Summary: I was a role-player in a recent workshop on practical integrative healthcare models. My job was to kick off small group work by presenting “major trends that are influencing integration.” The focus was on chiropractic medicine. The venue was the Association of Chiroprctic Colleges-Research Agenda Conference (ACC-RAC). The trends apply more broadly. Here are the 8, as seen first from a 50,000 foot level and slowly working down toward the ground level. The power of the pattern is compelling. What trend do you think is overstated, misstated or missing?
Claire Johnson, DC, MSEd, editor in chief of the Journal of Manipulative and Physiological Therapeutics, charged me with addressing this question in a 5-10 minute kick-off for a workshop entitled “Practical Integrative Healthcare Models for Chiropractic.” (Okay, she gave me 5 and I took 10.)
The interactive session closed the first day of the Association of Chiropractic Colleges-Research Agenda Conference (ACC-RAC) on March 18, 2011. The topic was alive. Robust exchanges in small groups in the packed room continued until after the scheduled close, despite the program’s late hour.
Below are the trends I noted. A subsequent article will share suggestions reported out via the small groupsÂ relative to:Â interprofessional research, education, clinical education and competencies for practice, via my colleagues in hte sessionÂ Greg Cramer, DC, PhD, Mike Wiles, DC, MEd, Deborah Kopansky-Giles, DC and Vince Debono, DC. These trends begin from the 50,000 foot vantage point and move successively closer to integration’s ground.
8: The Old Finally Die – and they get sick and use CAM before they do
A bastardization of a famous comment on theÂ evolution of scientificÂ throught is that things change when the older generation finally dies. The new generation of medical doctors is more likely to have grown up in families that usedÂ some forms of “alternative medicine.” Younger MDs are also more likely to be women. They are typically friendlier toward functionally-oriented explorations of new ways toÂ find health.Â At the same time, because use of non-conventional care is typically highest among those who have frank conditions, even the curmudgeons among the waning generation may soon be integrating new therapies and providers as their healths decline.Â Â
7: RWJF-IOM’s liberation from MD control for nursesÂ and perhaps others
The October 2010 Robert Wood Johnson Foundation (RWJF)-funded and Institute of Medicine (IOM)-published report, The Future of Nursing: Leading Change, Advancing, was not only an Integrator Top 10 for 2010. As a declaration of independence for nurses from MD oversight and control, that report may be the most significant policy document in US medicine since Abraham Flexner. MDs have been lousy at sharing authority. Expect more from the nurses. Expect more also from MDsÂ once the get accustomed to the new sharig of control.Â By piercing the AMA power-bubble and charging nurses to step up, the RWJF-IOM report also opens the potential for other disciplines to play significant roles in “leading change.”Â Â
6. To Err is Human and the rise of interprofessional education (IPE)
The IOM’s shattering 2000 report To Err is Human: Building a Safe Health System brought medical deaths out of Davey Jones’ locker. The search for solutions is highlighting poor communication between practitioners and disciplines. The need isÂ for more mutual respect and teamwork. A strategy: enhancing what has become known as interprofessional-education (IPE). While the U.S. is basically a generation behind Britain and Canada, Obama’s administrator for the Health Resource Services Administration, Mary Wakefield, RN, PhD, isÂ presently championing IPE. The American Interprofessional Health Collaborative is beginning to carry the movement nationally. One anticipates more ease in integrating non-conventional practitioners if one already living an ethos that affirmatively opens up peripheral vision to others.
5.Â Comparative Effectiveness Research (CER) and PCORI Â
This is the system is collapsing of its own weight so we’re finally going to focus on the real world trend. The approach focuses on better ue of what we have, including the non -conventional,Â rather thnÂ putting our eggs in some savior dressed up as a magic bullet or tweaked gene. Complementary and alternative medicine and integrative practices are specifically acknowledged as important topics for CER and in the huge new Patient Centered Outcomes Research Institute (PCORI). Inside the CAM universe, NIH NCCAM is finally looking at the “real world” in its 3rd strategic plan. The relevant NCCAM objective includes focusing on the integration ofÂ these disciplines into the delivery system. The plan hs a historic focus on disciplines. This direction may finally generate the data to support stakeholders on integration decisions – the central purposed of US Senator Harkin’s mandate in setting up NCCAM.
4.Â Patient-centered care and the karma of non-inclusion
The claim of patient-centeredness, from medical homes to optimal inpatient healing environments, is at the rhetorical center of U.S. healthcare. Given the known use of integrative and ‘CAM” practitioners by a significant subset of patients, one might assume that, sheesh, a patient-centered world would naturally reach out to include at least the licensed ‘CAM” folks: chiropractors, acupuncturists, naturopaths, massage therapists and homebirth-oriented midwives. One purported principle of a medical home is a whole person orientation in which the lead practitioner “is responsible for providing for all the patientï¿½s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.” Patient-centered care advocatesÂ will haveÂ karma issues if they don’t integrate these other providers. Are you patient-centered or are you not?
3.Â Inclusion of integrative and licensed “CAM” practitioners in the healthcare reform lawÂ
Whatever else once thinks of the Obama Affordable Care Act, a single-issue voter who cares principally about opening access to CAMÂ and integrative practices has got to like the historic inclusion of integrative and CAM practices in numerous sections of the law. Chiropractors and licensed CAM practitioners were legislated a right to be included in workforce planning, in prevention and health promotion, in CER (noted in the PCORI initiative, above), in delivery (medical home pilots) and even in payment, via a non-discrimination clause. Each is a stone in a lake with far-rippling, integrative effects, if acted upon appropriately.
2.Â Integration in the missions of multidisciplinary CAM universities
The last decade has seen the emergence of the multidisciplinary university of natural health sciences. The seed in each case was a single purpose chiropractic or naturopathic college. Now the National University of Health Sciences, Bastyr University, Northwestern Health Sciences University, Southern California University of Health Sciences, and, to a lesser extent, institutions like New York Chiropractic College, Tai Sophia Institute and University of Western States are each wrestling with integration internally . For the most part, each is also declaring leadership in integration in newly wrought mission statements.Â Expect them to be a base for this movement from the natural health professions.
1.Â “CAM” and integrative care leaders stepping up as simple healthcare leaders
An early presenter at the ACC-RAC argued from the podium that the work in integration is best undertaken not to promote chiropractic but to promote optimal health care. The focus is developing better care, period. This leadership concept is beginning to be seen elsewhere. Such a leadership ideas is front and center with CAM researchers working to shape an optimal research agenda. The best strategies for examining whole practice, practitioner-delivered health promoting outcomes will most likely emerge if theÂ researchers from these field step with two feet into the muddy dialogue, prtner with conventional colleagus, and urge their colleagues to do the same. CAM discipline and integrative MD leaders who roll up their sleeves to shape an emerging system of care are key to integration of the disciplines. The rising spirit is Kennedyesque: If not now, when, if not us, who?Â
Plenty of clay here. What will we make of it?
for inclusion in a future Your Comments Forum.