What is Integrative Medicine? DREAM BIG for the future of healthcare

This article concludes the series on What is Integrative Medicine? Past, Present, and Future. This article is an opinion piece exploring the necessary elements for a blueprint, not only for the future of integrative medicine, but also for the future of healthcare in the U.S. The U.S. integrative medicine past history and present perspective are covered in the aforementioned linked articles. 

The blueprint for innovative and sustainable healthcare

Integrative Medicine & Health (IM) is poised to be the blueprint for a sustainable future for healthcare in the U.S. The past and present perspectives set the stage for the evolution of IM and its eventual shift toward innovative and sustainable care. 

The future of healthcare (via IM) will be:

• Part of a whole system of primary care
• Team, Evidence, and Outcomes based
• Inclusive of -and- accessible to ALL
• Emphasizing self-care and empowerment

Whole System

IT IS TIME TO DREAM BIG. Recently, while reading David Rakel’s textbook, Integrative Medicine, I found a statement by the author that adding complementary and alternative therapies without changing our model of healthcare delivery will only lead to multiple disconnected providers treating the patient. What is really needed is a restructuring of integrative medicine to promote relationship-centered care.

These words are as true and relevant as ever. Let’s take a moment to envision a higher ideal for IM, besides simply a way to incorporate established and emerging complementary therapies into medical practice. That is not to diminish the relevance of continued research and development of non-pharmacological therapies for medical conditions, such as chronic pain. However, we are missing the boat if that is to remain the driving factor of the movement. The goal of true “integration” is the positive transformation of healthcare into a nurturing humanistic and holistic system that creates optimal environments for health.

The focus needs to be brought back to how to make the holistic philosophy of IM part of the primary care medical home. IM must become an integral part of value based primary care. This calls for a conscious effort to design primary healthcare to meet the patients’ emotional, physical, and spiritual needs, not as a way to perpetuate the current volume-based care system that dehumanizes the patients’ experience and treats medical providers like factory workers (no offense to factory workers is intended—but human healthcare should never be modeled after a factory). This also requires careful thought and financial analysis to make this a cost effective, sustainable model. 

Care for the mind, body, and spirit as a whole system is an ancient concept. It does not negate or contradict modern science; rather, it creates the infrastructure to deliver quality care. It supports medical science by addressing the human and relationship side of health and healing. Some argue that the word “spirit” invokes religion or otherworldly experiences. The word “spirit” for purposes of this discussion refers to the deepest source of connection and love a person can have with their own selves, environment, and those around them.

Teams, Evidence, Outcomes

Teams

As a specialist in Physical Medicine & Rehabilitation, team-based care is the rule, not the exception. We work closely with the rehabilitation team of therapists (PT, OT, SLP), social workers, and care managers to optimize patient function and medical status. We work together to develop a comprehensive care plan for each individual staying on an inpatient unit. The team members meet regularly and work together directly to synthesize treatment plans. This is termed interdisciplinary care. A similar term, multidisciplinary care, refers to care team members that work independently to provide treatment but are available to coordinate care by communicating their insights and recommendations to the team.

Interdisciplinary and Multidisciplinary care teams obviously are not a new concept but are needed more than ever in integrative primary care. Team-based integrative primary care fits into the patient medical home model of valued-based care. Further, team coordination and care plans are vitals elements of chronic care management, a reimbursable system of providing comprehensive services to medically complex patients. Medically complex patients with high resource utilization present an often missed opportunity for IM practices to provide team-based, cost effective chronic care management to prevent frequent hospitalizations.

Evidence

If you are taking an evidence-based approach to practicing IM, you have discovered quickly that all complimentary therapies are not created equal. Despite controversy, complimentary therapies should not be all grouped in one bag as “pseudoscience” as the critics argue. Conversely, they should not all be considered acceptable without proper clinical research methods or a critical review of the existing scientific literature. Further, many of us continue to call specific treatments “complimentary” that have been validated by scientific evidence and, by now, should be considered part of standard treatment. The term “complimentary” will continue to haunt us as long we continue to use it to rationalize adding extra therapies to standard care that others would argue to be medically unnecessary. The controversy will continue as long as we unconsciously (and others consciously) deem what we are doing to be medically unnecessary, costly, and no better than standard care alone. 

If we dream big and refuse to be sidelined, IM will not be complimentary in the future. It will be the standard of care. Paradoxically, IM will cease to exist once it achieves its goal of integration into medicine. To propel this forward we must present ourselves as the new blueprint for healthcare, a harmonious marriage between evidence-based and relationship-based holistic care. We will continue to strive everyday to practice good medicine and create high standards for our clinical decision making on behalf of our patients, prioritizing safe treatments with the most research evidence of effectiveness an individual’s medical condition(s). The present and future emphasis should continue to be at ALL TIMES— evidence-based care, informed consent, and patient safety. Transparency, replicable positive outcomes, and a proven track record of success are Evidence. 

Outcomes

Positive outcomes and continuous quality improvement are what will make IM sustainable and a worthwhile investment for future financial stakeholders and healthcare organizations. Similar to the scientific evidence gathered from research, positive outcomes provide evidence that a process or system is working.  Tracking outcomes for a clinic’s patient population is the foundation of population health. This ties in with a whole systems, value-based approach to integrative primary care. Health information technology and mobile apps afford this opportunity in a way that was unimaginable even a decade ago. Along with tracking, smart device technology enables patients to have direct engagement with their own health goals and progress. 

