A new perspective published in the Journal of General Internal Medicine by Farhad Mehrtash and JoAnn E. Manson of Harvard Medical School and Mass General Brigham proposes a practical way out of this impasse. Their answer is a team-based implementation of the 5A’s framework—Assess, Advise, Agree, Assist, Arrange—endorsed by the United States Preventive Services Task Force for behavior counseling. The core insight is a division of labor: clinicians handle only the brief, high-value steps that require their expertise, while the rest of the care team absorbs the time-intensive work of counseling, resource navigation, and follow-up. The model is designed to fit inside the constraints of real-world primary care rather than demanding an idealized clinic that does not exist.

The mechanics of the workflow begin before the clinician ever enters the exam room. Team members measure vital signs and patients complete lifestyle screening questionnaires, ideally through the patient portal at home or on a tablet at check-in. The screening covers six behaviors: tobacco use, body mass index, physical activity beyond regular work, dietary pattern, alcohol consumption, and sleep duration and quality of at least seven hours per night. Patients also complete the Rapid Eating Assessment for Participants, Shortened Version 2, a validated dietary screener recommended by the American Heart Association that also captures alcohol and physical activity. Crucially, patients also report social barriers such as food insecurity or lack of transportation, which can derail even the best-designed lifestyle plans. The team then summarizes everything for the clinician, who reviews the results to complete the Assess step.

What follows is deliberately compressed. During the Advise step, the clinician explains how the screening results relate to health risks—for example, telling a patient who smokes that their habit increases the risk of cancer, heart disease, and stroke. During the Agree step, clinician and patient use shared decision-making to select one achievable behavior change, such as taking 15-minute walks or cutting back two cigarettes per day. The entire clinician interaction is designed to take under five minutes. For patients facing social barriers, the team first prioritizes connecting them to existing resources such as the Supplemental Nutrition Assistance Program, local food banks, or Medicaid non-emergency medical transportation before targeting lifestyle change itself, an acknowledgment that advice about diet means little to someone who cannot reliably obtain food.

The Assist and Arrange steps belong to the team. Medical assistants, nurses, health coaches, or community health workers help patients translate goals into specific daily actions and track progress using tools matched to each behavior and to the patient’s digital literacy. Options range from paper-based food journals, weigh-ins, trigger logs, and sleep diaries to apps such as MyFitnessPal, step trackers, and Sleepio. When patients need structured programs beyond brief counseling, teams connect smokers to quit lines via electronic referral and enroll patients with prediabetes in the Diabetes Prevention Program. Clinicians refer patients with diabetes or dyslipidemia, or those needing weight, dietary, or alcohol support, to registered dietitians for individualized medical nutrition therapy, and refer persistent sleep problems to sleep medicine or behavioral sleep specialists for cognitive behavioral therapy for insomnia. In the Arrange step, teams schedule follow-up contacts by phone, portal, or visit to review progress, adjust goals, and track referral completion through the electronic health record.

Concerns that delegation would add to clinicians’ administrative burden appear to be unfounded. In a national study of more than 18,000 physicians, shifting documentation to the team lowered clinicians’ total electronic health record time rather than adding to it. The authors also lay out the financial plumbing that makes the model sustainable. Practices can bill for preventive counseling under codes 99401 through 99404, smoking cessation under 99406 and 99407, medical nutrition therapy under 97802 through 97804, obesity counseling under G0447, and physical activity and nutrition assessment under G0136. When social barriers impede treatment, Community Health Integration services under code G0019 reimburse team members for up to 60 minutes per month of resource navigation per patient. Coverage varies and payment for preventive counseling remains low, but value-based and capitated payment models, which reward preventing downstream chronic disease rather than paying only for counseling visits, make the framework more financially viable. Embedding referral and follow-up tracking in the electronic health record also helps programs persist after temporary grant funding ends, and lifestyle medicine assessment tools such as the American College of Lifestyle Medicine Short Assessment Form are now being integrated into platforms like Epic.

