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  • Writer's pictureJohn Kim

Optimal Implementation of Integrative Medicine Program in a Health Care System: Lessons Learned from Implementation of Integrative Medicine in Memorial Hospital – a rural critical access hospital.

Optimal Implementation of Integrative Medicine Program in a Health Care System: Lessons Learned from Implementation of Integrative Medicine in Memorial Hospital – a rural critical access hospital.

I.                     Introduction:

Integrative medicine utilizes, in addition to conventional medicine, lifestyle choices such as Yoga, Taichi, and meditation, as well as using food as medicine, and ingestion of vitamins, herbs, and supplements, and also utilizes alternative therapeutic modalities such as acupuncture, chiropractic care, and massage.  A recent survey performed by University of Michigan identified about 66% of adults reported using at least one integrative medicine strategy to treat a health concern.[1]

Reflecting public interest, NIH established Office of Alternative Medicine in 1991 which evolved to National Center for Complementary and Alternative Medicine in 1998 and changed its name to National Center for Complementary and Integrative Health to advocate integrative health in 2014 – a term which is more inclusive of contributions other modalities of healing than medicine.[2]

One of the most successful adoption of integrative medicine in a system wide implementation is the Whole Health transformation of VA Health Services providing a services around change in paradigm of supporting “What matters to you?” approach rather than “What is wrong with you?”[3]  Preliminary findings showed higher employee engagement and potential cost savings in pharmacy and outpatient care.[4] Today, there is a strong movement advocating adopting Whole Health strategies into health care systems supported by both Academic Consortium for Integrative Medicine & Health and Academy of Integrative Health & Medicine as well as efforts underway at federal level such as NIH and VA Health Care. 

If VA represents the largest organizational implementation of integrative medicine, Sutter Health would be earliest adopter of integrative medicine and successful utilization of integrative medicine as a market differentiator in the private sector.  Sutter Health founded the Institute of Health & Healing in 1994 in San Francisco – the first integrative medicine clinic certified by State of California.[5]  Today Sutter health has integrative medicine clinics in Roseville, Sacramento, San Carlos, San Francisco, and Santa Rosa and provides integrative medicine consultation services as well as integrative primary care services. 

Academic Consortium for Integrative Medicine & Health was founded by 1999 by 8 academic health centers including Duke University, Harvard University, Stanford University, University of California, San Francisco, University of Arizona, University of Maryland, University of Massachusetts, and the University of Minnesota.  As of April 2024, the membership includes nearly 80 institutions from Australia, Brazil, Canada, Mexico, South Korea and the United States.

II.                   Can Integrative Medicine Become Standard of Care?

While standard of care is the benchmark that determines whether professional obligation to patient has been met in a legal setting, for the purpose of this article standard of care means 1) acceptance of practice recommended by prevailing professional society and/or 2) insurance coverage of services as proxy measure of such acceptance.

Society for Integrative Oncology (SIO)was established in 2003 as Barrie Cassileth from Memorial Sloan Ketting Memorial Hospital serving as the founding president.[6]  SIO has worked diligently with American Society of Clinical Oncology (ASCO) in producing several practice guidelines.  In doing so, integrative oncology has successfully been integrated in many cancer centers including MD Anderson, MSK Memorial Hospital, and most recently at City of Hope.

Other examples of acceptance of integrative medicine include non-invasive treatments of acute, subacute, and chronic low back pain by American College of Physicians recommending non-pharmacological treatments over medications as first-line therapy.[7]  Another example is Ornish Lifestyle Medicine which provides the only scientifically proven program to reverse heart disease without medication.  As a result of outcome evidenced based approach, the 9-week online program is reimbursed by Medicare, Blue Shield of California, and Aetna.[8]  Yet another example is Virta Health which provides low carbohydrate lifestyle to reverse type II diabetes and obesity.  Virta Health is utilized by VA Healthcare, most health insurances, and Medicaid.[9]

