BY: CARL L. MIDDLETON, DMin
Dr. Middleton is vice president, theology and ethics, and chairperson,
Integrative Health Care Advisory Council, Catholic Health Initiatives, Denver.
U.S. health care has entered an era of rapid change with brief
transition periods. One force for change has been the health
care consumer; becoming better informed, consumers have demanded
higher quality, better service, and more choice.1
In 1999 consumer demand was reinforced by Crossing the Quality
Chasm: A New Health System for the 21st Century, a report
from the Institute of Medicine's Committee on Quality Health
Care in America. The report recommended a sweeping redesign
of the health care system to produce care that would be safe,
effective, patient-centered, timely, efficient, and equitable.2
In the same year, the Joint Commission for the Accreditation of Health Organizations
issued standards requiring care to be patient-centered, comprehensive, and multidisciplinary
in order to effectively address the issue of pain management for patients. Calls
for health care to become more patient-centered and holistic have also come
from the American Medical Association (AMA), American Holistic Medical Association,
American Holistic Nurses Association, and the AMA Medical Ethics Guidelines.
This article is intended to share the continuing journey of Catholic Health
Initiatives (CHI), Denver, toward the redesign and renewal of health care delivery.
Our journey of organizational learning, which began five years ago, has consisted
of three phases:
- Phase I focused on complementary and alternative modalities (CAM) of therapy.
- Phase II focused on the patient.
- Phase III focused on the design and implementation of patient-centered
care.
We refer to our patient-centered approach as "integrative health care." It
is important to note at the outset that integrative health care is not synonymous
with CAM, although it does include complementary therapies when those are appropriate.
Integrative health care is grounded in relationships and strives to unite the
best of the world's therapeutic traditions and evolving practices.
Phase I: Focus on Complementary Therapies
By 1997, CHI's leaders had noted growing patient dissatisfaction
with conventional medicine, which tended to be curative and
symptom-focused. According to one study, an estimated 60 million
Americans (33.8 percent of the adult population) were using
at least one of 16 alternative therapies in 1990.3
By 1997, alternative therapy use had increased to an estimated
42.1 percent of the adult population, or 83 million people.4
Of significant concern were the statistics for visits to primary care practitioners.
Between 1990 and 1997, visits to all such physicians remained flat at around
386 million, whereas visits to CAM practitioners increased 47.3 percent, from
427 million to 629 million.
Consumers most frequently sought CAM for chronic conditions,
including back problems, anxiety, depression, and headaches.5
Out-of-pocket expenditures for CAM increased 45 percent between
1990 and 1997 and were conservatively estimated at $27 billion.6
The increasing number of persons seeking CAM, especially among
the chronically ill, indicated that such therapies were meeting
the needs of consumers in ways that conventional medicine did
not. These statistics were most sobering.
Wayne Jonas, MD, formerly of the Office of Alternative Medicine at the National
Institutes of Health, Washington, DC, has written that in turning to complementary
therapies, the American public is basically seeking five essential elements
in the practice of medicine:
- Attention to the illness and to the suffering that accompanies all disease
- Personal attention and expanded time from practitioners (patients particularly
like the fact that most CAM practitioners spend at least an hour with each
person)
- Patient empowerment and participation in the healing process
- A focus on patients' inherent capacity for self-healing and health promotion
- The use of a variety of appropriate healing modalities7
As consumer dissatisfaction with conventional health care increases, the gap
between the public and the health care profession serving it will widen.
CHI responded to these significant lessons by conducting research and making
site visits to leading practices. In 1998 a steering committee was formed; this
group later became the system's Integrative Health Care Advisory Council. Intending
to combine the best of traditional allopathic (Western) medicine with complementary
therapies, we who served on the council continued exploring the feasibility
of CAM programs and services and examined the possible obstacles to offering
them to CHI patients. We also awarded a grant to the TriHealth Integrative Health
and Medicine Center, Cincinnati, to develop an integrative health program that
could serve as a model within CHI. The council was supported in these actions
by CHI's National Clinical Leadership Group, Mission Group, and Business Development
and Strategic Planning Group. The council's membership included representatives
of CHI facilities that were already providing some complementary therapies as
part of their services, as well as senior leaders and others from the three
supporting national groups.
