3
Models of Care

The keynote address for the session on models of care was provided by Dr. Donald Berwick, who emphasized the importance of design principles in model development and the necessity of patient-centeredness in all models intended to improve care. This panel discussion was moderated by Dr. Erminia Guarneri, Medical Director of the Scripps Center for Integrative Medicine, with panelists describing innovative models and necessary components for providing more integrative care, as well as the challenges they have faced.

Patient-centeredness was a key theme throughout this session. Berwick, for example, suggested that true patient-centeredness would attempt to explore patients’ deep feelings about their health goals, so that care decisions would most effectively serve them. Panelists said that the disease-oriented approach of conventional allopathic medicine, described by Guarneri and Dr. Tracy Gaudet, does not establish the type of patient–clinician understanding Berwick and other participants described.

Constructive patient–provider relationships are essential to effectively providing preventive services to individuals with established chronic illnesses, as well as those without, Dr. Edward Wagner noted. He and others suggested that the mindset and principles of primary care may provide a sound foundation for integrative health care. Dr. Arnold Milstein analyzed components of small medical practices, where most physicians work, that are effective in developing teams to manage chronic diseases and control costs. His research emphasized, once again, the effectiveness of establishing relationships with patients and linking them to the care needed to address the behavioral and social elements of health care. This close management and use of established and innovative clinical tools, including web-based tools, are key features of integrative



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3 Models of Care The keynote address for the session on models of care was provided by Dr. Donald Berwick, who emphasized the importance of design prin- ciples in model development and the necessity of patient-centeredness in all models intended to improve care. This panel discussion was moder- ated by Dr. Erminia Guarneri, Medical Director of the Scripps Center for Integrative Medicine, with panelists describing innovative models and necessary components for providing more integrative care, as well as the challenges they have faced. Patient-centeredness was a key theme throughout this session. Ber- wick, for example, suggested that true patient-centeredness would at- tempt to explore patients’ deep feelings about their health goals, so that care decisions would most effectively serve them. Panelists said that the disease-oriented approach of conventional allopathic medicine, described by Guarneri and Dr. Tracy Gaudet, does not establish the type of patient– clinician understanding Berwick and other participants described. Constructive patient–provider relationships are essential to effec- tively providing preventive services to individuals with established chronic illnesses, as well as those without, Dr. Edward Wagner noted. He and others suggested that the mindset and principles of primary care may provide a sound foundation for integrative health care. Dr. Arnold Mil- stein analyzed components of small medical practices, where most phy- sicians work, that are effective in developing teams to manage chronic diseases and control costs. His research emphasized, once again, the ef- fectiveness of establishing relationships with patients and linking them to the care needed to address the behavioral and social elements of health care. This close management and use of established and innovative clini- cal tools, including web-based tools, are key features of integrative 53

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54 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC health practice, as described by Dr. David Katz, Dr. Mike Magee, and Gaudet. Demonstration studies of new models, especially those that in- clude mechanisms of payment, could move integrative medicine forward and help overcome the current reimbursement challenges cited by Mil- stein, Katz, Gaudet, and Wagner. MODELS KEYNOTE ADDRESS Donald Berwick, Institute for Healthcare Improvement In his remarks, Berwick, who leads the Institute for Healthcare Im- provement, reflected on the array of earlier presentations and discus- sions, focusing on the elements of integration that emphasize patient- centeredness and smooth care transitions. He endorsed the Rorschach metaphor used earlier by Dr. Harvey Fineberg, saying that the speakers and audience were using a set of rather vaguely defined terms with great intention and wonderful spirit. However, he observed, these broad con- cepts of integrative medicine were being interpreted according to the in- dividual backgrounds and needs of the participants. To make sense of the ambiguity around the terms and their usage, Berwick looked for the common purpose that pulled such diverse participants together, a purpose on which models of integrative medicine could be designed and built. Despite the participants’ enthusiastic support for integrative medi- cine, the simple notion of common purposes could prove to be a weak foundation for unity. The weakest foundation would be to unite based on a shared claim to a piece of a limited pie, said Berwick. A quest for greater reimbursement, for more payment for integrative care and alter- native forms of care, may unite integrative medicine proponents today, but would soon divide them, as different groups assert their individual claims. Professionals do need to be compensated for their services so that they can continue to carry out the work they love, he said. However, that goal is not a sufficient rallying point for building the cohesiveness neces- sary to advance integrative medicine. This movement must find a deeper offer to make to society. “Guilds are like mushrooms, and they will grow very fast before our eyes,” he said. If integrative medicine becomes only a new list of guilds vying for reimbursement and organizational and pro- fessional power, “then we are wasting our time.” Our health care system already has had too much negative experience with fragmentation, sepa- ration, and combat for a piece of the health care dollar. Thus, the first