III.                 Results/Integrative Medicine Implementation

In 1995, Memorial Hospital, a rural critical access hospital in Carthage, Illinois, has identified integrative medicine as a strategically needed service by Ada Bair, CEO.  While waiting to recruit the right leader to start the integrative medicine program, Bair created a Health and Wellness Center complete with a teaching kitchen, team of RD nutritionists, and a 85% scratch kitchen where most foods are made fresh.[10]  In 2023, Bair recruited Yoon Hang Kim MD MPH to establish the program with Raigan Brown CNO providing administrative leadership.[11]

A.      Pre-implementation Strategy

Prior to hire, a meeting was conducted including CEO, CFO to ensure sustainability of the clinic and agreed that clinic should:

·         Accept all insurances for integrative medicine/functional medicine/lifestyle medicine and for acupuncture when coverage is available.

·         Acupuncture as a cash service when insurance coverage is not available.

·         Establish a Rural Health Clinic where there would be potential advantage of all inclusive rate (AIR) reimbursement by Medicare and Medicaid.[12]

 

B.      Implementation

Memorial Institute of Health and Healing was created currently provide below services:

·         Integrative Oncology

·         Integrative Approach to Chronic Pain

·         Integrative/Functional Medicine Consultation Services

·         Lifestyle Medicine Programs to Reverse T2 Diabetes and Mitigate Obesity

·         Integrative Medicine – Nurse Navigation Services

·         In-Patient Non-Pharmacological/Non-Interventional Pain Management Services

·         In-Patient Integrative Medicine Consultation

These services were chosen based on the integrative medicine accepted as standard of care and current practice standards of integrative medicine practiced in other hospital based institutions.

·         Integrative oncology (per SIO/ASCO practice guideline)[13]

·         Integrative Approach to Chronic Pain (per ACP practice guideline)[14]

·         Lifestyle Medicine Program to Reverse T2 Diabetes and Mitigate Obesity (low carb lifestyle similar to approach of Virta Health)

·         In-Patient Non-Pharmacological/Non-Interventional Pain Management Services (Joint Commission requirement)[15]

 

C.      Lessons Learned After Year 1 of Implementation

Lessons learned while implementing integrative medicine at Memorial Hospital was published previously.[16]

Taylor et al published an article on “What should health care systems consider when implementing complementary and integrative health: lessons from Veterans Health Administration.”[17]  Below is a summary of nine common factors facilitating the implementation of Complementary and Integrative Health (CIH) Implementation.

1.       Having CIH strategic plan and CIH steering committee

2.       Organizing the individual types of CIH into one program instead of spreading across several departments

3.       Having strong, professional, enthusiastic, and persevering CIH program leads and practitioners.

4.       Having leadership support

5.       Providers’ positive attitudes toward CIH

6.       Perceptions of patients’ attitudes toward CIH

7.       Demonstrating evidence of CIH effectiveness

8.       Having a champion

9.       Effectively marketing the CIH programs

Memorial Hospital experience reflect similar positive predictors of success seen in implementation of Whole Health program in Veterans’ Health Administration -

1.       Creation of Memorial Institute of Institute & Healing (MIHH) – with CEO, CNO, CCO, and CWO involved with various aspects of the operation

2.       Strong leadership support including C-suite – CEO, CNO, CCO, CFO

3.       Strong and healthy work culture including communication

4.       Strong, professional, enthusiastic, and persevering leader/practitioner

5.       Providers’ referral to MIHH

6.       Positive patient perceptions toward MIHH services

7.       Having chosen services areas such as Integrative Oncology, Integrative Approach to Pain, and Lifestyle Medicine to Reverse T2 Diabetes where there is strong evidence.

8.       Having Chief Wellness Officer as a champion

9.       Effective marketing of the program

First factor highlighted include strong leadership support in the C-suite which created Chief Wellness Officer position for the clinical leader for implementation of integrative medicine.  This also allowed for obtaining necessary financial data to explore financial sustainability prior to implementation.