In response to requests from CHI facilities, the council developed a white
paper to assist those seeking assistance with the credentialing process for
CAM. Two council members, Jeff Sollins, MD, and Milt Hammerly, MD, wrote an
extensive glossary on complementary and alternative modalities for the council's
use in researching integrative care.
In August 1999 the council engaged 54 CHI facilities in conversations
to determine the status of CAM programs and services in the
system. The major items covered in these conversations were
terminology, programs and services, supportive structures, and
educational needs. Those conversations revealed, first, that
there was great diversity in the system, and, second, that the
success of the integrative health services offered would depend
on their acceptance by the facilities' medical staffs and their
local communities. Terminology was found to be a significant
problem (see Box below).
After its conversations with CHI facilities, the council conducted a retreat
and reflected further on integrative care. We concluded that what was needed
was a vision and goal to provide a more holistic (mind/body/spirit) approach
to health care, an approach that would include a clinical and philosophical
rationale for combining differing therapeutic modalities into a seamless, unified
approach.
Phase II: Focus on the Patient
As we learned more about integrative health care, we came to
the realization that a more comprehensive approach to medicine — one
that would involve assessing, understanding, and caring for
the bio-psycho-social-spiritual dimensions of a person — was needed.8
The council believed it was important for this patient-centered
approach to be rooted in the tradition of Catholic health care
and the healing ministry of Jesus.
CHI's framework for health care is grounded in the heritage of its founding
congregations, which entered the world of medicine to serve as living witnesses
to Jesus' ministry of healing of the whole person: mind, body, and spirit. This
same purpose is reflected in the system's mission statement: "Fidelity to the
Gospel urges us to emphasize human dignity and social justice as we move toward
the creation of healthier communities." The council found it helpful at this
point to focus on healing, rather than curing (see Box below).
The term "healing" pertains to restoration, bringing wholeness and attention
to all dimensions of a human person.
With this important insight, we realized that "integrative
medicine" or "integrative health care" should not just
be a synonym for CAM. Instead, we decided, CHI's definition
of integrative health care should reflect the spirit of its
healing ministry and provide a comprehensive, collaborative,
and compassionate approach to care. This personalized response
to persons who are sick and in pain should be the hallmark of
every CHI facility. Integrative health care is integral to the
system's healing ministry and requires the uniting of medicine,
health, education, and pastoral and social services.
Integrative Care's Essential Components
As a result of the council's work, CHI has chosen to use the
word integrate (or integrative) because it implies
the combining of the best of different models of medicine. Integrative
medicine attempts to blend or unite the holistic mind/body approach
with the modern scientific approach of conventional medicine.
The council arrived at the following definition: "Integrative
health care is a personalized, comprehensive and collaborative
approach to assess and respond to a person's body, mind and
spirit needs for healing." Integrative care includes conventional
medicine, spiritual/pastoral care, behavioral health, and complementary
modalities. Our initial working definition of integrative health
care eventually became: "A holistic approach to health care
delivery that unites providers, modalities and systems of healing
in order to address and respond to body-mind-spirit connections
in every patient, resident or community encounter."9
Integrative Medicine's Characteristics
CHI's definition of integrative health care emphasizes three principal characteristics:
It is personalized, comprehensive, and collaborative.
Personalized Care Integrative care recognizes that each person is unique
and precious and that similar patients may experience the same disease process
differently and react to the same medications and treatments in different ways.
Integrative health care practitioners assess and respond to patients' holistic
needs by using a vast array of available treatments, therapies, and modalities,
tailoring them to fit each patient's response to his or her particular illness.
