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The HOPE Note: Bringing an Integrative Approach to Primary Care

January 2018

DrWayneJonas.com/HOPE

http://DrWayneJonas.com/HOPE

The HOPE Note:Bringing an Integrative Approach

to Primary Care

THE COST OF CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

UNDERSTANDING THE DETERMINANTS OF HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Understanding the Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

THE HOPE NOTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

The HOPE Note Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

PUTTING THE PATIENT FRONT AND CENTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

ADDING HOPE TO HEALTH CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

THE BENEFITS OF INTEGRATIVE HEALTH IN YOUR PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

PreventingBurnout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Improving Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Reducing Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

INTEGRATIVE HEALTHCARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

CREATING A HOPE LIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

SettingGoals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

PAYING FOR HOPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

4 The HOPE Note: Bringing an Integrative Approach to Primary Care

I t’s clear that the US healthcare system needs changing . The costs are too high and the results too poor.Thesystemalsoneedschangingbecauseourpatientshavechanged.Whatwegetmostlyfrom

healthcarewasbuiltonanacutecaremodeltotreatillness–usuallyappliedatlatestages.Thatapproachnolongerworksforhealingchronicdiseasewehavetoday.

Today,45percentofAmericanshaveatleastonechronicdisease,andmostpeoplepossessriskfactorsthatcouldleadtoafuturechronicillness.Chronicdiseasesaccountfor81percentofhospitaladmissions,91percentofprescriptions,and76percentofallphysicianvisits.1

Inaddition,just1percentofpatientsaccountformorethan20percentofhealthcarecosts,withthetop5percentofpatientsresponsiblefornearlyhalfofallhealthcarespendingintheUnitedStates(Figure1) .2Thisisunsustainableinanenvironmentinwhichthegoalsaretoimprovethehealthandwellbeingofpopulationswhilereducingcosts.

THE COST OF CARE

5% of patients account for

50% of all medical costs

ADVANCED ILLNESS:Requiring ongoing and complex case management

AT-RISK, MULTIPLE CHRONIC CONDITIONS:Requiring ongoing care management

HEALTHIEST:Utilizing preventive and wellness services, some acute care

21%–100%

6%–20%

5%

1%

RISING RISK

Figure 1: The Cost of Care

The HOPE Note: Bringing an Integrative Approach to Primary Care 5

THE COST OF CARE

Manyofthemedicalconditionsthesepatientshavecanbemanagedandevenpreventedwithinterventionsthathavelittletodowithmedicineascurrentlypracticed,suchasweightloss,exercise,smokingcessation,nutrition,andstressmanagement.Putsimply,ourhealthcaresystemdoesnotdeliverwhatourpatientsneedtohavehealthandwell-being.Today,seeingadoctorwillprovidepatientswithlessthan20%ofwhattheyneedtogetorstayhealthy.

Thus,weneedashiftfromthephysician-oriented,hierarchicalsysteminwhichmostdoctorsweretrainedtoonethatembracesacomprehensiveapproachtohealthinvolvingalternativeprovidersand,mostimportant,thepatientsthemselves.

That’swhereintegrativehealthcomesin.


Onereasonweneedtoreimaginemedicinetodayisbecauseoftheinfluenceofthenonmedicaldeterminantstohealth.Onlyabout15to20percentofhealth-relatedoutcomesareattributableto

medicalinterventions.Therestarerelatedtohealthbehaviorssuchasdiet,physicalactivity,andsmokingstatus,withthephysical,social,andeconomicenvironmentaffectingaperson’sabilitytomakehealthychoices and accessing medical care .3

Lifestylefactors,includingsmokinganddiet,aretheprimarycausesinsevenof10deathsand40percentofallprematuredeaths.3,4Socialfactors,suchaspoverty,education,racismandthelivingenvironmenteitherenableorinhibitapersonabilitytoengageinmodifyingthosecauses.