The evidence that each targeted intervention works is substantial. Delivering the Assist step for tobacco cessation increased the odds of quitting by 40 percent, and the Arrange step by 46 percent. Brief alcohol counseling in adults screening positive for unhealthy use reduced consumption by roughly 1.6 drinks per week and lowered the odds of exceeding recommended limits by 40 percent at six to twelve months. Medical nutrition therapy reduced total cholesterol by 4.64 to 20.84 milligrams per deciliter, LDL cholesterol by 1.55 to 11.56, and triglycerides by 15.9 to 32.55. The Diabetes Prevention Program’s lifestyle intervention, targeting seven percent weight loss, reduced diabetes incidence by 58 percent in adults with prediabetes over three years, an effect that persisted as a 27 percent reduction after fifteen years. Even small doses of activity matter: adding just five minutes of daily moderate-to-vigorous physical activity may prevent six to ten percent of all deaths, with the greatest benefit—roughly thirty percent lower mortality—among the most sedentary. And in a randomized trial of 642 adults across 35 primary care practices, four sessions of nurse-delivered sleep restriction therapy significantly decreased insomnia severity at six months.

The gap between this evidence and everyday practice is enormous. While 65 percent of smokers receive cessation advice, only 13.4 percent of visits include dietary counseling and just 5.3 percent include physical activity counseling. Only a quarter of patients with diabetes receive any lifestyle counseling, and fewer than 5 percent of adults with prediabetes are referred to the Diabetes Prevention Program. The authors attribute these failures to payment models that reward procedures and hospital-based care over prevention, combined with practices lacking the time, staffing, and payment support to implement evidence-based programs. Yet team-based referral systems demonstrably improve enrollment: a St. Louis program using community health workers enrolled 30 percent of referred patients in the Diabetes Prevention Program and a blood pressure self-monitoring program, and expanding medical assistants’ roles within team-based workflows raised smoking cessation counseling rates from 45 to 89 percent, sustained beyond one year.

A common objection is that most practices lack the staffing such models assume. Only 11.4 percent of practices reach the recommended two-to-one medical-assistant-to-clinician ratio, and more than half employ just one medical assistant per clinician. The framework’s answer is flexibility: because it does not depend on any specific role, it adapts to whatever staff a practice already has, whether nurses, health coaches, or community health workers. At minimum, a practice with a single medical assistant can deliver all five steps by splitting the workflow across the visit—screening at intake by the assistant, brief Advise and Agree during the visit by the clinician, and Assist and Arrange at checkout by the assistant, who connects patients to quit lines or prevention programs. The model is not merely theoretical for underserved settings: in one randomized trial, medical assistants trained in self-management support and follow-up raised the proportion of safety-net patients meeting at least one clinical goal for diabetes, blood pressure, or cholesterol to 46.4 percent, compared with 34.3 percent under usual care.

The broader significance of the proposal lies in its refusal to treat prevention as an ideal that must wait for a perfect health system. By limiting the clinician’s role to brief assessment and goal setting while leveraging team-delivered counseling, structured referrals, and existing billing mechanisms, the 5A’s framework turns what has long been framed as an impossible time problem into a solvable workflow problem. With up to 35 percent of adults lacking adequate sleep and chronic disease driving the bulk of morbidity and mortality, the authors argue that systematically addressing modifiable behaviors within routine care is one of the highest-yield opportunities in medicine—and one that, with the right division of labor, primary care practices can begin implementing now.

Subject of Research: Team-based implementation of the 5A's framework for lifestyle behavior counseling and chronic disease prevention in primary care

Article Title: Implementing the 5A’s for Lifestyle Behavior Counseling and Chronic Disease Prevention

Article References: Mehrtash, F., & Manson, J. E. (2026). Implementing the 5A’s for Lifestyle Behavior Counseling and Chronic Disease Prevention. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10860-2

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10860-2

Keywords: 5A's framework, lifestyle medicine, chronic disease prevention, primary care, behavioral counseling, team-based care, cardiovascular disease, type 2 diabetes, Diabetes Prevention Program, preventive medicine, health coaching, medical assistants