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55 MODELS OF CARE challenge for integrative care will be for the field to define what is being integrated, why, and then ultimately to integrate itself. The Core Value: Patient-Centeredness For nearly 20 years, committees of the Institute of Medicine have recommended better system designs in health care. These efforts have addressed traditional allopathic care, curative care, end-of-life care, and now the important new arena of integrative health care. This body of work is exemplified by IOM’s quality of care initiatives that have in- cluded the Roundtable on Quality in the mid-1990s and the Crossing the Quality Chasm report in 2001, both of which Berwick participated in. These efforts also grappled with the question of underlying purpose: Should anything be better about American health care? If so, what should that be? The roundtable’s answer emerged as a trio of generalizable problems: overuse, underuse, and misuse. It also developed a workable definition of quality: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The subsequent Committee on Quality of Health Care in America then built a framework for quality on the foundation developed by the roundtable. It went beyond overuse, underuse, and misuse to define a more ambitious agenda for the health care system. The committee con- cluded that, in order to achieve a system of excellence, the health system should have six goals: safety, effectiveness, patient-centeredness, timeli- ness, efficiency, and equity. In the committee’s early discussions, the list included patient control, rather than patient-centeredness. The change represented the tension and a compromise between those who thought health care should belong to the patient and those who thought patient decisions should be mediated by professionals who have knowledge and experience that patients do not possess. The term patient-centeredness was chosen to imply a partner- ship that includes dialog and shared control. The committee also enumerated 10 rules to redesign health care processes. The third rule, titled “The patient as the source of control,” says “Patients should be given the necessary information and the oppor- tunity to exercise the degree of control they choose over health care deci- sions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision mak-

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56 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC ing.” This backs away from the idea of patients’ having total control, but supports the need for them to have the steering wheel in their hands. The committee’s message was that patient-centeredness is important not only because it helps achieve better functional outcomes and greater safety, but that it is, in and of itself, a property of good care. Other organizations—the Dartmouth Institute for Health Policy and Research, the Institute for Healthcare Improvement, and the Picker Insti- tute, for example—began to expand the application of patient-centered care. The Picker Institute proposed that the very definition of quality lies through the patient’s eyes. The Institute for Healthcare Improvement asks patients whether they can agree with the statement that their pro- vider—whether it be physician, practice, or hospital—gives them “ex- actly the help I want and need, exactly when I want and need it,” which delegates the very definition of excellence to the experience of the per- son served. This is a high standard, but one deemed necessary in almost every other consumer industry. Modern health care did not begin with a pa- tient-centered standard. Instead, the field remained rooted in concepts proposed by Eliot Freidson in the mid-1900s. Freidson theorized that professions like medicine reserve to themselves the authority to judge the quality of their own work. Society gives professionals that authority on the assumption that the profession will be altruistic, has knowledge the public does not and cannot have, and can regulate itself. Again, this is not the basis for consumer relationships in most other industries. Berwick described how the model of patient-centeredness is being translated into practice in various settings—Mayo Clinic’s emphasis on “the needs of the patient come first,” or the statement that Boston’s Parker Hill Hospital set above its door, authored by its CEO, Arthur Ber- arducci, “Every Patient is the Only Patient,” or creation of the healing environments envisioned in the Planetree model of care. New work at the Institute for Healthcare Improvement focuses on three population-based views of excellence, constituting the so-called “Triple Aim”—judging the experience of care through the patient’s eyes, addressing the health of the population served, and considering per capita cost as a measure of system quality. Prior to recent decades and in many cultures worldwide, the domi- nant definition of health was, in essence, the extent to which the body can heal itself—physically, mentally and spiritually. In this view, the role of medicine and health care is that of a servant, an assistant to bodily processes already under way. Its job “is to let [the body] do so, to stand

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57 MODELS OF CARE out of the way, and to offer resources or assets to allow [healing] to move forward,” said Berwick. This conception adds to the significance of the patient-centeredness concept and begins to suggest what integra- tive medicine could mean and what its purpose is. Achieving Integrative Medicine’s Aims Just as the IOM committee on quality defined a set of design princi- ples that could realize its vision of quality care, certain design principles might move the health system toward more integrative care—“the care that connects technology to souls.” Berwick shared a poignant personal anecdote that illustrated the ways in which right care needs to draw from the integration of personal values and priorities with clinical concerns. Drawing on the day’s discussion, Berwick suggested eight such princi- ples, summarized in Box 3-1. The first principle put forward was to put the patient at the center. Good examples of this are the chronic care model developed by Wagner, or the Mayo Clinic’s “the needs of the patients come first.” Second, and related, is individualization. New technology, such as advances in genomics, makes the individualization of care ever more possible. Berwick predicted that a science-based, individually focused, predictive system of health and care could be the death knell for insur- ance as we know it today. Actuarial prediction of costs becomes impos- sible when “every patient is the only patient” and care is customized to the level of the individual. BOX 3-1 Berwick’s Principles for Integrative Medicine 1. Place the patient at the center. 2. Individualize care. 3. Welcome family and loved ones. 4. Maximize healing influences within care. 5. Maximize healing influences outside care. 6. Rely on sophisticated, disciplined evidence. 7. Use all relevant capacities—waste nothing. 8. Connect helping influences with each other.