For example, in the area of pain management, 200 mg of a particular medication
may be enough to control one person's pain, but not another's. Patients should
act as partners with their practitioners, providing the feedback that enables
practitioners to individualize care. In this way, patients assume responsibility
for their own healing, wellness, and coming to wholeness. Personalized or relationship-centered
care is accomplished through effective use of clinical narratives, the patient's
description of his or her illness.
Comprehensive Care Integrative care is based on a multidimensional
view of the patient. The mind, body, and spirit are three interrelated dimensions
of a whole human person. Factors affecting one of these dimensions will simultaneously
affect the other two as well. This holistic view considers the bio/psycho/social
dimensions of each unique and precious person. "Bio" refers to the biological
or physical dimension, "psycho" to the psychological dimension, and "social"
to the relational dimension. These, along with the spiritual and energy needs
of a person, constitute five interrelated dimensions of a unified reality.
In integrative care, the focus of all encounters between practitioners
and patients is the healing relationship or "patient/resident/client–centered"
approach to care. Concern for a particular person and for the
impact of illness or disease on that person is central to the
healing relationship. Although the outcome of an encounter may
include the cure of disease, the goal is to help the patient
come to healing or wholeness. As Fr. Gerard T. Broccolo, STD,
CHI's vice president of spirituality, has put it, "Coming to
wholeness is the ultimate treatment or care goal — in coping with
illness, in facing death, or in living life."10
Mind/body/spirit connections can be addressed by uniting the
various approaches or systems that provide healing. A comprehensive
approach to care both employs the expertise and practice of
conventional medicine and promotes its integration with holistic
and other forms or modalities of healing. Comprehensive care
also motivates patients to take responsibility for their health
and results in their ability to experience wholeness in illness
and in health. Comprehensive care is achieved through assessing
and responding to mind/body/spirit needs in a caring and compassionate
manner.
Collaborative Care Because integrative medicine takes a multidimensional
view of patients and their treatments, it stands to reason that no single provider
alone is capable of being genuinely comprehensive. Comprehensive care thus requires
collaboration by an interdisciplinary team of practitioners.
The word "collaboration" comes from the Latin com-laborare
and the French collaborare, which mean "to labor
together." As Fr. Broccolo says, "The objective (of collaboration)
is not to provide a system of experts but rather an expert system
for healing the whole person."11 Integrative health
care uses teams of dedicated practitioners who communicate with,
educate, and counsel patients to help them on their journeys
toward healing. A team combines its individual members' insights
and expertise to craft a unified care plan that will facilitate
a patient's healing. Continuity of care is provided through
a network of community resources and referral services.
Tools and Resources
After clarifying our vision, crafting a definition of integrative care and
identifying the compelling reasons for it, we council members turned our attention
to the tools and resources that would make this vision a reality. These resources,
we decided, are the clinical narrative, the comprehensive evaluation process,
and the educational resource manual.
Clinical Narrative In patient-centered care, patients and their families
are the focus and basic units of care. Health care practitioners enter these
relationships to facilitate the patient's self-healing process. For such a relationship
to occur, effective communication — a rapport — must develop between the practitioner
and the patient. The practitioner has, in the clinical narrative, a major means
of connecting with the patient and establishing a healing relationship.
The clinical narrative, the patient's story, enables the practitioner
to understand the patient's experience of illness, thereby minimizing
the differences in perspective and providing a framework for
empathy and insight.12 Gaining insight into a patient's
lived experience is imperative for four reasons:
- It is a primary way of treating patients as persons.
- It assists practitioners in making more individualized diagnoses and personalized
therapeutic interventions.
- It provides more information for decisions on scientific therapeutic interventions.
