Developing an Integrative Health Clinic and Program VASLCHCS

1. Developing an Integrative Health Clinic and Program VASLCHCS Sandra J W Smeeding PhD, CNS, FNP-BC Associate Director Integrative Health VA Salt Lake City

2. Objectives • Learn the research needed prior to proposing an Integrative Health Clinic. • Understand the people to involve in the planning stages. • Learn the steps needed to establish an Integrative Health Clinic and Program. • Describe strategies to overcome the challenges and organizational barriers.

3. Formative ResearchReadiness for change • Greatest mistake: attempting an innovative change without understanding pre-conditions for success. • Rigorous assessment to determining the level of “readiness” for change in the local market. • Do the research, lay the necessary groundwork before proposing, designing and implementing. • Literature Review for evidence of effectiveness and outcomes must be knowledgeable on your topic. • Investigate change management, benchmarking, and best practice.

4. Formative ResearchReadiness to change • Is there commitment from institutional leaders? • Analyze the supporters and barriers, identifying potential power struggles. • Assemble a powerful team to lead the change- steering committee. • Create and communicate a compelling vision of change- business plan. • Experiences of other VA organizations with similar attempts. • Readiness criteria that needs to be satisfied before proposing

5. Timing- External Market AnalysisResearch • CAM use in U.S. & Veterans CAM use surveys. • Klemm Analysis 1999. • White House Commission Report on CAM 2002. • National VA CAM Therapies & Practices (HAIG-2002). • National VA CAM Field Advisory Board - Credentialing and privileging guidelines. • Patient protection and affordable care act Title IV (subtitle A). Prevention of chronic disease, health promotion, Integrative Health.

6. Internal and External support #1.Administrators:Director, Chief Nurse, Chief of Staff, ACNS, Chief of Services: Anesthesia, Mental Health. #2.Providers Known to offer CAM (VA CAM Practice 2002), Psychologist, Nursing, DO/MD, PT, LCSW, Clergy #3. VA Integrative & CAM: Elizabeth.Hakas@va.gov #4.VA Acupuncture:Elizabeth.Hakas@va.gov #5. VASLCsandra.smeeding@va.gov #6. VA Long Beach anfu.Hsaio@va.gov

7. Timing Internal Market Analysis • VASLC Integrative Health Proposal (1997 ) approval 2000. • Identify high risk populations: high use, dissatisfied, underserved, high pharmaceutical use and cost. • High cost: potential to reduce cost. • High volume: ICD-9 codes. • Provider interest , acceptance or resistance- referral base • Understand local Veterans CAM use. - Dissatisfied: reliance on pharmaceuticals ,lack of whole person approach, lack health promotion (satisfaction surveys).

8. Institutional Assessment Informal Survey • Communication: technology , in-services, staff meetings. • Education and Information gathering. • Introduce concept: CAM & Integrative Health. • What is known, preconceived ideas, beliefs, motivations? • Confront the fears - Safety, effectiveness, efficacy • Identify champions and barriers, potential providers.

9. Challenges/ Concerns: Medical Staff, Clinical Executive Board • Physician resistance-safety, control. • Budgetary constraints. & limitations of insurance reimbursement • Credentialing and Privileging of providers and therapies. • Efficacy /Effectiveness of particular modality for specific medical conditions. Evidence-based practice. • Office and Clinic space.

10. Positioning in a service Patient Populations • Service positioning: Primary care Mental health Preventive Cardiology Integrative Oncology Anesthesia Chronic pain End of life/palliative care • VASLC: Anesthesia: Chronic Pain & Stress, Depression, Anxiety, Health Promotion. • Outpatient or Inpatient - best opportunity, most acceptance.

11. New Model of HealthCareVASLC Goals • Improve health related quality of life, reduce pain & stress related depression and anxiety, non pharmacological. • Focus on health promotion-lifestyle, self-management, minimize “facility and equipment dependent” treatments. • Whole person: healing vs. cure, mind/emotion/body/spirit, avoid the disease management model or mechanistic pathophysiologic model. • Choice: patient is the center of the decision making-in charge vs. hierarchical orders. • Active participation vs. passive recipient: coaching. • Include family in classes, offer classes to staff.