Morethanhalfofthetop25chronichealthconditions,includinghypertension,hyperlipidemia,diabetes,obesity,chronicbackpain,asthma,anxiety,anddepression,canbemanagednotprimarilywithmedications,butwithlifestyleandalternativeapproaches.Theseincludebetternutrition,physicalmovement,stressmanagement,sleep,socialsupport,andevidence-basedcomplementarymedicinesuchas yoga, acupuncture, and massage therapy .

Thus,preventingandmanagingchronicdiseaserequiresanapproachinwhichallaspectsofaperson’slifeareconsidered—oneinwhichthefocusisnotjustontreatingdisease,butalsoonpromotinghealth.Thisrequiresfullyintegratingpreventivecare,complementarycareandself-careintothepreventionandtreatmentofdisease,illness,andinjury.

Thedilemmaisthatourtrainingasdoctorsandtheincentivesinthecurrenthealthcaresystemencourageustolooknofurtherthanconventionalapproaches,suchasdrugsormedicalprocedures,tomanagetheseconditions.Weneedtointegrateself-careandevidence-basedcomplementaryhealingmethodsintoouroverall approach to health management .

UNDERSTANDING THE DETERMINANTS OF HEALTH

Figure 2: Determinants of Health

15%–20%Medical

treatment

Social & Economic Impacts

Behavior & Lifestyle Impacts

Environment



Understanding the Terminology

Integrative health is the foremost pursuit of personal health and well-being, while addressing disease as needed, with the support of a health team dedicated to all proven approaches—conventional, complementary, and self-care.

Optimal health and well-being arise when we attend to all factors that influence healing including medical treatment, personal behaviors, mental and spiritual factors, and the social, economic, and environmental determinants of health.

Conventional medicine is the delivery of evidence-based approaches for disease prevention and treatment currently taught, delivered, and paid for by the mainstream healthcare system.

Integrative medicine is the coordinated delivery of conventional medicine combined with evidence-based complementary and alternative medicine (CAM) designed to enhance health and well-being.

Lifestyle medicine involves the incorporation of healthy, evidence-based self-care and behavioral approaches into conventional medical practice to enhance health and healing.

Integrative health redefines the relationship between the practitioner and patient by focusing on the whole person and the whole community. It is informed by scientific evidence and makes use of all appropriate preventive, therapeutic, and palliative approaches, healthcare professionals, and disciplines to promote optimal health and well-being. This includes the coordination of conventional medicine, complementary/alternative medicine, and lifestyle/self-care.

Conventional Medicine

Self-CareComplementary

& Alternative Medicine

LIFESTYLE MEDICINE

INTEGRATIVE MEDICINE

INTEGRATIVE HEALTH

SOCIAL, ECONOMIC & ENVIRONMENTAL IMPACTS


Youmaybeoverwhelmedthinkingabouthowtobringinthenonmedicalsegmentofthehealingpie.Butitisnotasdifficultasyoumightimagine.

Responsibilityforthehealthofapopulation—forbothyourindividualandcollectivepatients—iswherehealthcareisgoing.Ifyoudon’tbegintoproactivelymanagetheirhealth,youwillseeyourreimbursementfall.That’swhyIdevelopedtheHOPEnote—toactasaroadmaptosuccessfullyprovideintegrativecare,andtoprovideasimpletoolwithwhichtostart.



THE HOPE NOTE

HOPEstandsforHealing Oriented PracticesandEnvironments . The HOPE note is a tool I designed to elicittheinformationyouneedfromapatienttobetterunderstandtheirissuesbeyondtheregular

medicalvisit.TheHOPEnotebuildsofftheSOAP(subjective,objective,assessment,andplan)notethateverymedicalstudentlearnsandthatyouapplyeverydayinpractice.

ThegoaloftheSOAPnoteistofindinformationonthepatient’sdiagnosisandtreatment.However,SOAPworksbestwhendiagnosingandmanagingacutediseasesorthesymptomaticmanifestationsofchronicillness,Itdoesnotworksowellforchronic,multifactorialconditionsorforaddressingthedeterminantsofhealing.TheSOAPonlysuperficiallytouchesonsocialandemotionalfactors,lifestyleissues,andapatient’sgoalsandvalues.Rarelydoesitencompassshareddecision-makingwiththepatientorseektosupportself-carepractices.Yet,theseareallcrucialtohealth,sometimesevenmoresothanspecificmedical treatment .

