Statement of the Problem
Patient engagement or patient activation is a method that embodies a collaborative role between provider and client (Hibbard, & Greene, 2013). This method in care equates to better patient care outcomes, customer satisfaction, and reduction of health care costs (Hibbard, & Greene, 2013). Patient-centered care in the United States has unique obstacles due to the reduction of physicians and increases seen in the patient population (Sargen, Hooker, & Cooper, 2011). Auxiliary medical professionals are heavily relied upon due to the increased patient volume, which is a result of health care policy changes and the aging baby boomer population (Sargen, Hooker, & Cooper, 2011). Systematic reviews indicate that in the short-term nurse practitioners provide uniform services when compared to physicians; however, the long-term care such as in chronic conditions is not well understood (Horrocks, Anderson, & Salisbury, 2002). A precipitous growth in chronic disease is seen not only in the adult population (50%) but alarmingly so in the pediatric population (45.1%) (Centers for Disease Control [CDC], 2012; Bethell et al., 2011). These statistics along with the high cost of care leads to the need for a new medical model if we are to provide adequate, affordable care to those living in the United States.
The Western medical model, which focuses on compliance, does not provide for patient accountability in personal health related goals. Mindful compliance is unsuitable for clients who choose to be active participants in their medical care. The patient-centered care model not only can drive down costs, but it also demonstrates improvement in overall health among individuals (Rickert, 2012; Bertakis, & Azari, 2011; Hibbard, & Greene, 2013). This model is greatly needed in today’s health care management if the United States intends to reverse the negative trends seen in our climate of health. The personal relationship between provider and patient is the foundation of Integrative care. It is the role of the organization to structure a framework that supports this concept achieving highly effective outcomes.
Purpose of the Paper
The interdisciplinary teams used to make up an Integrative health care department are vast and may include providers, nutritionists, physical therapist, naturopaths, and other complementary practitioners. Key relationships must be formed within the organization to strengthen team dynamic and communication to pursue optimal patient care outcomes. Ten specific principles needed for successful implementation of an Integrative health care organization will be explored, which include (a) comprehensive services across the continuum of care, (b) patient focus, (c) geographic coverage and rostering, (d) standardized care delivery through interprofessional teams, (e) performance management, (f) information systems, (g) organizational culture and leadership, (h) physician integration, (i) governance structure, and (j) financial management (Suter, Oelke, Adair, & Armitage, 2009).
The audience for the paper includes organizational management and a broad range of providers who seek the reduction of overall health care costs and aim in providing patient-centered care. Individuals who feel the frustration in the current health care model might find the information noteworthy. Leadership within health care policy construction which are dedicated to high-quality care with cost reduction could appreciate the paper’s concepts.
Significance to the Community
There is only one question to be answered by the literature. How can an organization structure a particular framework to support Integrative care within a community?
Review of Literature
Background. The combination of contemporary medicine and complementary and alternative medicine (CAM) produces Integrative health care (Kelner, Wellman, Pescosolido, & Saks, 2014, p. xii). An abrupt upward trend in CAM practitioners is socially driven by (a) normalization of users, (b) body concepts influencing providers, (c) the fitness movement, (d) the rise of chronic disease and (e) the high quality of therapies offered (Kelner, Wellman, Pescosolido, & Saks, 2014, p. xii - xiii). Integrative medicine began with conventional primary care, where physicians listen to their clients and respect the cooperation of other practitioners such as CAM referrals in the management of disease (Jong, van de Vijver, Busch, Fritsma, & Seldenrijk, 2012).
Organizational structure. The primary focus in the establishment of an organizational structure involving Integrative health care in a community is the connection of various professional, clinical, and systems services (Valentijn, Schepman, Opheij, & Bruijnzeels, 2013). The fundamental challenge in the collaboration of interdisciplinary teams is the professional culture in which the individual is aligned (Burns, Bradley, & Weiner, 2012, p. 131). However, the diversity in the teams facilitates a variety of perspectives that can create positive impacts on patient care (Burns, Bradley, & Weiner, 2012, p. 131). The findings of integrative medical centers that are affiliated with mainstream community medical organizations show that the centers collaborate with the patient’s primary care physician the majority of the time (90%) (Horrigan, Lewis, Abrams, & Pechura, 2012). The majority of the centers conduct their research (86%), and utilize electronic medical records (72%) (Horrigan, Lewis, Abrams, & Pechura, 2012). The top interventional therapies used include (a) food/nutrition, (b) supplements, (c) yoga, (d) meditation, (e) TCM/acupuncture, (f) massage, and (g) pharmaceuticals (Horrigan, Lewis, Abrams, & Pechura, 2012). The majority (86%) of the clinics also offer practitioner education (Horrigan, Lewis, Abrams, & Pechura, 2012). The education comes in the form of curriculum design for medical professionals, fellowships, grand rounds, continuing medical education courses, certifications, and conferences (Horrigan, Lewis, Abrams, & Pechura, 2012). Reimbursement rates are typically covered by cash transactions; however, the Integrative medical care consultations is usually the only appointment covered by insurance (Horrigan, Lewis, Abrams, & Pechura, 2012).
