Integrative medicine (IM) is patient-centered, whole person healthcare embracing the body’s self-healing capacity and emphasizing the importance of lifestyle to enhance health (Maizes 2009; Rees 2001) [1, 2]. IM is an evidence-based, prevention-oriented, clinical approach that incorporates conventional medical treatment together with complementary medicine (CM) modalities (Boon 2004, Maizes 2002) [3, 4]. Components such as ready access to care, promotion of self-care, and good patient-practitioner relationship are central to achieving successful patient outcomes.
The University of Arizona Integrative Health Center (UAIHC), in Phoenix, Arizona, was a novel clinic offering integrative primary care. UAIHC was designed to embody integrative philosophies and an integrative care delivery model. In addition to the two fulltime University of Arizona Center for Integrative Medicine (AzCIM) IM fellowship-trained primary care physicians, practitioners included a chiropractor, 1–2 acupuncturists, a behavioral health clinician, a dietitian, a health coach and a nurse. Prior to opening the UAIHC, all staff members completed an online Introduction to Integrative Medicine course and participated in a 2-week training period. This training included introductory sessions in Motivational Interviewing and Mindfulness Based Stress Reduction, along with an in-depth overview of current literature on various integrative and complementary approaches to the treatment of several major common conditions, including diabetes mellitus, metabolic syndrome, cardiovascular disease and chronic pain. Although no specific guidelines were employed in care delivery, the staff were well trained in their perspective disciplines. UAIHC was supported by a hybrid financing structure that combines health insurance reimbursement with membership fees paid by patients and/or employers.
Key features of the model included completion of a detailed health intake by the IM physician in which all aspects of health and lifestyle were evaluated including but not limited to diet, sleep, activity, stress, relationships and spirituality. Each patient entered into a Health Partnership Agreement with their practitioner in which each individual and their physician committed to lifestyle change and personal responsibility. Care was delivered using a team care approached in which the health partnership philosophy was enacted in support of patients’ needs, and in a manner consistent with each patient’s goals, beliefs and values. Evidence on the potential impact of various treatment options and modalities offered in the health center were presented to patients, and individuals were supported in making informed decisions regarding which types of practitioners would be participating in their care team. A health coach was also available to aid individuals in successfully making and sustaining lifestyle change. There were also a number of groups and classes offered to patients at the health center including courses on nutrition, stress reduction, optimal weight and lifestyle, along with the opportunity to participate in yoga and Tai Chi groups offered on site.
During operation of the clinic, there were 1700 individuals who purchased memberships. The demographics of the clinic population closely matched those of the group that participated in this portion of the study and is described in the results section below.
While growing numbers of integrative clinics are being developed nationwide, few have tested whether an integrative model of care is actually being practiced. Therefore, it is challenging to assess which of the components of integrative medicine are being delivered, how well, and whether they contribute to health or cost outcomes (Dodds 2013) . Fidelity refers to delivering an intervention as designed, here describing implementation integrity (Carol 2007) .
Research on UAIHC outcomes includes an assessment of fidelity to the principles and practices of IM using validated measures whenever possible; i.e., is the UAIHC practice model being delivered as intended? Is the care patient-centered? Do patients receive whole-person care? Do patients have access to care? The specific components included in the fidelity assessment are: patient-centeredness, whole person care, enhanced access to care, and patient satisfaction. Additional outcomes to be reported in other papers include patient reported outcomes of mental, physical, and overall health; work productivity and activity; and overall well-being.
Patient-centeredness encompasses practitioner communication style (listening, understanding, explaining, validating, empathy), patient-practitioner partnership (shared decision-making and treatment planning), adequate visit time, and patient trust (Stange 2010) . Patient-centered care is generally assessed by the following areas of practitioner communication: 1) understanding the patient’s condition; 2) understanding the reasons for the visit and the patient’s information needs; 3) reaching a shared understanding of the treatment goals; and, 4) creating a continuing partnership (alliance) in which patients actively share in decision making and responsibility for their health. When these relational qualities are achieved, greater trust is instilled between patients and providers (Epstein 2005; Bertakis 2011) [8, 9]. Patients also may experience greater health self-efficacy (i.e., the extent to which patients feel capable of reaching their health goals) (Epstein 2005; Bertakis 2011) [8, 9]. Extended time with providers (60–75 min initial visits with 30-min follow-ups) allows sufficient time to discuss options and decisions, and allows the patient-practitioner relationship to grow (Maizes 2009) . Questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) (Hargraves 2003)  and the Consultation and Relational Empathy (CARE) measure (Mercer 2004)  were used to assess patient-centeredness.
Whole person care
Whole person care requires attention to all patient factors influencing health, wellness, and disease, including body, mind, spirit, and community (Long 2002) . These may encompass lifestyle choices, work and home environments, nutrition, interpersonal relationships, exercise and activities, and outlook on life. Items from the Ambulatory Care Experiences Survey (ACES) (Safran 2006)  and the CAHPS (Hargraves 2003)  evaluated whole person care.
Enhanced access to healthcare
Access in primary care is the ease with which a patient can secure an appointment with a clinician without experiencing administrative and financial barriers (Bell 2002) . The UAIHC hybrid financing approach was established as a means to increase patient access to healthcare through shorter wait times for appointments, same day appointments when clinically warranted, a broader primary care team, and longer appointments. For fidelity evaluation, access to care was assessed using a scale developed for the study that recorded the time between the patient’s initiation of service and receipt of an appointment. Items from the ACES (Safran 2006)  about courtesy and helpfulness of clinic front desk staff, and one item from the CAHPS (Hargraves 2003)  evaluated adequacy of the visit length and access.
Patient satisfaction ratings have long been used as dependent variables to evaluate health services and facilities on the assumption that satisfaction is an indicator of the structure, process, and outcomes of care. Satisfaction has also been used as an independent variable to predict patient behavior (e.g., service utilization, treatment adherence). Patient satisfaction was assessed with a 2-item measure from the CAHPS (Hargraves 2003) . An additional measure of satisfaction was assessed by asking the likelihood of recommending UAIHC to family or friends.