- It provides a foundation for healing relationships.13
The main way practitioners gain insight into patients' lived
experience is by having them tell the stories of their illnesses,
the clinical narratives. Such narratives are not to be confused
with medical histories, which include information about inoculations,
past injuries, allergies, hospitalizations, chronic conditions,
and past and present diagnoses. Clinical narratives contain
the facts and events of the current illness, as well as the
patient's explanation and interpretation of the illness, including
his or her pains, concerns, fears, and apprehensions.14
The narrative is considered "clinical" because the information
gained from the story assists practitioners in making a clinical
(medical) analysis. A clinical narrative should be as important
to the practitioner as physical symptoms.15
A clinical narrative's content should also include the patient's
own ideas concerning the causes of his or her symptoms; his
or her perception of the seriousness of the illness; and his
or her description of any major emotional or spiritual crises
before the onset of symptoms, such as the loss of a job, death
of a spouse, or divorce. In addition, practitioners should ask
questions that elicit information about how the illness has
affected the patient's life and what he or she fears most as
a result of being ill.16 Clinical narratives provide
invaluable insights into patients' perceptions of their illnesses.
What patients seek from practitioners is not only scientific
explanations of the cause of illness but also understanding
of and empathy for their suffering.
By using the clinical narrative effectively, a practitioner can both enhance
his or her own ability and show the patient that the practitioner is a partner
and friend on the healing journey.
Comprehensive Care Evaluation Integrative health care focuses on optimal
holistic (mind/body/spirit) well-being. For comprehensive patient assessments,
CHI has developed the Comprehensive Care Evaluation (CCE). This three-part process
is designed to incorporate both the medical assessment model SOAP (subjective,
objective, assessment, and plan) and the nursing assessment model APIE (assessment,
plan, implementation, and evaluation). The evaluation tool incorporates subjective
and objective data, assessment, plan of care, implementation, and evaluation
of the overall plan of care.
Part I of the CCE is the "Intake Self-Evaluation Tool," which
patients complete before they are seen by a health care professional.
This tool gathers general information about the patient's well-being
by using a six-category taxonomy: biochemical, structural/anatomical,
functional/movement, mind/body, environment (see Box below).
During the patient's first visit, health care professionals
review his or her self-evaluation regarding wellness and document
any findings or comments, as well as the patient's responses.
This taxonomy and stratified stepped-care model for integrative
medicine was developed by Hammerly, CHI's director of Integrative
Medicine. His model allows for the inclusion of CAM and enables
practitioners to rationally and judiciously select the most
appropriate therapies, given the risk/benefit ratio in the clinical
situation.17
Part II of the CCE is the "Practitioner Clinical Evaluation," which incorporates
findings from the patient's physical examination. This evaluation includes a
review of the patient's systems and the practitioner's assessment and clinical
summary. The primary physician and other practitioners to whom the patient may
have been referred document their findings on an interdisciplinary care team
coordination form. These forms can be used on the patient's first visit and
updated as needed.
Part III, called the "Wheel of Well-Being," is designed for practitioners
and patients to use in reviewing the findings. It identifies areas of a patient's
health and well-being that need improvement and educates the patient about them.
The review incorporates the taxonomy used in the Intake Self-Evaluation. Practitioners
can address patients' needs, but the patients themselves determine what is most
important to them and take responsibility for improvement. Patients create personal
"contracts," writing down what they intend to do to correct imbalances in their
health and well-being.
A thorough patient evaluation requires teamwork involving a wide range of
disciplines. The CCE enables the health care team to focus on both the patient's
perceived needs and needs that the patient may not yet recognize. The team may
include a primary physician, nurse, physician's assistant, advanced registered
nurse practitioner, chaplain, nutritionist, and pharmacist, as well as representatives
of other disciplines if a need for them arises. A nurse or physician's assistant
may initially be responsible for reviewing and clarifying patient data. The
team should refer the patient to appropriate resources, depending on the needs
identified; spiritual care needs, for example, may indicate referral to a chaplain
for a detailed assessment.