Comprehensive services across the continuum of care. Integrative care centers are treating the entire range of the patient population from pediatrics to geriatric care, and ongoing patient survey reports are standard (Horrigan, Lewis, Abrams, & Pechura, 2012). This is an essential element of Integrative medicine, which provides comprehensive long-term care (Suter, Oelke, Adair, & Armitage, 2009).
Patient focus. Integrative health care is patient-centered and appeals to a variety of cultures and philosophies (Hao, & Ke-ji, 2011). Shared decision making is preferred by the patient population (Moreau, Carol, Dedianne, Dupraz, Perdrix. Laine, & Souweine, 2012). There are three components in providing an adequate framework for patient-focused care, which include patient competencies, physician skills, and system competencies (Bernabeo, & Holmboe, 2013). Patient competencies include the individual’s ability to be pro-active in the problem-solving and decision-making process of their health care. Physician competencies release their knowledge-based power over to the patient and allow for inclusion in the decision-making process. The system competencies include the supportive technical knowledge and staff to help in the decision-making process; further, this skill allows for adjustments in consultation times to adequately engage with patients (Bernabeo, & Holmboe, 2013).
Geographic coverage and rostering. Due to the relatively narrow implementation of Integrative care centers in the United States this aspect of needs is not currently an issue. However, as the patient care model increases geographic coverage and rostering should be implemented to decrease the prevalence of duplication and identify the impacted focused population (Suter, Oelke, Adair, & Armitage, 2009).
Standardized care delivery through interprofessional teams. Effective interprofessional teams function in a uniform way, meaning equality among professionals with preserved individualism (Suter, Oelke, Adair, & Armitage, 2009). Further, improved efficiency occurs when an organization incentivizes positive health care outcomes (Suter, Oelke, Adair, & Armitage, 2009). The role of each professional must be identified, and all therapies and procedures must meet evidence-based guidelines. Active communication, through multiple venues, is the best deterrent for the breakdown in interprofessional collaboration (Suter, Oelke, Adair, & Armitage, 2009).
Performance management. Quality control protocols must be in place to actively measure the organizational performance in financial management, patient care, and safety. A monitoring system, survey reports, and performance reward systems may be useful in keeping performance levels high (Suter, Oelke, Adair, & Armitage, 2009).
Information systems. Health informatics are vital in assessing performance management along with providing supports for active interdisciplinary communication and information sharing. Further, this is an essential component in financial management, in which the organization can monitor the cost of care across the integrative services provided (Suter, Oelke, Adair, & Armitage, 2009).
Organizational culture and leadership. Bringing together professionals who are trained from various schools of thought can create disruption in integration (Suter, Oelke, Adair, & Armitage, 2009). It is essential that the organization structures strong leadership with vision, which nurtures collaborative communication between the various medical cultures, needed in Integrative care. The two polarized schools of thought, allopathic and complementary and alternative medical (CAM) care has largely excluded each other in the patient treatment protocols. Interestingly, both professional groups primarily worked together prior to the 1858 Medical Act in England that established allopathic care as being the institutional health care authority (Wiese, Oster, & Pincombe, 2010). CAM providers did not however disappear. The consumer market is mainly driving the two schools of thought to again work together in providing patient-centered care (Wiese, Oster, & Pincombe, 2010). The conceptual model of Integrative health care gains greater attraction from the allopathic trained professionals because CAM therapies are incorporated into patient care; however, primary patient management is monitored by an allopathic provider (Wiese, Oster, & Pincombe, 2010). It is important for the organizational leaders to create cohesion without supporting a mindset that marginalizes CAM providers, which is known to occur in integrated practices (Wiese, Oster, & Pincombe, 2010).
Physician integration. With strong leadership allopathic and CAM provider teams can work effectively towards the organizational vision of Integrative care. Communication in formal meetings and regular informal relations should be structured and ongoing (Porter, Pabo, & Lee, 2013). The meetings should focus on patient outcomes and organizational financial management. The provider teams will appoint a leader that is accountable to the organization and a reward system will be established for exceptional patient outcomes with use of the Integrative care model (Porter, Pabo, & Lee, 2013).