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58 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Third, welcome and embrace the patient’s family, loved ones, and community. This means not separating a person from the loving commu- nity that provides energy, self-esteem, solace, and wisdom. In today’s hospitals, “We create nothing so reliably as we create loneliness,” said Berwick. New Zealand’s Maori health care system defines health quality as including physical health, emotional health, spiritual health, and fam- ily health. Such a definition emphasizes the essential value of connected- ness. Fourth, maximize healing influences in health care facilities. In other words, make current treatment facilities healing places by, for example, refocusing human interactions and using evidence-based designs that reduce patient, family, and staff stress; prevent errors and nosocomial infections; and increase positive influences on health status. Fifth, maximize healing influences outside the care system. This re- quires the system and providers to learn about and help patients imple- ment the many actions they can take in their daily lives to heal themselves or minimize the impact of illness or disability. The formal system of care rarely considers these opportunities. Sixth, rely on sophisticated and disciplined evidence. For an integra- tive system of care, this may be the most difficult challenge. It requires forms of evidence and approaches to learning that are far less developed and far less recognized today than canonical experimental designs and randomized trials. This is because, in the full expression of patient- centered, individualized, integrative care, each person is a continuous experiment of one, and rigorous measurement and evaluation need to be applied to individual learning cycles, over the long term. This type of research is not currently embraced by traditional research funders or sci- entific journals, Berwick noted. While patient-centered research needs to be every bit as robust and disciplined as current methods, it requires a forward leap in methodology to learn from the experience of the individ- ual patient. Seven, use all relevant capacities. In a sense, the potential health care workforce is exactly as large as the entire population. The concept that we have a shortage in primary care is conditioned on a very limited view of the capacity of almost all human beings, said Berwick. Individ- ual patients, their families, and even their community can have insights about the person’s condition that formal care providers cannot. Finally, the importance of connection. Potential helping influences must connect with one another. One strategy for this is through health navigators and health coaches. Another is through interconnected infor-

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59 MODELS OF CARE mation systems. However, the fundamental generator of connection be- gins with an attitude of cooperation among all individuals and institu- tions involved in a person’s care. Conclusions Durable, worthy connections among and across the many individuals and organizations supporting integrative medicine can be forged by re- discovering and affirming a common purpose: what we wish to heal. What we health care professionals wish to heal, Berwick suggested, are those who come to us for help; ourselves who are among them; a broken, imbalanced, greedy, technocentric, unself-conscious health care system; and a world that has displayed infinite cleverness in increasing human suffering. “The sources of suffering are in separateness,” Berwick said, “and the remedy is in remembering that we are in this together. Integra- tion, if it is to thrive, is the name of a duty to contribute what we can to a troubled and suffering planet.” PANEL ON MODELS OF CARE Panel Introduction Erminia Guarneri, Scripps Center for Integrative Medicine Panel Moderator Dr. Erminia Guarneri described how, when she graduated from medical school in 1988, she thought that she knew everything there was to know about medicine after reading the essential textbooks of the field. As a young intern and resident, she was rewarded for applying the find- it-and-fix-it approach, getting her differential diagnoses right, followed by appropriate patient treatment and discharge. That was considered a success, and she was considered a good physician because she could achieve it. In those terms she again proved successful in the mid-1990s, this time in the field of coronary stenting. She—and the field—said that correctly placed and correctly timed stents could wipe out heart disease, the number one killer of Americans today. For Guarneri, the wake-up call came when she realized that “a 16- millimeter stent does not prevent cardiovascular disease.” Nor does commonly used statin therapy, which only reduces morbidity and mortal-

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60 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC ity by about 30 percent. Further, she was learning from her patients that, when it comes to cardiovascular health, the illnesses of loneliness, de- pression, anger, and hostility are every bit as devastating as hypertension and diabetes. The wake-up call told her that “we need to embrace it all”—the best of what she had learned in medical school, the best of a wide array of therapies, and the best of high technology, all blended with a recognition that the complex human being is made up of body, mind, emotions, and spirit. “It is a misnomer to think that clinicians can just treat the physical body and call it medicine,” said Guarneri. For the past 12 years, Guarneri has been working on a model of care that embraces the fact that having a positive purpose in life is as impor- tant as good laboratory values and that our social and physical environ- ment is as important as having a low LDL reading. Models That Integrate Continuous Care Across Caregivers and Settings Edward Wagner, MacColl Institute for Healthcare Innovation at Group Health Center for Health Studies Dr. Edward Wagner raised several particularly challenging issues for integrative care. Earlier summit discussions highlighted the unsound state of primary care in the United States. Yet Wagner noted that primary care has the mindset, the orientation, and the relationship with the popu- lation that make it a promising foundation for integrative health care. Since it is not realistic or desirable to expect the development of an en- tirely separate integrated health care system, it is necessary to update primary care as it exists today, in order to make it an effective platform for building integrative care models. Wagner’s second point related to the false distinction commonly drawn between preventive care and care for chronic illnesses and condi- tions. This distinction must be broken down, he said, because the needs of the healthy population and the needs of the vast majority of those who have chronic disorders—some 40 to 50 percent of the population—are, in many cases, the same. Like those without chronic disease, people with chronic conditions still require prevention efforts for conditions they do not have. At the same time, prevention of adverse events is also required for the condition or conditions they do have. Both groups need effective, evidence-based clinical, behavioral, and supportive treatments. Fortunately, the health system has made great