12. Outcome Measures Quality • Improve Health Related Quality of Life (Computerized SF- 36)-MH testing package). • Reduce depression - related to pain and stress (Computerized Beck Depression Inventory-MH testing package). • Reduce Anxiety - related to pain and stress (Computerized Beck Depression Inventory- MH testing package) • Patient Satisfaction • Improved Function • Reduced Stress • Improved resiliency & coping • Improved Sleep • Decreased healthcare utilization-urgent care • Medication • Pain reduction

13. Budget • Integrative Health- Associate Directors: NP (.8 FTE -existing) (5/8) (MD retired), Nurse Administrator (.2 FTE existing), MD Acupuncturist in Anesthesia (existing) & MD VA (PM&R retired – WOC). • Funding for training: hypnosis graduate class U of Ut and then mentoring; Aquatic bodywork (Watsu water shiatsu). • Provider FTEE were other duties as assigned ( 2-4hr. blocks or teaching classes/movement therapies: mental health and social work). Contract certified yoga teacher (RN). • Facilities: Virtual clinic space- start small ½ day clinic and therapies 3 days/wk, expand with demand, include cost of supplies and equipment.

14. Credentialing and Privileging • Standardized the Process for provision of therapies and privileging of providers. (Appendix A & B). • Utilize the same process as conventional therapies and treatments. • VA provider applied for credentialing and privileging in CAM therapy. • Therapies approval : Administration, Integrative Health Steering Committee and final approval : Clinical Executive Board (CEB). • VA and contract providers credentialed and privileged in Professional Standards Board (PSB) in the CAM therapy.

15. Providers • Know State licensing and VA requirements. • Set high CAM Standards, similar to conventional professions: - understand credentialing, licensing, training for CAM therapies. - Practice of CAM without sufficient training or credentials ? • Cost driven HCS, CAM studies on cost-effectiveness. - number of treatments for CAM therapy. - amount and cost of supplies and equipment. - consider: cost & outcomes of CAM providers: MD CAM & non MD CAM- advantages and disadvantages. • Collaborative relationships: academic and research: grants, funding.

16. Selection of CAM ServicesModalities • Target population: Supported by research evidence of effectiveness - for particular indications. • Non-controversial,critical initial acceptance. • Desired /requested by patients and providers . • Consider VA staff CAM modalities first. • Start small expand in a step wise fashion and as demand grows. • Financial & Legal considerations. • Consider integrating and/or expanded existing services e.g. hypnosis into smoking, multidisciplinary wt. with hypnosis

17. Program Business Plan*Approved by Clinical Executive Board • Executive Summary: Summary of VA, current CAM and IH literature review. • Program intent, purpose. • Modality and Provider selection criteria, standardized credentialing and privileging. • Vision, Mission Statements • Specific measurable goals • Strength, Weakness, Opportunities, Threats (SWOT) • Budget for the Integrative Health Program • Timeline for implementation in the first year. Appendix - Executive Summary: Klemm Analysis :VHA Complementary Alternative Medicine (CAM) Practices and Future Opportunities, White House commission summary, VA CAM Advisory Board Credentialing and Privileging, Patient Protection and Affordable Care Act IV, other relevant research.

18. Multidisciplinary Steering Committee Administration Information Technology Management Providers Neurology Interested staff Nutrition Telemedicine Pharmacy Anesthesia Primary Care Chaplain Pt. Education Mental Health Pain Medicine Staff Education PM & R Phys. Therapy Rheumatology Social Work

19. Integrative Health Outpatient Clinic and Program Model • Computerized Consult Referral Service: - 5 state catchment area - Consult screen: inclusion/exclusion modality criteria • Intake evaluation H&P by MD and NP: cc, pain , stress, H&P, social support, emotional, mental health assessment, lifestyle, IH therapies and classes selection, outcome tests (BDI, BAI, SF-36) pain and stress (0-10) NRS. • Orders and appointments for therapies and classes • F/U re evaluation at 6-months, 1-yr, 2-yrs, etc. • Clinic progression from last hope to try this first ! • Outcome Research

20. VASLC Therapies and Mind-Body Skills • Acupuncture • Aquatic bodywork(watsu) • Herb/Drug interaction counseling • Hypnosis • Meditation • Qigong

21. VASLC Therapies and Mind-Body Skills • Stress Management • Yoga • Weight Management • Tobacco Cessation

22. Marketing Integrative Health Education of Providers • Monthly in-services in primary care. • As requested: residents, specialty services, School of Medicine, School of Nursing, community requests. • Integrative Health holistic philosophy and goals included. • Modality in-services: Description, evidence base, how to refer, patients to refer (inclusion), benefits, risks, patients who are not candidates for the therapy (exclusion) and why. • Mind-body skills in-services-include experiential • Developed educational brochures, posters-pictures.