The intervention at the heart of the Whole Health Options and Pain Education, or wHOPE, study is the Whole Health Team, an interdisciplinary unit composed of a medical provider, a complementary and integrative health provider, and a health coach. Together, these clinicians provide holistic, non-pharmacological pain care grounded in VA’s broader Whole Health approach, which begins with open-ended inquiry into what matters most to each patient and proceeds through collaborative Personal Health Planning. Over twelve months, patients attended five or more collocated visits with the team’s medical and integrative providers, supplemented by eight or more health coaching visits, while weekly team huddles supported case management and care planning. In a national randomized controlled trial of 764 veterans with moderate to severe chronic pain, the Whole Health Team outperformed both modified Cognitive Behavioral Therapy for Chronic Pain and usual care in reducing pain interference and increasing use of non-pharmacological pain services, with patients also reporting greater improvements in overall health status and treatment satisfaction.

Given that demonstrated effectiveness, the research team led by Natalie Purcell, Liliana C. Moore, William C. Becker, and Karen H. Seal turned to a critical follow-up question: can this model actually be scaled? Because the Whole Health Team approach is not simply multimodal but also team-based, interdisciplinary, and integrated, requiring collocated clinical visits, routine coaching, and weekly huddles, it is more complex and resource-intensive than many other pain interventions. To investigate, the researchers conducted semi-structured interviews with 43 clinicians and staff involved in implementing the intervention, including 14 health coaches, 6 primary care providers, 6 integrative-trained providers, 5 other clinical professionals, 8 local site investigators, and 4 study coordinators. Guided by the Practical Robust Implementation and Sustainability Model, a framework that maps contextual factors from planning through sustainment, the team used template-based rapid analysis to distill themes from interviews lasting 30 to 60 minutes each.

The first major theme concerned team composition and collaboration, and here the clinicians were emphatic. They praised the interdisciplinarity of the model and described working in a genuinely integrated fashion rather than in silos. One medical provider captured the spirit of the collaboration vividly, recalling that the team was working with patients together, talking together, interrupting each other, and asking questions rather than operating separately. Collocated patient visits served as a central venue for this active collaboration, but so did the weekly huddles between visits, where hearing one another’s perspectives helped the team generate multiple options when patients faced challenges. A complementary and integrative health clinician noted that a single lens might not be the best thing for the patient, and expressed appreciation for the ability to hear the same piece of information and encounter completely different perspectives on how to manage it. Clinicians also believed that visible collaboration increased veteran engagement, with one coach observing that simply knowing the team was working together on their behalf gave patients another layer of buy-in.

Consistency of team membership emerged as another essential ingredient. Clinicians stressed that building trust with patients requires time and continuity, and that the twelve-month structure of regular clinical and coaching visits cultivated increased trust, deeper rapport, and genuine continuity of care. Patients came to depend on a familiar team they got to know, which in turn facilitated active involvement in care planning. Yet sustaining that consistency proved difficult. Because clinicians were volunteers lending their time from other duties, they were sometimes pulled off the study to devote resources elsewhere, a problem amplified during the COVID-19 pandemic during which all study interventions were delivered virtually. Clinician turnover interrupted care relationships and left key roles vacant at times, burdening remaining team members and making it harder to practice with a Whole Health approach. Interviewees stressed that team stability must be prioritized if relationship-based care is to survive contact with real-world staffing pressures.

Adequate, formally allocated clinician effort was perhaps the most contested resource of all. The Whole Health Teams operated in an institutional environment focused on optimizing productivity, where bookable hours were measured closely and every clinic scheduling grid was scrutinized. Both clinicians and site investigators emphasized the importance of protected time for team work, including dedicated clinic hours, time for writing notes, and time for the weekly huddles they considered critical. All participating sites did secure protected time, but doing so required staunch advocacy amid competition for clinical resources, and maintaining it remained an ongoing challenge. One site investigator described it as probably the biggest obstacle the team had faced. Clinicians also valued formal orientation to the team, which covered roles, visit protocols, and documentation requirements, though some, including several medical providers, retained uncertainty about their prescribing role relative to patients’ primary care providers, underscoring the need for clearly delineated responsibilities in interdisciplinary teams.