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61 MODELS OF CARE progress in this arena, and such treatments now exist. Both groups need meaningful, personalized information, and they need emotional and psy- chosocial support to help them in their self-care and self-management. Both groups also need regular assessments tailored to the severity of their individual risks or health condition, systematic follow-up, and co- ordination of services across care settings. Over the past two or three decades, researchers and quality im- provement professionals have begun to understand the system changes that assure that these needs are met. Reviews of interventions across a multitude of conditions and situations show that effective practice changes are similar, whether in the preventive or in the chronic care management arena. Such interventions involve greater use of nonphysi- cian members of integrated, high-functioning practice teams. They also include planned, organized patient encounters. For prevention services, encounters may be organized around protocols, such as those developed for prenatal or well-child care. These protocols, for example, involve giving parents an active role in managing their children’s health or medi- cal conditions. Evidence-based protocols, which have been developed not only for children, can easily be translated into checklists, e- prescribing, and follow-up steps that assure that the right thing to do is the default. More intensive management is necessary for people at high risk, but information technology can facilitate the planning and organiza- tion of their care, too. Fulfilling patient needs and achieving system change for prevention is where primary care comes in. Primary care needs to be transformed into a more effective foundation for integrative health care, through wider implementation of the kinds of practice teams and improved pa- tient encounters described. “The future of our health care system depends on primary care’s ability to improve the quality and efficiency of its pre- ventive and chronic illness care,” Wagner said. Wagner noted that improving efficiency begins with clear policies about which interventions are of value, which are uncertain yet safe— and their use, therefore, subject to personal preference—and which are ineffective or unsafe. Clarity about the performance of various interven- tions will make the development of high-quality, efficient primary care easier. Additionally, more time, energy, and perhaps more people on the primary care team than the current reimbursement system allows are re- quired for primary care personnel to achieve the ideal of timely, person- centered, continuous, and coordinated care. Payment reform and infor- mation technology can help a great deal, but to enable primary care to

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62 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC meet the goals of integrative medicine requires a major transformation and redesign of primary care practice, he said. Care Models That Lower Per Capita Spending and Improve Outcomes Arnold Milstein, Pacific Group on Health and Mercer Health & Benefits The current top national health care policy priority is to reduce near- term per capita health care spending, or to at least reduce its rate of growth. According to Milstein this needs to be accomplished in a way that is clinically responsible, by preserving or, ideally, improving both patient experience and clinical outcomes. He indicated that much integra- tive medicine emphasizes upstream care and long-term benefits, which does not position it well to reduce near-term spending. Milstein explored the question of whether integrative medicine could play a role in reduc- ing near-term spending, noting that the national policy priority to reduce spending is especially important for families in the bottom half of Amer- ica’s income distribution, who are unable to afford conventional health insurance, but not poor enough to qualify for Medicaid. Working with several insurers across the nation, Milstein identified five physician practices that have successfully used integrative care methods to achieve positive patient experience ratings, improve clinical outcomes, and reduce short-term costs by at least 15 percent per patient, per year—his cutoff point for including a practice in his onsite study. No large integrated health care delivery systems were able to achieve this trio of accomplishments. This does not mean that large high- performing systems do not exist, just that they did not emerge in this search. (He noted that most observers believe that large systems have the greatest potential for improvement in all six aims of quality health care defined by the IOM’s Crossing the Quality Chasm report [IOM, 2001a]). Milstein theorized that “smaller organizations may be more agile in cut- ting-edge attempts to break through the price-performance frontier.” The five successful practice settings Milstein identified were of two types. The first model was “needs-tailored.” These practices redesigned their care platform to address shared needs of chronic illness patients. They were the types of practices that Wagner described during his pres- entation.

