenhouse supplies right conditions to facilitate the growth of the plant. Similarly as the ground, warmth and light play their essential roles in the growing of the plant, in our paper we offer conceptual tools to understand the dynamics of safe and accepting learning environment in facilitating the processes of reflection and transformative learning.

People working on behalf of population health, community health, or public health often experience confusion or ambiguity in the meaning of these and other common terms--the similarities and differences and how they bear on the tasks and division of labor for care delivery and public health. Shared language must be clear enough to help, not hinder people working together as they ultimately come to mutual understanding of roles, responsibilities, and actions in their joint work. Based on an iterative lexicon development process, the authors developed and propose a definitional framework as an aid to navigating among related population and community health terms. These terms are defined, similarities and differences clarified, and then organized into 3 categories that reflect goals, realities, and ways to get the job done. Goals include (a) health as well-being for persons, (b) population health as that goal expressed in measurable terms for groups, and (c) community health as population health for particular communities of interest, geography, or other defining characteristic--groups with shared identity and particular systemic influences on health. Realities are social determinants as influences, health disparities as effects, and health equity as both a goal and a design principle. Ways to get the job done include health care delivery systems for enrollees and public health in population-based civic activities--with a broad zone of collaboration where streams of effort converge in partnership with served communities. This map of terms can enable people to move forward together in a broad zone of collaboration for health with less confusion, ambiguity, and conflict. Key words: population health; lexicon; definitions; primary care public health integration, THE IMPERATIVE AND THE PROBLEM The terms population health, community health, and public health are often used interchangeably, yet imprecisely, leading to conceptual and practical misunderstandings. Each term relates in [...]

Introduction The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity. Methods From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions. Results An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had. Conclusion These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs. [ABSTRACT FROM AUTHOR]

Context: Behavioral health integration (BHI) in primary care improves outcomes and decreases costs; yet its uptake has been limited by inadequate payment. Payers have expressed a need to understand how additional resources for BHI will be used. Implementation of BHI varies depending on patient population needs, practice resources, and local workforce availability. Objective: To develop a framework for BHI in primary care that would inform the design of alternative payment models supporting BHI, align payer expectations, decrease administrative burden on practices, and achieve a level of standardization of BHI care delivery requirements that enhance patient care while still allowing for flexibility. Study design: (1) Milestones used for the Colorado State Innovation Model were examined to select items specific to BHI that could be overlaid on more general milestones for advancing primary care. These items were divided into foundation and additional modular components of BHI: advanced coordination and care management, integrated behavioral health professionals, psychiatry, and the advanced care of substance use disorders. (2) Other frameworks for BHI were reviewed to identify any gaps. (3) Key informant interviews were held to obtain feedback from relevant stakeholders to further refine the framework. Dataset: Other frameworks and tools reviewed: Colorado State Innovation Model milestones, NCQA BH distinction, Continuum-based framework for integrated care, Integrated Practice Assessment Tool, Practice Integration Profile. Population studied: 15 key informant interviews were conducted with payers, policymakers, behavioral health and primary care providers, practice transformation experts, and patient advocates. Instrument: A semi- structured, piloted interview guide was used for key informant interviews. Results: A refined framework outlining care delivery expectations for varied implementation approaches of BHI, designed to be used by payers and policymakers in developing alternative payment methodologies to support BHI. Conclusions: This framework can be applied to alternative payment models at the state, regional, and federal levels to improve alignment of expectations across payers, providers, and patients., Presenters Stephanie Gold, MD, Larry Green, MD, Perry Dickinson, MD, Stephanie Kirchner, MSPH, RD, Emma Gilchrist, MPH, Bahroze [...]

Integrated Care Pioneers While the journey to integrated behavioral health and primary care for some pioneers in Colorado started decades prior, we begin our story with Advancing Care Together (ACT), [...]

Sociologist Zygmunt Bauman characterizes our time as a time of "liquid modernity" (Bauman in "Liquid modernity." Polity Press, Cambridge, 2000). Rather than settled meanings, categories, and frames of reference Bauman contends that meaning is always in flux, open ended rather than closed. Given Bauman's assessment, pedagogies that are directed towards finding, accepting, or imposing meaning come up short. They offer closed, "finished" meanings instead of an examination of the ongoing, open ended, process of meaning making. What might a pedagogy for a liquid time look like? This is the animating question of this essay. Pedagogically we are interested in this ambiguous space between paradigms of meaning. Rather than resolution or the accommodation and building of new schema (or the acceptance of established schema), we explore the need for constant schema building and renewal--the necessity of living in a state of perpetual emergence. Zygmunt Bauman's notion of "liquid modernity" suggests that anomalies, rather than exceptions, are the norm; we are living with permanent uncertainty, needing to hold all schemes lightly (Bauman 2000).