The second major theme involved organizational infrastructure and integration, beginning with the need to fill gaps rather than duplicate existing services. Because some VA health systems already offer pain-management and wellness programs, clinicians and investigators argued that the more resource-intensive Whole Health Team model must demonstrate unique value to make a viable business case for sustainment. They found that value in delivering an integrated, consistent message to each patient. One medical provider lamented that the health system is so fractured that patients see different people who tell them different things, and described the team as an efficient and effective way to help patients with a coherent care plan, noting that veterans like to see that their clinicians are all on the same page. The model also improved the clinicians’ own work experience, fostering mutual support and confidence when caring for patients with complex needs. At the same time, interviewees identified shortcomings: coordination with primary care sometimes felt informal, relying on discretionary co-signature of notes that primary care providers did not always read, and referral pathways to wellness and complementary modalities were often poorly mapped, forcing coaches to act as conduits to information that higher-level staff knew less and less about.

The third theme centered on administration and documentation, an unglamorous but decisive factor. Implementing collocated visits and concurrent health coaching is administratively complicated, and each site benefited from a study-funded, full-time coordinator who scheduled meetings and patients, set up clinic grids, collected point-of-care measures, tracked visits, completed documentation, made reminder calls, and served as an information hub for the whole team. One coordinator cautioned bluntly that if the model were implemented elsewhere, the level of administrative support provided in the study simply would not be available in a clinical service. Clinicians also chafed against standardized clinical note templates designed for study data collection, which felt ill-suited to personalized whole-person care. One provider asked why they needed to do math during a visit and take time away from listening to a veteran’s story, while another complained that templates force a robotic style that annoys patients. The consensus favored simpler, more flexible documentation that could adapt to each visit’s focus.

Perhaps the most striking finding was the depth of clinicians’ belief in the Whole Health model despite every implementation hurdle. Interviewees described practicing in line with their own values, connecting with patients more authentically, and witnessing emotional exit visits in which patients felt deeply cared for and equipped with new resilience and tools. One provider offered a sentiment that captures the model’s philosophy: patients are people, more than just a list of diagnoses, and they are fun and complicated. These accounts align with broader evidence that Whole Health practice may reduce clinician stress and burnout, and with VA survey findings that clinicians engaged in Whole Health view their workplaces more favorably and are less likely to resign. Yet many participants doubted the system would retain and spread the teams, perceiving the model as resource-intensive in an environment that rewards volume and perceived efficiency over quality, experience, and outcomes. They saw the teams as an upstream investment with downstream benefits, but acknowledged that a comprehensive longer-term cost-effectiveness analysis may be needed, particularly as an alternative to interventional pain care.

The study’s lessons amount to a practical blueprint for any health system contemplating integrated, person-centered pain care. Success requires consistent team membership, sufficient protected clinical effort, well-defined roles, team-based training, routine huddles, and skilled administrative support that could be provided by a nurse care manager or medical support assistant in the absence of a study coordinator. It also demands organizational readiness: accessible complementary and integrative health modalities, wellness programs, and health coaching, along with clear referral pathways connecting pain teams to those resources. Deeper integration with primary care, through periodic in-services or coaches already embedded in primary care, could strengthen both patient care and sustainability. As VA continues its transformation into a Whole Health System of Care, and as other integrated systems such as Kaiser Permanente pursue similar holistic models, the wHOPE findings illuminate both the promise and the price of treating chronic pain as a whole-person problem, offering hard-won insight into a care model that the clinicians who delivered it clearly believe is worth sustaining.

Subject of Research: Implementation of interdisciplinary whole-person chronic pain care in the Veterans Affairs Whole Health Team model

Article Title: Implementing Integrated Whole-Person Care for Chronic Pain: Lessons from VA’s Multisite wHOPE Study

Article References: Purcell, N., Moore, L. C., Becker, W. C., & Seal, K. H. (2026). Implementing Integrated Whole-Person Care for Chronic Pain: Lessons from VA’s Multisite wHOPE Study. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10825-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10825-5

Keywords: chronic pain, Whole Health, Veterans Affairs, interdisciplinary care, implementation science, complementary and integrative health, health coaching, multimodal care, biopsychosocial, qualitative research, primary care, clinician burnout