PURPOSEThe purpose of this analysis and commentary was to explore the rationale for an integrated approach, within and outside the offi ce, to help patients pursue healthy behaviors.
METHODSWe examined the role of integration, building on (1) patterns observed in a limited qualitative evaluation of 17 Prescription for Health projects, (2) several national policy initiatives, and (3) selected research literature on behavior change.
RESULTS The interventions evaluated in Prescription forHealth not only identifi ed unhealthy behaviors and advised change, but also enabled patients to access information at home, use self-help methods, obtain intensive counseling, and receive follow-up. Few practices can replicate such a model with the limited staff and resources available in their offi ces. Comprehensive assistance can be offered to patients, however, by integrating what is feasible in the offi ce with additional services available through the community and information media.CONCLUSIONS Blending diverse clinical and community services into a cohesive system requires an infrastructure that fosters integration. Such a system provides the comprehensive model on which the quality of both health promotion and chronic illness care depend. Integrating clinical and community services is only the fi rst step toward the ideal of a citizen-centered approach, in which diverse sectors within the community-health care among them-work together to help citizens sustain healthy behaviors. The integration required to fulfi ll this ideal faces logistical challenges but may be the best way for a fragmented health care system to fully serve its patients.
INTRODUCTIONA ddressing health behaviors in primary care involves a familiar sequence of steps: (1) identifying the behavior(s) in question, (2) giving brief advice, (3) setting goals, (4) arranging for more intensive assistance, and (5) ensuring follow-up. 1 This sequence of tasks is embodied in a variety of models for behavioral counseling, notably the 5 A' s-assess (ask about the behavior status and the factors affecting change), advise (give a clear, personal message of encouragement to change), agree (set goals based on readiness to change), assist (use behavior change techniques, such as self-help, counseling, or both, to promote acquisition of the skills, confi dence, and environmental supports for change, supplemented by medical treatments when appropriate), and arrange (schedule follow-up contacts, including referral for more intensive treatment). 2 The effectiveness of clinicians in promoting healthy behaviors and the quality of their service to patients are probably maximized when practices have systems in place to support this entire counseling sequence-all of the 5 A' s-rather than simply components of the process.3 Systematic reviews and clinical experience have shown that practices that use multifaceted inter- How might such a comprehensive system look in conventional primary care practices? In a perfect world, it would include a redesigned system of offi ce prac...