Once a streamlined process management system is created to improve workflow with data collection and interpretation, metrics can be tracked and the IM practice can respond quickly to unanticipated changes and identify emerging trends in the care of their patient panels. The information and insight gained can move the practice forward toward improving care and outcomes. IM can prove medical necessity, work toward achieving cost effectiveness, and provide sound rationale to become the standard of care. Presenting outcomes data to stakeholders is a powerful tool to advocate for a system wide model of integrative value-based primary care, rather than remaining sidelined. 

Inclusive of and accessible to all

The bare and unpleasant truth about IM’s struggle to be affordable, inclusive, and accessible was introduced in my last blog post. IM is so broad and encompasses so many diverse types of practice settings. It is admittedly difficult to address the needs from all the perspectives of integrative health practitioners. Nevertheless, in general, there is a need to restructure and redesign integrative healthcare to promote accessibility and inclusivity. 

Redesign Integrative Healthcare

Here are concepts that can help redesign integrative healthcare to be open access. 

• Community heath center IM primary care model

Bring the holistic and integrative philosophy to primary care in a centralized community health center model. This is where team, evidence, and outcomes based care create a sustainable and accessible system. Example: Southcentral Foundation (Alaska)

• Value-Based Care for Chronic Illnesses 

A validated chronic care model already exists to risk stratify and care for patients of varying levels of complexity through a systems approach to healthcare design and implementation. This potentially opens up IM to the entire patient population. Specific applications in IM are discussed further in a series of two white papers created for my e-mail subscribers. 

• Academic Integrative centers as innovation centers

Academic IM centers will to evolve to become hubs for research and education on breakthrough “non-pharma” medical therapies as well as incubators for healthcare innovation pilot projects and practice prototypes to bring IM to all patients. These centers will be in direct contact with the community primary care centers and serve as leaders in practice innovation and clinician continuing education. These centers will also support and partner with integrative specialists within the organization to develop innovative partner programs and update evidence-based treatment guidelines for health conditions. 

• Community referral network for private practice

The future design of a referral network of providers for private practice IM providers is a must to ensure sustainability and access to vast resources for care. This is especially important for specialists practicing integrative medicine who want to be directly connected to primary care clinics or join a value-based care network. Integrative specialists are vital consultants for medically complex patients, and access to their knowledge means access to better patient care.  

Initiatives to increase access

• Telehealth

Teleready or not, it’s here. We were catapulted into the world telehealth and telemedicine this year by the global pandemic. It is the time to start the process of learning about the practice logistics, state laws, coding, and reimbursement aspects of providing virtual IM visits. The idea that IM providers can reach people with transportation limitations and make healthcare more accessible is both exciting and daunting at the same time. This is an opportunity to expand service and break the barriers behind the office walls. Telemedicine can fill the gap in rural area where there are provider shortages, especially in integrative psychiatry and behavioral health.

• Health Coaching & Patient Education

Team-based care using health coaches expands access to support for lifestyle change and personal transformation. Along the same lines, cross training nursing and medical staff to provide personalized and group education gives access to knowledge that shifts the patients’ relationship to their health from from simple compliance to empowerment. 

• Group medical visits

A popular sustainable IM care model, providing access to both medical care and education, is the group medical visit. Care teams will continue to develop innovative ways to provide integrative care to groups, taking advantage of the power of support among group members to catalyze collective transformation. 

• Community Partnerships

Partnerships with underserved communities and engaged community volunteers are essential for reaching all demographics that would benefit from integrative healthcare. This is true reciprocity—teaching IM care strategies in exchange for learning the rich culture of a community through engaged listening and heart-to-heart connection. In addition to public health and cultural competency, community partnerships address solutions to unmet needs, such as a shortage of healthy food choices and malnutrition. 

Self-care and empowerment

The shift from patients receiving passive integrative therapies to becoming active participants in their health journey starts with focus on the holistic philosophy of the IM (as discussed in the first section). Body work like massage therapy and biofield therapies like acupuncture are ways to enhance the connection between mind, body, and spirit. These tools open up an avenue for patients to develop a deep experiential awareness of and connection to their bodies. It also introduces the participant, firsthand, to a relaxation response that can be replicated. It opens up the possibility of a new experience of life and a new perspective on stress and health. 

In an integrative care setting, the shift then should progress from a passive experience to learning to actively open awareness using techniques, such as Mindfulness Based Stress Reduction. Teaching others to control their body’s physiology through their minds is neither a new nor strange concept. Biofeedback used to be performed in laboratories with expensive equipment. Now, it can be done at home with mobile apps. 

Movement therapies like yoga and cardiovascular exercise programs further bring a focus on lifelong fitness, flexibility, and injury prevention. Nutrition and dietary counseling seeks to create sustainable healthy eating patterns.

Further progression toward active self-care requires patients to set their own lifestyle goals and develop their own system to track their progress. Wearable technology and remote patient monitoring offers another opportunity for self-tracking and sharing data with the care team for treatment, feedback, and encouragement.

Problem-solving and communication skills are taught in group chronic disease self-management classes like those taught and offered through SRMC and its affiliates. Group accountability and support offered in self-management programs add a deeper dimension toward fostering an empowered patient population dedicated to awareness, learning, action, and change.

Dream Big for the future

This final article wraps up the blog series, calling ourselves to action as the dreamers of healthcare change. This blueprint guides a future shift in our healthcare system but requires innovators and doers to collaborate and hash out the fine details. There are enough passionate healthcare professionals and talented minds out there to build a movement for redesigning healthcare. I invite you to join me in transforming healthcare!


Disclosures:
I'm passionate about socially conscious entrepreneurship and gave my modest financial support as an investor in two start-ups, Fruit Street Health and Karisha Community. Fruit Street Health uses telehealth and wearable technology. Karisha Community will be built as an integrative community health center. 

© 2020 Danielle Zelnik, MD.