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63 MODELS OF CARE The second successful model was a somewhat larger practice, con- taining about 60 predominantly primary care physicians. This group had gone one step further and developed multiple distinct care platforms to address subcategories of need among chronic illness patients. These were not only disease-specific platforms; some were built to respond to narrow problems that cut across diagnoses, such as presurgical stabilization. Leadership for these platforms was provided by hospitalists, but they were mostly implemented by a nonphysician team that included nutri- tionists, ambulatory care nurses, and a variety of other health profes- sions. Hospitalists led the teams because they are the clinicians most often face to face with the failures of the ambulatory care system. Both models depended heavily on their health plans’ sharing with them the savings achieved from their improved care delivery methods. None of the practices could have survived on current fee-for-service payments. Almost all of them tried to be globally capitated for as many of their patients as possible, because their better methods of caring for high-risk patients are simply financially infeasible with the very brief encounters allowed under current fee-for-service reimbursement rules. Milstein thinks of these five practice settings as “medical home runs.” They achieved positive clinical outcomes and patient experiences, and they reduced total health care spending. A reengineered care model allowed them to reduce, cost-effectively, the number of expensive health crises among their chronic disease patients. Three principal strategies helped them accomplish this. First, the practices excel at salient chronic illness caring. Their phy- sicians and care teams effectively convey to patients that it matters to them personally that the patient be spared health crises. This has a highly favorable effect on patient self-management and provides a sense of hope. Second, they use teams effectively. Third, each practice discerned that selected specialists in their communities exemplify high-quality, conservative practice, and they were careful to refer patients only to these specialists or to other similarly conservative service providers, such as pain management centers. In most cases, the successful practices incorporated many features of integrative health care by routinely assessing psychological, social, and environmental health risk factors for unstable patients. To enable this, the practices allowed at least 30 minutes for each clinical encounter, during which time clinicians thoroughly reviewed the patient’s list of problems. After this review, instead of “reaching for the doorknob,” as Milstein put it, providers would ask, “What else is bothering you?” and “What is hap-

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66 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC eases and their symptoms; and tertiary prevention, which reduces the problems associated with an established disease or injury. Katz illustrated the center’s work with brief reports of two clinical cases. He used these examples to demonstrate how integrative, holistic, team-based approaches can be used to successfully diagnose and treat patients who had not experienced improved outcomes through the conventional medical system. Katz noted that holistic practice helps clinicians find ways to reconcile responsible use of science and respon- siveness to the needs of patients. These needs continue, even when evidence runs thin. It should not be necessary to choose between the two. The aspiration of a more holistic and integrative care system is meritori- ous and worthy, said Katz. Getting there may not be easy, but “we should certainly persevere.” Models That Optimize Health and Healing Across the Life Span Tracy Gaudet, Duke Integrative Medicine Keying off the day’s presentations and the development of innova- tive models for integrative care in the United States and elsewhere, Gau- det described a vision for a transformed health care system and how the models might be achieved within it. The changes needed are not incre- mental; they require a complete revolution in the mindset that shapes our current system, said Gaudet. Chronic conditions account for more than 75 percent of U.S. health care costs or approximately $1.87 trillion per year. The development and consequences of chronic conditions are heavily influenced by individu- als’ lifestyle choices and health behavior. Making a difference in these trends will require a true health care recovery plan. Increasingly, there is both a professional and an economic imperative for change. Gaudet noted that the current health care model does not work be- cause it starts from the wrong place. It is problem based and disease ori- ented, and it inadequately addresses the significance of personal health behavior in maintaining health and preventing disease. Unless health care professionals can help patients understand their sense of meaning and purpose and the sources of joy in their life, people do not alter their life- style choices or modify their health behavior. Nor will behavior changes be sustainable unless they have deep personal significance, she said.

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67 MODELS OF CARE No aspect of the current health care system is actually designed to address the personal needs of the individual, and this is the fundamental organizational mindset that must change, according to Gaudet. If clini- cians understand this concept deeply, they will recognize they must start their relationship with their patient from an entirely new place. While the underlying concept is radical, she said, its implementation can be accom- plished relatively easily within current structures. Gaudet suggested that four primary strategies would create a new framework for health. The first strategy is the creation of new standard- ized tools for clinical use. In the current medical model, physicians have tools that guide them in taking histories and performing physical exams. These problem-based tools start with the chief complaint. A new integra- tive intake tool that asks about and addresses all aspects of a patient’s health would reorient the patient–physician partnership from the outset. Instead of a disease-based medical record, clinicians would use a whole- person medical record that reflects the physical, mental, spiritual, and relationship-centered life of a patient. Instead of creating a problem list, they would develop an integrative health risk assessment. Finally, instead of this resulting in an assessment and plan for the problem, clinicians would create a health profile and a personalized health plan for the per- son. Tools like these would help clinicians look at the individual’s health risk from a holistic perspective and lay out a path for moving toward op- timal health. The second strategy Gaudet discussed would be the development of strong provider teams that are not necessarily centered around a physi- cian. Important roles and functions are missing from today’s conven- tional medical teams. One discipline that is critical to this approach to health is the integrative health coach who would fill a currently unmet need in the system: a professionally trained provider whose expertise is in partnering with patients to help them enact the lifestyle changes and behavior that result in better health. Third, training in the health care disciplines must be geared to teach- ing the core competencies needed to deliver this model of health. Reori- ented educational programs are needed for existing disciplines and providers, as well as new programs that would prepare new members of the health care team. Finally, Gaudet suggested that efforts should be made to disseminate and implement new models of care that are emerging, for example, from the Bravewell Clinical Network. The centennial of the last major reform in medical education and health care is approaching; the “Flexner Re-