 Second factor highlighted include strong and health work culture including communication.  Because of the work culture at Memorial Hospital which includes authentic, transformative, and deliberate leadership displayed by its CEO Ada Bair and embraced by her senior leadership team, potential issues threatening viability of the projects were identified and remedied in real time.

Discussion:

The implementation success shared similar factors.  The critical factors appear to be strong and broad-based senior leadership support followed by having a strong, effective, and enthusiastic practitioner and leader to establish the program consisting of service areas with high degree of acceptance due to existing evidence and/or acceptance.  This translated providers’ referral and positive perception from patients or “word of mouth marketing”.  Effective marketing consisted of a comprehensive approach including local papers, SNS, and communication of achievements – such as joining Academic Consortium for Integrative Medicine & Health as well as national presentations made in 2023 Integrative Medicine for the Underserved (IM4US) conference.  

Success of this project would be defined by meeting below mission statement developed by our team and senior leadership.

Mission Statment: To become a sustainable regional center of excellence for health & healing creating meaningful and impactful clinical, academic, educational, and research programs and to serve as a model site facilitating diffusion of health & healing innovations in rural underserved settings.

Evaluation of the Program Through Mission Statement

Characteristics of Mission Statement include:

·         Sustainability

·         Regional Center of Excellence

·         Meaningful and impactful

·         Two areas of immediate focus to be:

o   Clinical

o   Academic   

·         Diffusion of Innovation in Rural Underserved Settings

·         Sustainability – 3 year break-even goal – about 33% which is close to budgeted amount

Year 1 results show that we are successful in achieving our objectives as written below:

·         Regional Center of Excellence – patients travel further up to 90 minutes which is significantly further than most services; for integrative oncology and functional medicine, patients have travelled out of state including states not bordering Illinois.

·         Meaningful and Impactful

o   Will be tracking patient engagement through Press Ganey.

o   Will also collect patients’ narratives of outcomes

·         Clinical

o   Adjusted year 1 patient is at about 1000 visits per year

o   All of the seven clinical programs have been successfully launched

·         Academic

o   Two presentations were given during 2023 Integrative Medicine for Underserved Conference in Austin, Texas

·         Diffusion of Innovation in Rural Underserved Settings

o   Memorial hospital was consulted by another rural underserved hospital interest in implementing integrative medicine regarding Memorial Hospital’s experience of integrative medicine implementation.

In the coming years we are exploring enhancing sustainability through creating additional income stream through establishing an on-site supplement store, on-site functional medicine lab services, and exploring membership options.  We currently employ nurse navigators who engage patients at all stages of care and will be monitoring which will be tracked through Press Ganey.  At this time, we are also studying innovative ways for us to engage patients – through group visit (shared medical visits), telemedicine, and membership.  We are continuing to submit proposals for presentations at national conferences.  We also have recently proposed establishment of a whole health institute in a university designed to serve as diffusion of innovation in matter of whole health implementation to interested organizations.


[1] Maciasz R, Kullgren J, Singer D, Solway E, Kirch M, Smith E, Malani P. Use of and Interest in Integrative Medicine Strategies. University of Michigan National Poll on Healthy Aging. July/August 2022. Available at: https://dx.doi.org/10.7302/4879

[7] Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians*. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of internal medicine. 2017 Apr 4;166(7):514-30.

[10] Kim YH, Housewright A, and Bair “Journey Using Food as Medicine: Memorial Hospital – a critical access hospital” presented at 2023 Integrative Medicine for the Underserved (IM4US) Conference, Austin TX

[14] Tick H, Nielsen A. Academic Consortium for Integrative Medicine & Health commentary to Health and Human Services (HHS) on inter-agency task force pain management best practices draft report. Global Advances in Health and Medicine. 2019 Jul;8:2164956119857656.

[17] Taylor SL, Bolton R, Huynh A, Dvorin K, Elwy AR, Bokhour BG, Whitehead A, Kligler B. What should health care systems consider when implementing complementary and integrative health: Lessons from Veterans Health Administration. The Journal of Alternative and Complementary Medicine. 2019 Mar;25(S1):S52-60.

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