Integrative Health Care Manual To educate others regarding integrative
health care, the council decided to compile and publish a manual, Integrative
Health Care: An Emerging Approach to the Art of Healing. The manual provides
a comprehensive resource for system leaders and members of facility steering
committees, so that they can learn about integrative and patient-centered care
and teach others about it. The manual is intended to provide background, ideas,
strategies, processes, and tools for the implementation of this emerging approach
to care.*
* The manual costs $15. For a copy, contact the author's
administrative assistant, Carolyn Burmont, at Catholic Health
Initiatives, 1999 Broadway, Denver, CO 80202; phone: 303-383-2625.
Phase III: Implementation of Patient-Centered Care
After completion of phases I and II, the council convened a cross-section of
CHI's leaders in a national "summit." The meeting was intended to solicit input
and guidance regarding the implementation of integrative health care. The participants
basically affirmed the council's definition and rationale.
Participants did recommend that, in implementing integrative care, CHI should — rather
than making the initiative systemwide and mandatory — allow each facility to customize
it according to the facility's own strengths, resources, needs, and opportunities,
as well as the readiness for it in the surrounding community. Participants also
urged CHI to make the implementation process multidisciplinary and to include
in it a practical template that each facility could adapt to its local market
and culture, concrete measures of success, and pilot projects with which the
facility could demonstrate the value of integrative health care.
The council, putting to use the insights gained from this feedback, has developed
an IHC Implementation Action Plan that includes both education and pilot projects.
Implementation Education Integral to the council's action plan is education
regarding the integrative care philosophy. It is important that practitioners
understand that CHI's approach to integrative health care primarily consists
of compassionate and attentive listening to the whole person as a way of:
- Delivering clinical care
- Engaging staff loyalty
- Ensuring organizational alignment of interdisciplinary resources, initiatives,
competencies, and infrastructure
Education that addresses the conceptual framework, skills, and competencies
of person-centered care is an essential component of the pilot projects.
Pilot Projects Given the summit participants' affirming response, CHI
launched the pilot projects in 2001; these are now under way. We hope to demonstrate
through them the difference that the integrative care approach can make clinically,
organizationally, and financially. The projects' specific purpose is to implement
and assess the impact of:
- A comprehensive patient/resident care evaluation process that will facilitate
development of a single patient/resident care plan
- Retreats for the facility staffs, both clinical and administrative, that
are involved in integrative health care implementation
- Modifications made by a facility interdisciplinary team to address infrastructure
barriers and resolve alignment issues
- The development of pre- and postpilot measures regarding patient satisfaction,
management-by-objective performance improvement, and staff performance management
competencies and behavior
Moving into the Future
CHI's multiphased integrative health care journey began with the recognition
of the contributions and limitations of the conventional medical model, especially
the limitations of any single method of healing used in isolation from others.
We have now evolved in our focus from complementary and alternative therapies
to an integrative approach to care that is personalized, comprehensive, collaborative,
and based on a multidimensional view of the patient.
At present, we are assisting the implementation of integrative health care
pilot projects at our pilot sites. This requires cooperation with community
resources to ensure continuity across all health care settings. Holistic assessments
and the development of care plans by multidisciplinary teams and their patients
drive the process. Care plans use conventional medicine, behavioral health,
and spiritual care, as well as complementary therapies, to respond to an individual's
mind/body/spirit needs. CHI is developing pre- and posttest measures, conducting
educational retreats, and addressing infrastructure issues through national
staff support.
We hope to mainstream integrative health care, thereby shaping and redesigning
clinical care delivery. By taking a leadership role, CHI advocates a health
care ministry that is "safe, effective, patient-centered, timely, efficient
and equitable"18 and sponsors a healing ministry of reverence and compassion.
NOTES
- See Health Care Environmental Assessment 1999-2001: The Forces Driving
Change, Catholic Health Initiatives, Denver, 2001, p. 12.
- Committee on the Quality of Health Care in America, Crossing the Quality
Chasm: A New Health System for the 21st Century, National Academy Press,
Washington, DC, 2001, p. 6.
- David Eisenberg, et al., "Trends in Alternative Medicine Use in the United
States, 1990-1997: Results of a National Follow-Up Survey," JAMA, November
11, 1998, pp. 1,569-1,575.
