Integrated Before Integrative

Wayne - Fountain pen

Let’s cut the confusion.  One hears a lot of talk these days about “integrative” health care.

In fact, the name of the National Center for Complementary and Alternative Medicine recently changed to the National Center for Complementary and Integrative Health. We also hear a lot about the need to have “integrated” systems built into our health care. Approaches such as the patient-centered medical home (PCMH), Accountable Care Organizations (ACA) and improved systems of care are built into the Affordable Care Act. 

Although the words seem similar,


integrative and integrated
are often miles apart.

What is Integrated Care?

Integrated systems are efficient and smooth. The parts work well together and within the whole. Individuals communicate well, have clear roles and operations, and deliver only what’s necessary in an efficient manner.

Methods for improving efficiency were originally developed for other industries, like the Toyota production method, and are now being applied to health care to create an integrated system.[i] In an integrated system members of the health care team trust each other, know what their job is, communicate rapidly and know how to work together. Each person knows when someone is not accountable for his or her particular part of the team’s care. Team members don’t go too far outside of the box in delivering what’s in their competency, is demonstrated and paid for. And the patient expects what’s in the box when they come in through the clinic door.

Integrated Health Care is not Integrative

The patient-centered medical home (PCMH), when properly operating and effective, is a good example of an integrated system. Recently, I visited a well-integrated PCMH practice in Tennessee. The physician there said the secret to good primary care is having an effective and efficient system that meets the needs of the patient and gets costs covered by the system of health care.

However, when I asked him if he implemented any integrative practices or had thought about hiring a nutritionist or behavioral medicine expert into his practice, he immediately said no. He believed most patients cannot make the behavioral changes they need to do anyway, especially with the limited number of visits that were reimbursed, which would not cover a full-time person. Instead, he refers patients out when those services are really needed, that is, when recommended in national guidelines and paid for by insurance.

As for integrative medicine he does none of those types of practices. It is not that he is against them (except for dietary supplements, which he thinks are unsafe for most people) but because he doesn’t think there is much evidence that they’re very effective. He does not believe in passing these costs on to patients if they are not proven. “When they get approved by the FDA and covered by health insurance,” he said, “then I will be ready to implement them in my system. I keep my practice evidence-based.” So although his practice is integrated, it is not integrative.

What is Integrative Care?

Health practices that attempt to bring in other non-conventional healing modalities, so-called “complementary and alternative medicine,” into the mainstream are called integrative. They bring healing techniques that are outside of the mainstream into the current system of care. They have a philosophy and a set of practices, and a scientific basis that’s often quite different from conventional medicine. They seek healing and not just cure.

The practices that are trying to be “integrative” derive from traditional practices or independent systems of medicine, such as Chinese medicine, Ayurvedic medicine, chiropractic, homeopathic, and others. Complementary and integrative practices include acupuncture, massage, manipulative therapies, and education on diet, nutrition, and other self-care approaches.

Unfortunately, these integrative practices are not very integrated, with conventional medicine or themselves. They are not part of normal medical training, are usually delivered in silos of practice, often aren’t found in the same place, are not part of a PCMH, are not incorporated into national guidelines and are not paid for by insurance. Therefore, integrative practices tend to operate in isolation—and are not well integrated.

The true integrator in this case, is the patient, who searches around and tries to do their best in putting practices together that resonate with them and decide for themselves whether they’re effective or not.

Achieving Both Goals: Integrative and Integrated Care

I recently visited a health care center that was attempting to achieve both goals of integrated and integrative care. Despite the challenges it faces in doing so, the Casey Health Institute in Gaithersburg, Maryland is attempting to integrate their integrative systems. However, they are finding the efficiency of such a system challenging and are still working to make it a profitable one.

What lessons can we learn from these approaches in health care?

First, we shouldn’t confuse the two terms or processes of integrative and integrated. We need both. But, right now they have different goals and they fundamentally operate differently. In some cases, they’re incompatible with each other; one seeking healing and the other cure.

Those who seek to put both of these together must ensure that experts in integration and experts in integrative are first working together as a team. This involves properly selecting and training people, so that they can work together cooperatively and effectively. The patient must be at the center rather than the focus being on the condition or the modality that they happen to know about or the tool they want to apply.

For example, while it’s always preferable to relieve pain without more drugs and medications, that’s not always the best course of action. Sometimes, in fact, it’s better to use a drug or a surgical intervention. Sometimes it’s better to incorporate behavioral techniques that are not normally part of complementary medicine. Sometime diet changes can improve a condition. But how do we figure that out when these practitioners rarely work together and our systems are not organized with clear roles and accountability?

Relationships are key for both integrative and integrated systems. In fact, they’re the first thing that needs to happen. Simply substituting a healing practice like Reiki for a drug like Reglan does not make it integrative medicine.

Finally, the services needed to be tailored to the needs and the readiness of the patient.

There are times when the patient has limited resources (time, energy, interest or money) for their own care. It’s essential for the care providers to acknowledge this, and incorporate the patient’s wishes and resources into the plan of care. The services can later be expanded as the patient is willing and able to accept a larger investment in their care. If integrative practices are not effectively integrated into our delivery systems, they will not become widely available.

But there is progress. As I write this blog I am at a week-long training program from the Institute of Functional Medicine, an approach I have worked with for decades. Fifteen years ago it used to be chaotic, hodgepodge of findings about nutrition and lifestyle seemingly thrown at random at patients.

However, now much progress has been made. An organized approach for working with patients, nutritionists, physicians and health coaches is being developed to deliver integrative care in a more integrated manner. Nearly 500 physicians, many of them new to integrative medicine, have responded by attending.

An efficient, integrated, well-operating, patient-centered team system needs to be the focus of any health care delivery. Only then can bringing in complementary and alternative practices, so-called integrative medicine, be of value. First make sure the system works well and then expand to more holistic and integrative care. Then we will be able to provide healing to all people.

First integrated and then integrative.

 


[i] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3678835/