Afteryearsinpractice,Irealizedthatintegrativehealthcare–healthcarethatincludesconventional,complementaryandlifestyleapproaches-requiresadifferenttypeofassessment,onethatcomplementstheSOAPnote.Itrequiresafocusedassessmentofthebehaviorsandtreatmentsthatcanfacilitatethepatient’sowninherenthealingcapacity.

That’swheretheHOPEnotecomesin.Idevelopedthistoolbecause,asaprimarycareprovider,IfoundtheSOAPnotetoonarrowtoeffectivelyaddressthecausesandapproachesformanyoftheconditionsIsee, such as chronic pain, obesity, diabetes, and hypertension .

HOPEconsistsofasetofquestionsgearedtoevaluatethoseaspectsofapatient’slifethatfacilitateordetractfromhealing.Thegoalistoidentifybehaviorsthatstimulateorsupporthealingandserveasatoolfordeliveringintegrativehealthcarethrougharoutineofficevisit.

TheHOPEnoteaddressesthesocial,behavioral,environmental,andspiritualcomponentsrequiredformanagingcomplex,chronicdiseases.Workingthroughthequestionswiththepatienthelpsengagetheminshareddecision-makingabouttheirhealthandhealing,puttingthemfrontandcenterinthecareplan.Bestofall,itbringsoutthepatient’sownintuitionaboutwhattheymostneedtohealandcombinesthatwithyourknowledgeoftheevidenceforwhatheals.

Thegoalistoreframethepatient/physicianorientationfromoneofdiseasetreatmenttoonethatemphasizeshealthpromotionandself-healingwhileintegratingevidence-basedcomplementaryandlifestyleapproachesintoconventionalmedicalcare.

The HOPE note is a patient-guided process designed to identify the patient’s values and goals in their life and for healing. Your role as the physician is to provide the evidence and support to help them meet those goals.


THE HOPE NOTE

The HOPE Note Template

The following questions are used to guide the conversation between you and the patient during the HOPE consultation. Other questions can be added and personalized for each patient based on the individual’s personality, readiness to change, and circumstances.

Mind and SpiritThese questions address the patient’s goals for healing—their desires, beliefs, and needs. They are designed to reveal what the patient finds meaningful, what motivates them, and what provides them with a sense of well-being. In other words: “What matters?” versus “What’s the matter?”

1. Why do you seek healing? What do you want to happen through health care?2. What are your plans and aspirations in life? What is your purpose? What do you find to be your

most meaningful daily activities?

Social and EmotionalSocial support is salutogenic. Healing and disease are intertwined with personal relationships and social support networks, including family, friends, and colleagues. With these questions, you are trying to capture the interpersonal components of the individual’s daily life.

1. How is your social support? What are your social connections and relationships?2. Do you have family and friends with whom you can discuss your life events and feelings? Could

you comfortably call up someone tomorrow if you needed their help? Are there people you have fun with? How often?

3. Have you had any major social or physical traumas in the past? What was your childhood like? (This must be approached delicately, often prefaced with an explanation as to why in may be important to explore adverse childhood experiences.)

4. Tell me about your family and friends? Do you have someone you talk with in confidence and trust?


Behavior and LifestyleBehavior and lifestyle can impact up to 70 percent of chronic illnesses; therefore, healthy behaviors are essential for creating health. But behavior change must be connected to what is meaningful for the person or it cannot be sustained. These questions provide a snapshot of the patient’s lifestyle which, when coupled with the patient’s motivations, provides a path forward for change.

1. What do you do for stress management? How do you relax, reflect, and recreate?2. Do you smoke or drink alcohol or take drugs? If so, how much? 3. How’s your diet? (Describe your last breakfast, lunch, and dinner)4. Do you exercise? If yes, what types and amounts?5. How is your sleep (quality and hours)? Do you wake refreshed?6. How much water, sugary drinks, and tea or coffee do you drink?7. Do you use complementary and alternative medicine? Do you take supplements?