23. Strategies to overcome resistance • How will an Integrative Health Service: - Distinguish your organization ? - Sufficient patient population numbers? - How will IH affect other department referral patterns? • Formation of a multidisciplinary Steering Committee Providers: referrals Administrators: policy, fiscal Managers: staffing • Monthly Education series in primary care. • Visibility, Accessible, Communication!

24. Factors to Ensure a Successful Program • Use evidence based therapies. • Follow norms of clinical practice. • Develop strong administrative component. • Remain adaptable and responsive to patients. • Maintain professional image. • Publish, present, research.

25. Greatest barriers and reasons for failure • Lack of local champion or wrong champion. • Lack of interdisciplinary collaboration. • Hierarchal approach-top down. • Lack of safety and/or clinician knowledge. • Lack of outcome studies or research. • Lack of standardized consistent credentialing and privileging. • Lack of communication within the facility

26. What would we do differently? • More consultation on: • Data management & Program evaluation. • Clinic staff support. • Unable to get massage approved. • Unable to get chiropractic approved. • Unable to get Energy work approved for clinic, was used in nurses under their license on the medical floor to a limited extent. • Limited personnel to introduce inpatient programs. • Obtain permanent staff-FTE from start.

27. Appendix VASLC – CEB Modality Application VASLC - PSB Provider Application Examples of Business plan content

28. CAM Modality Clinical Executive Board (CEB) Application • A description of the therapy and the mechanism of action. • Literature review of effectiveness/efficacy of therapy. • List of medical conditions proven to benefit by the researched evidence base or patients to refer. • Describe any adverse effects. • List medical conditions to exclude, contraindications, patients not to refer. • Expected duration/numbers of treatments and the benefits. 7. References from the literature review.

29. CAM Professional Standards Board (PSB) Application 1. Therapy description and mechanism of action . 2. Literature review of effectiveness/efficacy of therapy. 3. List of medical conditions proven to benefit based on researched evidence or patients to refer. 4. List medical conditions to exclude, contraindications, adverse effects or patients not to refer. 5. Expected duration/numbers of treatments and the benefits. • References from the literature review. • Training, certification, licensure for the therapy.

30. Business Plan (Example) • The intent is to develop an interdisciplinary, collaborative Integrative Health Program at the SLC VAHCS involving physicians, nurses, pharmacists, dietitians, psychologists, and other health care professionals. • The purpose is to: (1) integrate CAM and mind-body skills into patient care services with conventional medical care; (2) provide CAM education programs and materials to professional staff and patients, and (3) initiate outcome research. • Criteria used to select the initial CAM therapieswill include: (1) research based data in the literature, (2) considered non- controversial and near mainstream modalities (3) desired/supported by SLC VAHCS staff and patients, and (4) availability through existing SLC VAHCS professional staff or consultants.

31. Business Plan (Example) The goals for the initial phase: • Implement an Integrative Health clinic and program with a physician, a nurse practitioner, and a clinical support manager as a outpatient department offering selected CAM therapies in a careful and stepwise fashion. • Perform a survey of the current use and preferences for CAM therapies at the SLC VA. • Define a credentialing and privileges process for providing CAM services. • Develop a realistic and clear definition of success for the CAM initiative . • The Program will start small, be evaluated at prescribed intervals, and grow as appropriate.

32. Business Plan (Example) Strengths: • The VAHCS definition (1996) of medical need includes care and/or services that will promote, preserve, or restore health. This definition is congruent with the core philosophy of a wellness orientation with most CAM therapies. • A significant proportion of VHA patients with chronic conditions that have not responded well to a singular conventional medicine treatment approach. Providing CAM therapies as an additional option to address these problems is supported by many VA providers and patients. • Every VISN, including the SLC VAHCS, reports some use of CAM therapies. • A CAM initiative would allow the SLC VAHCS to develop collaborative relationships with nationally known research organizations, academic centers, to conduct outcome research.

33. Business Plan (Example) Weaknesses: • The science/technology model of care offered at the SLC VAHCS has traditionally excluded CAM therapies. • There is limited awareness and understanding of CAM therapies among SLC VAHCS professional staff. • There may be resistance to the implementation due to traditionally- held attitudes about CAM therapies, about scientific efficacy. • Lines of communication to disseminate evidence of CAM effectiveness are not established • The VAHCS’s reputation as a conservative system may provide a barrier to a new, and potentially controversial, CAM initiative. • Offering CAM therapies may require the development and acceptance of a new paradigm. The new paradigm expands thinking from a disease oriented, pharmacology/surgery- based treatment to one promoting prevention, self - responsibility, and a belief in the body’s ability to heal itself.