- Eisenberg, p. 1,572.
- Eisenberg, p. 1,573.
- Eisenberg, p. 1,574.
- Wayne Jonas, "Alternative Medicine: Learning from the Past, Examining the
Present, Advancing to the Future," JAMA, November 11, 1998, p. 1,616.
- See, for example, Barbara Dossey, Holistic Nursing: A Handbook for Practice,
Aspen Publishers, Gaithersburg, MD, 1995, p. 7.
- Gerard Broccolo, Integrative Health Notes, May 2001, p. 1.
- Broccolo.
- Broccolo.
- Moira A. Stewart, "Effective Physician-Patient Communication and Health
Outcomes: A Review," Canadian Medical Association, May 1, 1995, pp. 1,432-1,433.
- Stewart, p. 1,424.
- Stewart, pp. 1,425, 1,428.
- Stewart, p. 1,428.
- David Burns, The Feeling Good Handbook, Penguin Books, New York
City, 1990, p. 364.
- For a more detailed discussion of Hammerly's model, see "Integration of
Complementary Therapies," Integrative Health Care: An Emerging Approach
to the Art of Healing, Catholic Health Initiatives, Denver, 2001, pp.
1-9.
- Committee on the Quality of Health Care in America, p. 6.
Why "Integrative" Health Care?
When CHI's Integrative Health Care Advisory Council began its work, it saw
early on that it would have a problem with terminology. The terms "complementary
medicine" and "alternative medicine" had severe limitations, including the fact
that they were perceived as negative by many physicians. The council therefore
began to use the term "integrative health care." The word "integrate" comes
from the Latin integratus and means "to form or blend into a whole; unite,
to unite with something else, to end the segregation of and bring into common
and equal membership in society or an organization."
We found that the term "integrative health care" had at least three meanings
in active use:
- The integration of Native American practices and Eastern healing modalities
with conventional medicine
- The integration of complementary and alternative medicine (CAM) with conventional
medicine
- The integration of mind/body medicine, or holism, with conventional medicine
The second definition seemed to be the most common. The problem with this
definition is that it is therapy-focused rather than patient-focused, and carries
with it no obvious rationale for combining these therapies and no directions
for doing so. The council came to realize that a more meaningful and useful
definition would be "patient-centered" care, care that included both theological
and philosophical rationales for combining differing therapeutic approaches
into a seamless, unified approach.
— Carl L. Middleton, DMin
"Healing" and"Curing"
The word "healing" comes from the Greek holos, which means to make
sound or whole, and is thus different from "curing." The word "cure" comes from
the Latin cura and refers to care, particularly care of souls. Currently
"cure" is used to mean something that corrects, heals, or alleviates a harmful
or troublesome situation and restores health or soundness, whereas "healing"
pertains to restoration, bringing to wholeness, and attention to all dimensions
of a human person.
— Carl L. Middleton, DMin
Intake Self-Examination Taxonomy
The Intake Self-Evaluation uses the following taxonomy:
- Biochemical refers to metabolic processes and incorporates nutrition,
medications, hormones, and other substances that interact within the body.
- Structural or anatomical focuses on the human body, including past
and current medical history and signs/symptoms related to disease processes.
Listening to patients' concerns may help practitioners identify underlying
health problems.
- Functional/Movement examines patients' ability to perform activities
of daily living. Use of the SF-8 General Health Evaluation allows the evaluator
to consider disease outcomes and compare the patient's functions with those
who have related health conditions.
- Mind/Body incorporates mental health; sleep; financial concerns;
and emotional, social, and spiritual concerns as they relate to patients'
well-being. Part of the SF-8 is also built into this category.
- Environmental examines the impact of external factors on patients.
It incorporates safety issues and awareness of communicable diseases and can
serve as an opportunity for practitioners to educate patients regarding personal
responsibility.
— Carl L. Middleton, DMin