EnvironmentThe safety and security of one’s physical environment plays a greater role in health than many of us are aware. For instance, an unsafe neighborhood could prevent someone from going on walks. A noisy apartment building along a busy road can aggravate asthma and other pulmonary conditions, as well as produce stress and lack of sleep.

1. What is your home and work environment like?2. Is there a place at home where you can go and feel joyful and relaxed?3. What is your exposure to light, noise, clutter, music, colors, and art?4. How much contact with nature do you have?5. What is your exposure to toxins, especially heavy metals or endocrine disrupting chemicals?

Before ending the visit, I summarize the top three items that emerged from the conversation that the patient would like to work on by saying: “This is what I’ve heard. Is this right?” I then ask them to email me with what we have discussed and what are their top three items for action.

THE HOPE NOTE


BelowisasampletemplatefordoinganintegrativevisitandaHOPEnote.

P racticinganintegrativemodelrequiresrestructuringthetraditionalpatient/physicianrelationshipandengagingthepatientmoreintheirownhealthandhealthcare.

A2013editorialinthejournalHealth Affairscalledpatientengagement“theblockbusterdrugofthecentury,”whiletheInstituteofMedicineconsidersengagedpatients“centraltoaneffective,efficient,andcontinuouslylearningsystem.”5,6

Engagedconsumersaremoremotivatedtotakecareoftheirhealth;makebetterday-to-daydecisionsabouttheirhealth;aremorelikelytokeepappointments;tendtobemoresatisfiedwiththeircare;experiencefewercomplications;andhaveanimprovedqualityoflife.5,7,8

Theyarealsomorelikelytochoosemoreconservative,lessexpensiveinterventionsresultinginlowercosts .9Onestudyfoundthatindividualswhoweremoreknowledgeable,skilled,andconfidentaboutmanagingtheirhealthandhealthcarehadcosts21percentlowerthanthosewithsimilarmedicalconditionsandlowerlevelsofengagement.10

Whydoesthismatter?Becauseyouarenowpracticing—orsoonwillbepracticing—inavalue-basedsystem,inwhichyourreimbursementdependsnotonwhatyoudobutonhowgoodyourpatientoutcomesareandifyoucanloweroverallcosts.Forinstance,beginningsoonyou’llseelowerMedicarepaymentsbutwillhavethepotentialforbonusesifyoumeetcertainqualityindicators.11Guesswhatmostofthoseindicatorsarefor?Yes,chronichealthissues.Forinstance,onehigh-prioritymeasureisbloodglucosemanagementinpatientswithdiabetes.Andweknowthatlifestyleisamajorcomponentforthepreventionandtreatmentofdiabetes.12

PUTTING THE PATIENT FRONT AND CENTER


PUTTING THE PATIENT FRONT AND CENTER

The Diabetes Prevention Program

The Diabetes Prevention Program was a pivotal clinical study in the history of the disease. Sponsored by the National Institutes of Health, this multicenter study was designed to learn if it was possible to prevent or delay the onset of Type 2 diabetes with weight loss, diet, and exercise, or with the oral diabetes drug metformin, in overweight individuals with higher than normal blood glucose levels.12

The results were so significant that the study was stopped a year early. Basically, losing just a modest amount of weight through dietary changes and increased physical activity sharply reduced the risk of developing diabetes. Taking metformin also reduced risk, although less dramatically than lifestyle changes.

This study changed our approach to diabetes prevention and management. It also led to innovative funding approaches for diabetes management through the Medicare Diabetes Prevention Program, a structured intervention with the goal of preventing type 2 diabetes in those with prediabetes.