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68 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC port” (1910) brought stronger science into medical education, and the reorganization of the Johns Hopkins School of Medicine served as the demonstration project for that initiative. No matter how insightful and powerful Flexner’s report was, Gaudet said that if it had not been paired with a demonstration project, its impact most likely would have been minimal. The time is now for a new vision for 21st century health care. A clearly articulated vision, combined with a strong demonstration project, can catalyze the second revolution in health care. Models That Promote Primary Care, Medical Homes, and Patient-Centered Care Mike Magee, Center for Aging Services Technologies, American Association of Homes & Services for the Aging Past work on cross-sector partnerships and the elements that make them successful may cast light on some of the requirements for moving forward with integrative medicine. Magee has studied such partnerships and finds them analogous to the situation confronted by the multiple dis- ciplines that integrative health care requires. In the beginning, such partnerships focus on developing a common language and tools and articulating a common mission and values. These needs are important preliminary steps to assure sustainability and suc- cess. However, in the long run, three critical elements determine whether cross-sector partnerships thrive, said Magee. These elements can be ex- pressed by how effectively partnerships answer these key questions: Do you know what you want to build? Is the vision sufficiently powered not to be overtaken by change? Is there readiness to build out that vision? Over time, the supporters of integrative health care will need to answer the questions. A decades-long supporter of relationship-based health care, Magee agrees with the values embedded in the current medical home concept endorsed by various medical and osteopathic professional organizations. It emphasizes comprehensive partnerships, mutual decision-making teams, holistic coordination, facilitated technology, quality, safety, evi- dence, access, and personal relationships. These are worthy attributes, he said, but the medical home concept may be significantly underpowered to manage the nation’s future health needs. His concerns begin at the starting point for care and can be summarized in six words: “Too much medical, not enough home.”

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69 MODELS OF CARE A home-centered health care model would focus on helping people achieve their full human potential. This model requires looking at the many forces and individuals that influence health-related decisions day by day, month after month. For a young child, the view may extend out over a 100-year horizon. Magee said that it requires planning ahead, con- sidering a person’s uniqueness, socially and scientifically. It requires “being where the person lives,” in the home. In this context, home means both a geographic and a virtual place. It is where one feels safe and secure, supported and loved, awash in social capital. While the geographic home may change location, the state of feeling at home should ideally follow. “So much has changed all around us that perhaps we could be excused for having overlooked the home as a logical destination and cornerstone for the health system,” said Magee. Misreading the significance of trends has compounded the problem. Magee noted three examples of trends that affect home and family that health care systems should address: how longevity has made families more complex, as they have moved from involving three generations to four- and five-generations; how the Internet, which can push massive amounts of information at high rates of speed, is essentially geography free and offers almost infinite opportunities for connection; and how three decades of consumer health information has led to empowerment that has suppressed medical paternalism and encouraged teams and mu- tual decision making. This last trend is now giving way to health activism, led primarily by informal family caregivers. Magee said that most of these are middle- aged women, often managing frailty in the older generation and imma- turity in the younger. Caregivers labor as both providers and consumers, yet are not generally recognized as part of the health care team. For them, it is not the lack of information that is literally killing them, it is the lack of a system. A sufficiently powered vision of a home-centered health care model must make complexity, connectivity, and consumerism an advantage. However, our health care system continues to focus on the loop from the doctor’s office to the hospital and back again as shown in Figure 3-1. The home, if considered at all, is an afterthought. A person with a health concern must find a way into the loop.

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70 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Hospital Home Physician’s office FIGURE 3-1 Doctor–hospital loop. Magee suggested a new health care system where the home is at the center, and the loop begins from home and goes to the care team and back to the home as shown in Figure 3-2. A rich array of information that is personalized and customized with vital signs, diagnostics, and plan- ning milestones could be transmitted automatically and wirelessly from the home to the care team. In the other direction, data, analysis, advice, support, and coaching could come into the home continuously. All would be part of a virtual system committed to efficiency, connectivity, and mobility, rather than being tied to the bricks and mortar of health care facilities. Such a vision obviously entails serious challenges, but it builds on a number of our strengths. Magee highlighted five examples of strengths that could be built upon. The first strength is the high value that Americans place on their homes, where loved ones support and value them. “Americans abhor homelessness yet have learned to accept healthlessness,” he said. The second strength is Americans’ increasing support for universal health care. With this right must come responsibility, he said. Readiness to define roles and responsibilities in individuals, families, and commu- nities in return for universal care could provide multiple societal benefits. Third, health care providers are beginning to accept information technology. The next step will be to take full advantage of its capacity to humanize, plan, connect, and bring order and sense to a segmented and broken system. Helpful resources for expanding this capacity might be