In this article, I describe a practice that employs somatic awareness as a method for both disclosing and working with internal conflict. In the two cases described, transformational change became a possibility for one client, and an actualization for another, I instantiate these abstract claims in two case studies. In the first case, I describe the initial launch into the transformational process and, in the second, the unanticipated and beneficial results occurring later. This process is produced by a creative act that replaces limited foundational premises with ones that transcend those limits - thereby changing the person's life trajectory. Creative agency is both the source and force capable of generating this fresh psychic form. This capacity is accessed by stepping outside the confines of personal consciousness. Once there, one can operate from an impersonal consciousness. This possibility is based on the notion that humans are endowed with impersonal consciousness at birth. Originally it is employed to construct a personal self that will eventually become a sedimentation of that individual's experiential history. Transformation requires access to the same psychic powers that produced the original self. Both the original creation and its subsequent transformation occur through the exercise of impersonal consciousness. Throughout the piece, I interpolate theoretical interpretations that clarify how my approach taps into somatic, existential intelligence - creative agency. [ABSTRACT FROM AUTHOR]

The article discusses the concept of pre-personal consciousness and the pre-reflective self in transformative learning. The author argues that the pre-reflective self, which operates out of awareness and is based on experiential history, is what transforms. Pre-personal consciousness, which is present at birth, is responsible for constructing the pre-reflective self. The author emphasizes that agency is an activity rather than an entity and that pre-personal consciousness is necessary for genuine creation and improvisation. The article also highlights the difficulties in theorizing agency and the challenges of detachment and grieving in the process of transformation. [Extracted from the article]

In 2022 NAPCRG is celebrating its 50th anniversary of researchers coming together to share their questions and solutions! Since 1972, when Maurice Wood first envisioned NAPCRG, we have become a [...]

Although the notion of transformative learning points to a desirable destination for educational endeavors, the difficulty in the journey is often neglected. Our intention is to map the experiential micro-processes involved in transformative learning such that the phenomenon is illuminated from a first-person rather than third-person point of view. Employing that point of view, we believe, provides a common frame of reference for both the mentor and the protégé. We employ the notions of liminality, comfort zone, and edge emotions to elucidate the transformative process. The more intimate understandings that result should assist educators to support students who are undergoing such a metamorphosis. In addition, the article will consider some of the challenges encountered by the educator who wishes to support students through this process.

Objective: This study assesses whether the National Health Service Corps's legislated goals to see health improve and health disparities lessen are being met in rural health professional shortage areas for a key population health indicator: age-adjusted mortality. Methods: In a descriptive study using a pre-post design with comparison groups, the authors calculated age-adjusted mortality rates at baseline (1981-1983) and follow-up (1996-1998) for the populations of 448 rural whole-county health professional shortage areas arrayed into 3 groups based on the number of study years they were staffed by National Health Service Corps physicians, physician assistants, and nurse practitioners (terms of 1 to 7, 8 to 11, and 12 to 15 years). The authors compared changes over time in age-adjusted mortality rates in the 3 county groups that had National Health Service Corps staffing with rate changes in 172 whole-county rural health professional shortage areas and 772 non-health professional shortage area rural counties that had no National Health Service Corps. Results: At baseline, age-adjusted mortality was higher in all 4 health professional shortage area county groups than in the non-health professional shortage area county group. Age-adjusted mortality rates improved with time in all groups, including health professional shortage area counties both with and without National Health Service Corps support, and non-health professional shortage area counties. Essentially, baseline differences in age-adjusted mortality rates between health professional shortage areas and non-health professional shortage area counties did not diminish with time, whether or not there was National Health Service Corps support. Conclusions: From the early 1980s through the mid-1990s, the National Health Service Corps's goal to see health improve in rural health professional shortage areas was met, but its goal to diminish geographical health disparities was not. Because age-adjusted mortality rates improved in all county groups, the authors conclude that improvement was likely due to a variety of factors, including decreasing poverty and unemployment rates and increasing primary care physician-to-population ratios, to which the National Health Service Corps may have contributed.

A survey of 97 chairmen of academic departments of family medicine found that over half intended to leave their position within 5 years, with job dissatisfaction given as the reason by 52. Findings suggest that future demand for academic chairmen of family medicine departments will be large and that chairmen will be young with limited academic experience. (Author/DB)