The clinical intervention consists of a minimum of 16 intensive, core sessions of a Centers for Disease Control and Prevention–approved curriculum furnished over six months in a group-based, classroom-style setting. The education provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After completing the core sessions, attending less intensive, monthly follow-up meetings help ensure participants maintain healthy behaviors. The primary goal is that participants lose at least 5 percent of their body weight. Physicians receive incentive payments for patients who attend sessions and/or lose weight.13


Bythetimepatientsseeme,theyoftensaytheyhave“triedeverything”toaddresstheirproblem.ThiswascertainlytrueofSally,whoretiredfromherjobasacorporatevicepresidentbecauseofchronic,

refractorylowbackpain.

Itstartedadecadebefore,whenSallywashurryingfromonemeetingtothenext,oninadequatesleep.Sherear-endedacarinwhatshethoughtwasarelativelyminoraccident.Soonafter,however,herbackpainbegan.Iprescribednonsteroidalanti-inflammatories(NSAIDs)andphysicaltherapy.Thathelpedforabit,andshequicklywentbacktoherbusyschedule,butthepainnevercompletelydisappeared.

Amonthlater,shehurtherbackagainpickingupasuitcase.ShewasprescribedmoreNSAIDs,anopioid,andmorephysicaltherapy,butsheonlygotworseandbegantoseekoutmoreopioidsfromseveralphysicians.

Moretestsfollowed,aswellasaconsultationwithasurgeonwhoconfirmedherpainwasmusculoskeletalandsurgerywasnotanoption.Sallywasalsodiagnosedwithdepression,butrefusedtoundergocognitivebehavioraltherapyorgointorehabilitationforwhathad,bythen,becomeanopioidaddiction.

“Iamnotcrazyoraddicted,”shesaidtomewhenshecameinforherHOPEvisit.“Mybackhurts.”

Unfortunately,Sally’sstoryisalltoocommon.Asyouknow,morethanadecadeofinappropriatepainmanagementhascreatedtoday’sopioidaddictioncrisis.

Yet,theresponsetothiscrisishasbeenone-sided,viewedthroughanarrowinglens:removeaccesstotheopioids.Butthisdoesnothingtoresolvethepain.Weneedtowidenourlenstointegratenon-pharmacologicalapproachestopain,includingevidence-basedcomplementaryandalternativemedicine.Indeed,agrowingnumberofmedicalorganizations,includingtheAmericanCollegeofPhysicians,arenowaddingCAMapproachestotheirpainmanagementguidelines.14

That’swhatIdidwithSally.UsinganintegrativevisitandtheHOPEnoteframework,Ihelpedherlearnhowtoimprovehersleep;createarelaxingenvironmenttoreducestress;andcometotermswiththefactthatshewasstillaworthypersoneventhoughshewasnolongerahigh-poweredexecutive.Thisunhappiness,Ilearned,wascontributingtothepain.

Ididn’tdothisonmyown.IbroughtonateamofprofessionalstoworkwithSally,includingapharmacologisttoprovideguidanceonoptimizingmedications;abehavioraltherapyexperttohelpwithsleep;ayogaprofessionalwithtrainingandskillsindealingwithchronicpain;andherfamily,whoneededtolearnhowtogivehertimeandspacetoheal.Sallywasalsoamemberoftheteam,learningthatitwasOKtoforgiveherselffortakingherlifeinadifferentdirection.

Intheend,thisintegratedapproachprovidedlong-termpainreliefandimprovedfunctionandwellbeingforSally .

Sallyisnotunique.Sometimestheytellmerightupfront,“I’velosthopeinevergettingbetter.”Whenpatientsleavemyoffice,Ilooktoseeiftheyhavehope.Idon’tmeananacronymhere.Imeanactualhope.

Whentheyleave,Ihopethey’remotivatedandhaveaplantomoveforward.

ADDING HOPE TO HEALTH CARE


TherearenumerousotherbenefitstotheHOPEapproach.