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71 MODELS OF CARE Vitals Blood results Imaging Rx Home Pharmacy Data Coaching Hospital $ Diet changes Insurance Alter meds Exercise routine Specialist FIGURE 3-2 Home-centered care team loop. found by partnering with sectors that have tremendous information tech- nology expertise and an existing position in the home but which are cur- rently locked out of health care, like the financial, home technology, and home entertainment sectors. Fourth, many people are beginning to appreciate that, rather than creating a socioeconomic digital divide, information technology may do just the opposite. Connectivity can be targeted first at those who need it most, whether that is an 18-year-old pregnant, single mother of two in West Philadelphia; a Montana farm family 200 miles from the nearest hospital; or the only daughter of a widowed mother living three states away. Finally, embracing these trends may allow more efficient and effec- tive management of the existing chronic disease burden while simultane- ously building a truly preventive system that will serve generations to come. The missing connection at this point is a software application, which Magee predicts will be ubiquitous on all new computers within 5 years. This application should be called a “lifespan planning record (LPR)”. LPRs will supplant personal health records and will come from the con- sumer side—with or without the support of clinicians. LPRs could be the tipping point enabling a truly preventive health care system. They will be a graphically pleasing, highly-powered application capable of automati- cally extracting and compiling a wide range of individual, family, com- munity, environmental, and scientific data, then converting that data into a personalized, predictive, preventive, and participatory strategic health

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72 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC plan. LPRs will accept real-time modifications and provide information and support for plan adherence. With what we currently know, the 100- year plan for today’s child could already be imbedded with thousands of targeted inputs, he said, and 10 years from now, that plan could include hundreds of thousands of data points. In short, Magee said that the medical home movement’s values are not wrong, but its destination is, and that must change. Preserving rela- tionship-based health care requires embracing current trends and leading with a vision sufficiently powerful to excite the imagination. This vision must embrace complexity, connectivity, and consumerism, while rein- forcing the social health capital imbedded in relationships between peo- ple and the people who are taking care of them. Panel Discussion Following the panel presentations, the audience submitted questions for further panel discussion, which was moderated by Guarneri. Reimbursement The first question asked about the reasons that many young physi- cians choose to go into specialty care. These reasons are not all financial and include perceptions about intellectual challenges and professional respect. Ed Wagner responded that nonfinancial disincentives are power- ful, but that the lack of respect is largely evident by the way primary care physicians are paid. He said that the most important way to overcome the payment problem would be to stop reimbursing primary care physicians using the fee-for-service payment model. Fee-for-service has a variety of disincentives to providing the kind of personalized, integrated care dis- cussed at the summit. These disincentives are not just the levels of reim- bursement, but the emphasis that the fee-for-service system places on throughput and brief interactions. “If we can do any one thing in health care reform, I would say get primary care on capitation as quickly as possible,” Wagner said. Noting that reimbursement ran through much of the dialogue, Katz said, “We have not so much an evidence-based system of health care as a reimbursement-based system of health care.” For example, the reim- bursement system makes it difficult to provide team care. If every patient

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73 MODELS OF CARE sees not just one high-cost clinician but several simultaneously, the costs are prohibitive. Demonstration research programs are needed to test the effectiveness of team-based practice, said Katz. A program designed by Dean Ornish, in which Guarneri participated many years ago, showed that every dollar spent on care for very sick car- diac patients could save $6.66 on angioplasty and bypass surgery. Thus there are precedents for demonstration models and clinical networks that can deliver effective preventive care. We should test these concepts and take them out of the realm of integrative medicine, she suggested, saying, “Let’s just make it medicine.” Genomics and Epigenomics Another participant asked about the role that emerging concepts within systems biology that relate to genomics, proteonomics, and me- tabolomics will play in integrative medicine in the future. Certainly, Guarneri said, we will have people rushing to websites like 23andMe and Navigenics to have a look at their genomes. They will obtain the information, but they may not realize that genetic risk does not mean they will manifest a particular disease. Their genetic blueprint can be influenced by their environment through epigenetic processes. Inte- grative medicine includes attention to the environment, where and how people live, with whom they live, and their lifestyle—what they eat and how they exercise, for example. Understanding these factors, as well as the biologic ones, is essential to unfolding the potential for illness. After all, “we are more than our genes,” she said. Katz added, “As we pursue the trees represented by our genetic polymorphisms, we ought not lose sight of the forest.” The overwhelm- ing contribution of personal behavior to morbidity and mortality has been well elucidated for nearly 20 years. Health care providers should focus at least as much on applying the knowledge they already have, he said, “which does not require the use of electron microscopes or profiling our individual genomes.” If they did, they could slash heart disease by as much as 80 percent, diabetes by 90 percent, and cancer by 60 percent or more. While it will be helpful to know what specific genetic variations an individual has, there is an enormous wellspring of opportunity already in place that practitioners should not overlook as they attempt to foresee future events.