Governance structure. In order to define clear roles in Integrative care it would benefit the organization if there are defined patient subgroups, which could include (a) healthy patients, (b) at risk patients, (c) chronic disease patients, (d) patients with overlapping comorbidities, and (e) acute care (Porter, Pabo, & Lee, 2013). Each subgroup could contain unique age variations that will further divide case management. All patient subgroups will have its own patient care model exclusive to that individual team (Porter, Pabo, & Lee, 2013). There will be provider overlap within the subgroups; however, case-management leaders will remain autonomous to their unique team. This governance structure provides highly individualized, needs-based, patient-centered care (Porter, Pabo, & Lee, 2013). Exceptions will arise, and organizations must be flexible; however, this structure is superior to typical organizational structures (Porter, Pabo, & Lee, 2013).
Financial management. Financial reimbursement for CAM therapies has historically not had the support as allopathic care (Pelletier, Astin, & Haskell, 1999). The patient population is forcing the change in financial reimbursement. There are eight reasons driving consumer support, which include (a) consumer dissatisfaction with the limitations of conventional medicine, (b) consumer perception that the Western model of medicine treats patients as if they were mechanical processes rather than human beings with psychological and spiritual lives, (c) a greater awareness of medical practices from other cultures, (d) a growing body of scientific literature suggesting that diseases are linked to nutritional, emotional, and lifestyle factors, (e) a desire and expectation of wellness by baby boomers, (f) consumer desire to take fewer medications and decrease side effects, especially seniors, (g) consumer desire to reduce personal health care spending, especially seniors, and (g) support of nationally renowned clinicians (Pelletier, Astin, & Haskell, 1999). Chiropractic, Osteopathy, and acupuncture therapies are typically covered; however, traditional Chinese Medicine and reflexology are rarely reimbursed (Pelletier, Astin, & Haskell, 1999). Third party influences such as state-mandated legislated policy could be a solution to the obstacles seen in CAM reimbursement.
The organizational structure for financial management in Integrative care could bundle reimbursement based on patient subgroups (Porter, Pabo, & Lee, 2013). The lowest reimbursed subgroup would be the healthy population, and the highest would be patients with overlapping co-morbidities. Bonuses could be distributed as financial incentives based on patient outcomes and appropriate cost-effectiveness. Insurers should find value in organizational payment models that provide quality of care rather than volume (Bernabeo, & Holmboe, 2013).
There are several obstacles when trying to implement an Integrative health care model. The top three barriers include (a) the need for more research on efficiency (µ 58%), (b) fear of change by medical establishment (µ 29%), and (c) economics (µ 26%) (Pelletier, Astin, & Haskell, 1999). As the patient population facilitates the need for collaborative cooperation between the two medical ideologies, it is responsible to say that organizations can quickly overcome these obstacles. Bringing together separate mindsets creates a unique set of challenges; although, the outcome in community health and reduction in health care expenditures should bring this model into focus.
Creating a patient-centered medical model that is needs-based is a unique way of delivering care. Organizing patients in subgroups creates bundling opportunities in case management and financial reimbursement. Patients that require lengthy evaluations and complex therapeutic strategies are quickly identified and supported within this organizational framework. Individuals that necessitate screenings and management will draw less time from the practice; however, still receive quality Integrative care. Providers can flow between subgroups and potentially specialize in specific categories. To maintain continuous surveillance in health care outcomes and financial management, assigned leaders of each subgroup will remain focused within their designated department. The framework supports positive patient outcomes while utilizing multiple overlapping providers offering a broad range of evidence-based therapies.
Future surveys and community participation should include in the development process. An ongoing assessment in community opinion should regulate the direction of the organizational structure. The health care facility should reflect the needs and view of the community that it serves. Research teams should deploy statistical analysis in the clinical outcomes and financial impacts that the facility has in the Commonwealth. The organization should continue to appraise current literature to ensure that the services provided are evidence-based and supported by science. Routine conferences should be held and include area providers who are interested in the concept of organizational structure in Integrative care. The research produced by the facility should be submitted to both the Federal and State government legislatures so that presumably active in-depth policy changes could meet a wider population. Hospitals that are participating in Integrative care should open up to the teaching institutes so rotating medical personnel can participate in clerkships and residencies as is being done at some major Universities throughout the United States. This will profoundly impact the up and coming medical providers and hopefully support a more tolerant atmosphere for growth in the Integrative care. The ten specific principles outlined in this paper should be implemented to provide a framework for the organization's success.
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