PREVENTING BURNOUT

Morethanhalfofphysicians(55percent)in2014saidtheywereburnedout,a10percentincreaseover2011andaratefarhigherthanthatofthethegeneralpopulation.15

Studiesfindseveralreasonsforthisgrowingrateofburnout.Thisincludesexcessiveworkload,lossofcontroloverthework,lossofmeaninginthework,andtimedocumentingtheelectronichealthrecord,whichplacesmoreclericalburdenonphysiciansandinterfereswiththepatient/physicianrelationship,whichreducesjobsatisfaction.15Fundamentally,however,burnoutcomesfromtheinabilitytoknowanddevelopmentarelationshipwiththeirpatients.

UsingtheHOPEnoteandamoreintegrative,team-basedapproachcanaddressmanyoftheseissues.Itcanrestorethepatient/physicianrelationship;leadtorealbenefitsforseeminglyintractableconditions;and,hopefully,inspireyoutoparticipateinsomestress-relievingapproachesandliveahealthierlifestyleyourself.

IMPROVING OUTCOMES

Thereisgoodevidencethatthistypeofholisticapproachcanimproveoutcomesandreducecostsinpatientswithchronicdisease.

Forinstance,theCornellProgramforHealthyLiving,partofanAetnahealthinsuranceplan,offersanenhancedwellnessprogramformemberswholiveintheIthaca,NewYork,area.ItincludesthedevelopmentofaHealthyActionPlan,whichtheprimarycarephysicianthenhelpsthepatientimplement.Whentheplanincludesreferralstolocalresourcessuchassmoking-cessationorweight-lossprograms,thoseservicesmaybecovered100percentoratadiscount.FacultyandstaffatCornellUniversitycanalsochoosebetweena$15monthlydiscountfromalocalfitnesscenterorafreeCornellWellnessmembership.Despiteanextra5percentspentonthiswellnessbenefit,AetnaandCornellreportlowergrowthinexpenditurescomparedtoasimilarplanwithoutthewellnessbenefit(23percentverses37percent),aswellasloweroverallcosts.16,17

Bybroadeningourviewofhealthandthefactorsthatsupportordetractfromhealth,wecanimprovethecareweprovidetoourpatients–andreducecosts.

THE BENEFITS OF INTEGRATIVE HEALTH IN YOUR PRACTICE


REDUCING COSTS

Valueisdefinedasquality+outcomes/cost.Youcan’thavevaluewithoutallthreeofthesecomponents.Asyourpracticebecomesmorereliantonvalue-basedreimbursement,thecostofcareinrelationtotheoutcomesbecomesparamount.Thereisexcellentevidencethatprovidingintegratedcaretopeoplewithchronicconditionsnotonlyimprovesoutcomes,itisalsocosteffectiveandevenresultsincostsavings.18-20 Indeed,somegovernmentandcommercialinsurersarewillingtopayextraforthetypeofcarecoordinationanintegratedmodelaffords.

Carecoordinationforthemanagementofthosewithadvancedillnessandmultiplehealthconditionscanimproveoutcomesandreducecosts.Carecoordinationrequiresanintegratedapproachwithinconventionalmedicine.Integratedcarecoordinationcan:

• Prevent unnecessary hospital admissions, readmissions, and emergency department visits • Limitexcessiveuseofspecialists• Reduceexcessiveandunnecessarylaborimagingstudiesandprescriptions

Forthosewithadvancedillness(thetop5%ofFigure1),focusonprovidingcarecoordinationforthesepatientsinalignmentwiththe2017reportfromtheNationalAcademyofMedicinetitledEffective Care for High-Need Patients .21

AHOPEnoteisnotmeantspecificallyforthe5%managedbycarecoordination.Butitdoesoftenuncoverissuesthatcanenhancecareofadvancedillnessandintegratedcare.TheHOPEvisitismeanttoassistthosebelowthetop5%withadvancedillnesswhohavechronicillnessesorareat-riskforthoseillnessasseeninFigure1.HOPEfocusesonpatientswithoneormoreofthechronicconditionsthatmakeupthe6%-20%band.Itsgoalistopreventorreversetheprogressionoftheseconditions.ThisisthefocusofanintegrativehealthvisitandtheHOPEnote.