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74 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Strategically, it may be wise to link integrative health to these tech- nological advances in a profound way, said Gaudet. She said “We need a health care system, not a disease care system, if we are going to utilize the science that we are advancing.” While people may believe high-tech interventions are at the opposite end of the spectrum from integrative health, she said, high-tech interventions need to be incorporated into in- tegrative health care in the same personalized and holistic way as other services. PRIORITY ASSESSMENT GROUP REPORT 1 Identifying and Advancing Workable Models of Integrative Care Themes and Highlights Dr. Fred Sanfilippo provided the report for the priority assessment group that reviewed ways to promote models of integrative care. This summary reflects the priorities discussed and presented by the assess- ment group to the plenary for its discussion and consideration; these pri- orities do not represent a consensus or recommendations from the Summit. This group began with the presumption that its discussion would focus on models that represented substantial changes, and it dis- cussed priorities, relevant actors, and short- and long-term progress. The group’s three most important priorities were that models should demonstrate value, sustainability, and scalability. In discussing ways to demonstrate value, the group acknowledged that all models have poten- tial value of one type or another. Prime indicators of a model’s value are whether it achieves quality outcomes and is safe; another is reflected in its costs relative to these outcomes; and another is whether it effectively engages patients and, in their eyes, provides satisfactory care. In terms of sustainability, the group noted that models being assessed must work across populations, be financially viable and self-sustaining, and self-actualizing or continually improving. To the group, scalability meant making sure that the models could scale up to large and more diverse populations, but also scale down to the individual level. The 1 See Chapter 1 for a description of the priority assessment groups. Participants of this assessment group included Carol Black (moderator), Fred Sanfilippo (rapporteur), Brian Berman, Lilian Cheung, Mary Hardy, Mark Hyman, Bradly Jacobs, Woodson Merrell, Chuck Sawyer, Timothy Birdsall, and Lori Knutson.

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75 MODELS OF CARE models should work effectively across providers and employers and across communities and states. The second question the group addressed related to key actors and their roles. People who are recipients of health care services were deemed the most important group of actors. Their roles include becom- ing more aware of nonmedical factors that affect health and healing, in- cluding social, economic, environmental and behavioral factors; setting realistic expectations for their care; and demanding changes and ac- countability from payers and providers. The second set of key actors identified is the health care provider group. Their role is to be proactive, not reactive, and to develop comprehensive, coordinated models of health care delivery that involve multidisciplinary teams whose member- ship reflects patient needs. These teams should take into account both biological and nonbiological contributors to illness, health, and healing. A third set of key actors comprises facilitators—employers, state and federal governments, payers, and others whose role is to help drive this change by demanding value. Another group of actors is found in acade- mia, where educational programs can foster this broader approach to health and healing. Such programs should be located in each of the health care disciplines and professions, and new programs can create new disciplines that may be needed, such as coaches, navigators, and others. The group noted that even within 3 years, it should be possible to have the evidence to identify some demonstration models that work, as well as some well-functioning, vertically and horizontally integrated de- livery systems. It would be important to demonstrate, in this time, suc- cessful ways to provide financial incentives for developing these models and rewarding their development. Finally, in 3 years, there should be good evidence of changes in the educational curricula for existing disci- plines but also educational programs for new professional categories. In 10 years, the group said that it should be possible to identify best- practice models that fulfill the value parameters described earlier. These models should be supported by reformed financial and reimbursement systems for health care; this step is necessary for any of the advancement of integrative medicine in general. By 10 years time, information tech- nology applications should be in place that can facilitate health care transactions and provide decision support. Also by 10 years time, and with the right education, both the public and providers can be expected to have a much better understanding of the socioeconomic factors in health and disease and should have begun to address them.

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76 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC The group also identified several major next steps. The first steps are to create a definition of integrative health care that engenders wide agreement and then to reach agreement on a standardized set of outcome measures. Next would be to inventory existing models and identify their pluses and minuses; to inventory the health provider arrangements that exist in various models and see how they might fit into a more coherent model or inform the future; and to inventory data and information sys- tems to gain a comprehensive view of current best practices and effec- tiveness around work processes and decision support. Other important steps the group suggested would be for the Centers for Medicare and Medicaid Services to support demonstration projects, the National Insti- tutes of Health to support clinical effectiveness studies, and the IOM to hold follow-up summits. Discussion and Questions The summit participants’ discussion of the assessment group report revealed a number of models that could be ripe subjects for demonstra- tion projects in integrative medicine almost immediately, if funding for such studies were available. According to Sanfilippo, applications for such funding might come from a variety of places, including large em- ployers and various communities positioned to move ahead fairly quickly. Some existing projects with potential to participate in a trial that might not immediately be thought of as integrative care models also were suggested, such as the life program of the University of Pennsylvania’s School of Nursing, which is a capitated, independent living program for elders that involves nurses, doctors, dentists, and occupational and physi- cal therapists. Another audience member cautioned against assuming more empow- erment and health literacy than many people actually have. The partici- pant noted that any demonstration model would be a helpful advance, especially if it included facilitators, health care advocates, language in- terpreters, and information technology specialists who could make care more accessible to everyone.