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Integrative Medicine in Hospitals and Academic Institutions

Dr. Ather Ali, ND, MPH, MHS (c)Associate Research Scientist, Department of PediatricsIntegrative Medicine Specialist, Yale Stress CenterDirector, Integrative Medicine at Yale

Atatürk ÜniversitesiMay 2014

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Outline

• Considerations• Consortium of Academic Health Centers for Integrative

Medicine• Models of Integrative Medicine

– Yale Stress Center– Integrative Medicine Center at Griffin Hospital

• Best Practices• Resources for information

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Considerations

• Academic Health Centers and Teaching Hospitals – High credibility– Seen as highest quality care– Mission to educate and train– Innovators in methods– Discovery and application of knowledge

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Integrative Medicine and U.S. Academic Medicine

• < 20 year-old movement• Consortium of Academic Health Centers for Integrative

Medicine– Started with 8 universities + Deans (2000)– Now – 57 Medical Schools (140 total)– National and global influence– Working groups focusing on

• Research• Clinical care• Education• Policy

– International Congress on Integrative Medicine and Health (IRCIMH)

• Every 2 years• Miami, Florida (USA) – May 2014• Partners with International Society for Complementary Medicine

Research (ISCMR)

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International Research Congress on Integrative Medicine and Health – May 2014

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CAHCIM

• “Our mission is to help transform medicine and healthcare through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing and the rich diversity of therapeutic systems.”

• Schools with demonstrated programs in (two of):– research, education, or clinical care

• Members include Yale, Stanford, University of California San Francisco, UCLA, Harvard, Duke, Johns Hopkins, Mt. Sinai, Columbia, Mayo Clinic, UWashington, University of Pennsylvania

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Models of Integrative Care (Outpatient)

• Referral-based• One-stop-shop

– Doctor who has multiple skills• Multispecialty integrative medicine practice

– Ataturk University example– Yale Stress Center example

• Multidisciplinary evaluations– Griffin Hospital example

• Inpatient care is unusual– Inpatient consults

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Yale Stress Center

• Directed by Rajita Sinha, PhD (clinical psychologist)• Clinical care started 2012 / Research Center since 2007• Integrated mind-brain-body framework

– treatment and prevention of stress-related conditions– symptom control– primary, secondary, tertiary prevention

• First Integrative Medicine clinic at Yale• 400- 500 patients / month• Clinical training

– Predoctoral and postdoctoral psychology fellows– Medical residents– Undergraduate students– CAM students

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Yale Stress Center – clinicians

• Clinical Psychologists (PhD or PsyD)• Psychiatrist (MD PhD)• Naturopathic Physician / Integrative Medicine Specialist

(ND MPH)• Yoga and Mindfulness Instructor (MA RYT)• Licensed Drug and Alcohol Counselor • Endocrinologist (Adult and Child) (MD PhD)• Licensed Professional Counselor (LPC)• Clinical Psychologist /Acupuncturist (PsyD)• Registered Dietitian /Certified Diabetes Educator (RD

CDE)• Exercise Physiologist (PhD)

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Yale Stress Center – services

• Extensive stress evaluation and diagnostic assessment – Biochemical analysis for stress, health and immune

functioning • Stress reduction workshops• Mindfulness-based stress reduction, guided breathing,

and relaxation training • Personalized life coaching • Integrative Medicine evaluations • Dietary supplement evaluations • Weight loss programs (individual and group) • Acupuncture • Exercise coaching • Individual and group psychotherapy • Psychopharmacology

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Yale Stress Center - Financial

• Commercial insurance• Medicare/Medicaid (government national and state

programs)• Yale Health Plan (for Yale University employees)• Practice of the Yale Medical Group

– a multi-specialty academic group practice of full-time faculty at the Yale School of Medicine

• Portion of revenue goes to Medical School

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Integrative Medicine Center at Griffin Hospital

• Yale-affiliated community hospital• “Evidence-based integrative care”• Uses a novel MD-ND model of care

– Dual evaluations with internal medicine doctorand naturopathic doctor

• Focus on health and wholeness • Least invasive therapies when possible• Also predicated upon:

– The belief that no one person can know it all

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Goals and Ideals

• There is no “alternative” vs. conventional care• There is a single spectrum of options for care and healing,

encompassing all• The spectrum of healing arts is subject to the same

evidence hierarchy, and creatively applied research• Patients are guided/accompanied to the best, tailored

options

Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for Institute of Medicine (IOM) of the National Academies .2009.

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Examples of therapies

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CAHCIM Survey Data - Best Practices

• Built relationships with other departments– pain, cancer, rheumatology, cardiology

• Became part of the medical center through education– teach medical school electives and classes– supervise practicums, residents and fellows– speak at grand rounds

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Best Practices – CAHCIM Survey

• Clinical services (most profitable): chiropractic/manual medicine, acupuncture (especially community model), and integrative mental health

• Philanthropy• Group Classes • External: Partnerships resulting in diversity, outreach,

and innovation • Internal: Collaboration and case conferences • Metrics

– Demonstrate economic impact to Academic Health Center– Patient satisfaction, return on investment– demonstrate efficiency/effectiveness– helps decision-making

MacElhern L. CAHCIM Survey 2013.

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Experiences of successful centers

• Work with integrative health experts • Start small and grow • Collaborate with non-faculty providers • Network heavily on campus and in the community with

“friends” who could be referral sources • Choose modalities that are evidence-based, readily

acceptable, and build trust • Use electronic medical record to share• Conferences / retreats / workshops• Many have mindfulness meditation programs

– MBSR Research• (Influential) Faculty Champion

Vanderbilt Center for Integrative Health

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Financial Considerations

• 48% - Philanthropy/donations• 21% - Other• 18% - Grants• 13% - Academic Health Center

MacElhern L. CAHCIM Survey 2013.

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What not to do

• Fall prey to the “guillotine effect”– Keep people in different centers/departments

• No distinct identity from academic health center• Having only one area of expertise

– Trying to have expertise in too many areas• Be content / complacent with current successes

MacElhern L. CAHCIM Survey 2013.

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Recommendations: Outcomes Research

• Systematic data capture and analysis– To measure population health – To predict health outcomes – To address demands for accountability – To improve the knowledge base of a practice or procedure – To evaluate treatment intervention effectiveness – To improve quality – To market a practice, service or procedure

Kemper K / Kane, R.L. and Radosevich, D.M. (2011). Conducting health outcomes research.

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Outcomes Research in IM: Understand philosophy

Kemper K. IRCIMH 2014.

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Resources

• Bravewell Collaborative Reports– Integrative Medicine in America– Integrative Medicine: Improving Health Care for Patients and

Health Care Delivery for Providers and Payors – The Efficacy and Cost-Effectiveness of Integrative Medicine – Best Practices in Integrative Medicine: A Report from the

Bravewell Clinical Network• The Integrator Blog

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This work was supported by a grant from

National Center for Complementary and Alternative MedicineNational Institutes of HealthU.S. Department of Health and Human Serviceswww.nccam.nih.gov