THE BENEFITS OF INTEGRATIVE HEALTH IN YOUR PRACTICE

Care Coordination/Management“Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services. It is generally provided by a registered nurse who works with a team of healthcare professionals.”

Source: Bodenheimer T, Berry-Millett R. Follow the money: controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521-1523.


Oneproblemwithpracticesthatprofesstobeintegrativeisthatwhiletheysupporttheuseofevidence-basedCAM,theyfailtotrulyintegratethosepracticeswithconventionalmedicine.Simply

substitutingahealingpracticesuchasReikiforadruglikemetoclopramidedoesnotmakeitintegrativemedicine.Evidenceandpatient-centerednessarethedistinguishingfactorsinintegrativehealthcare.

Currently,integrationtypicallyfallstothepatient,whoisoftentheonesearchingforcomplementaryapproachesanddecidingforthemselveswhetherthey’reeffective.Thisisriskyasthepatientusuallydoesnotknowtheevidenceorhowtojudgeitappropriately..

Whencomplementaryoralternativeapproachesareappropriate,itisimportantthatyouworkcloselywiththeCAMprofessionalsratherthanleavingituptoyourpatienttonavigatethatterritory.Thisinvolvesgettingtoknowthepractitionersinyourarea,theirqualificationsandprofessionalism,anddevelopingalistforreferralsandcoordination–asyouwouldwithotherspecialists.

Italsorequiresputtingthepatient,notthepatient’scondition,atthecenterofanyapproach.

Forexample,whileit’sgenerallypreferabletorelievepainwithfewerdrugsandmedications,that’snotalwaysthebestcourseofaction.Sometimesit’snecessarytouseadrugorasurgicalinterventionorincorporatebehavioraltechniquesthatarenotnormallypartofcomplementarymedicine.Sometimesdietchangescanimproveacondition.Butyou’llneverknowwhatworksifyouarenotmonitoringthepatientcloselyandworkcloselywithotherpractitioners.

Integrativehealthservicesmustbetailoredtotheneedsandreadinessofthepatient.Forinstance,thepatientmayhavelimitedresources(time,energy,interest,ormoney)fortheirowncare.Ifthatisthecase,healthcareprovidersneedtoacknowledgethisandincorporatetheseconditionsintothecareplan.

INTEGRATIVE HEALTHCARE


AttheendoftheintegrativevisitiscreationofaHOPElist.Theseareitemsraisedduringthediscussionthataremostmeaningfultothepatient,aresupportedbyevidenceandareorganizedintotheareas

thetwoofyouwillworkon.

TheHOPElistgenerallyfallswithinthefollowingcategories.

• Stress management and resilience.Usingmind-bodytechniquessuchasmeditationorimagerycanreducetheeffectsofthestressresponseonthebodyandimprovereceptivityandmotivationforlifestylechange.Thesepracticescanalsoenhancehealthandstrengthenpersonalresilience.“Mentalfitness”isausefulconceptforexplainingthedifferencebetweenstressmanagementandbuildingresilience .

• Physical activity and sleep.Physicalactivityandsleepcanreducestress,improvebrainandimmunefunction,reducepain,slowagingandheartdisease,helpestablishandmaintainoptimumweightandenhancewell-being.Sleephygiene,CPAPandsupplementscanallassistinoptimalsleep,whenappropriately used .

• Nutrition and substance use.Idealweightandoptimalphysiologicalfunctionoccurbestinthecontextofpropernutritionandreducedexposuretotoxicsubstancessuchasnicotine,alcohol,drugsandenvironmentaltoxins.Foodandsubstancemanagementrequiresmotivation,environmentalcontrols,foodselectiontraining,andfamily,peer,andcommunityinvolvement.

• Social support.Thesocialenvironmentisessentialtohealthandhealing,asisservicetoselfandothers.Socialcohesionisnotonlyhealthenhancinginitsownright,butisessentialforsustainablebehavioralchangeinanycultureandsetting.

• The inner environment.Theinnerenvironmentmaycomefromspiritualorreligiouspracticesorbegroundedinmeaningfulandpurposefulactivities,suchashelpingothers.Itcanalsobefoundincreativeactivitiesorworkthatbringspurposeandmeaning.

• The outer environment.Ahealthyouterenvironmentattendstothephysicalsettingthatfacilitateshealing.Attentiontoarchitecture,art,andexposuretonature,sound,smell,andlightarekeyelements.

CREATING A HOPE LIST


SETTING GOALS

NowthatyouandthepatienthaveaHOPElist,thehardworkbegins.It’scriticaltoconnectthepatient’sprioritiesandhealthgoalstomedicaladvice,andoffersupportinimplementingthechanges.

Healthcoachingandregularcheck-insarekey.Herearesomestrategiestoprovidetheregularcheck-insthatpatientsneedtoprogresstowardtheirhealthgoals:

• Health coaching.Ahealthcoachcanfollowupbyphoneorviatelehealthtohelppatientsovercomedailychallengesandsupportthemforsuccess.Healthorwellcoachingareadistinctsetofskillsdifferentfromexpertadvicethatmightbeprovidedbyaphysician,nutritionistorfitnesscoach.

• Group visits.Theseareanexcellentoptionforpatientswithchronicconditions,providingthemwithpeer support and team learning . They may also be reimbursable .

• Technology assists.Encouragepatientstouseappsandtrackingdevicesthatcanprovideinsightintotheirprogress.Increasinglysophisticatedtechnologiesareinteractingwithpatientsforbehaviorchangeanddirect,not-drugtreatments.

• Education.Provideresources,tools,andlinksapplicabletotheindividualpatient’ssituation.Seemywebsitedrwaynejonas.comforagrowingsetofinformationsourcesandtoolsforprovidingintegrativehealthcare .

CREATING A HOPE LIST


T herealityisthatourhealthcaresystemisnotyetdesignedforthetypeofintegrativeapproachrequiredintheHOPEmodel.Instead,ourmostlyvolumedriven,fee-for-servicemodelisbasedonanacutecare

system,withreimbursementhingingonwhat you do rather than howyoudoitandhowwellitworks.Itisasystemthatfavorsvolumeovervalue,andrewardsproceduresandpillsmorethanpreventionandhealthpromotion.

Withthatsaid,thereareareaswheretheHOPEapproachcanbepaidfornow.Theseinclude:

• Annual wellness visits.MedicareandmostMedicareAdvantageplans,Medicaidsystems,andcommercialinsurerscoverannualwellnessvisits(AWVs).TraditionalMedicarecoversaninitialpreventivephysicalexaminationwithinthefirstyearofenrollmentandanAWVeveryyearthereafter.TheAWVincludesadvancecareplanning(withaseparateCPTcode),referralstoeducationalandcounselingservicesorprogramssuchasnutrition,tobacco-usecessation,weightloss,biometricscreening,andfunctionalabilityscreening,andnumerousothercomponents.Patientswithdepressionorothermentalhealthissuescanalsohaveextravisitscovered.

• Care coordinators.Carecoordinatorsareoftennursesorlicensedsocialworkerswhoprovidecasemanagementsupporttohigh-needpatientswithadvancedillnessorspecialneedspatients.Forexample,oneprimarycarepracticewithfivephysiciansandthreenursepractitionershiredacaremanagerwhowasabletoaddressebarrierstocare.Asthedoctorsputit,thesewere:“barrierswewouldn’thavefoundinthetypical15-minuteofficefollow-upvisit.”Thisincludedlackofaccesstoelectricity,healthyfood,orsafehousing.Thecaremanagerthenconnectedpatientswithcommunityservices to solve those problems .22ThepracticepaidforthecarecoordinatorbybillingfortheseundertheAWVandothercodes.

• Chronic care management.Medicarenowreimbursesunderseparatecodesforchroniccaremanagementservicesforpatientswithtwoormorechronicconditions.23Thereisalsoadditionalcompensationpotentialforpracticesthatbecomepatient-centeredmedicalhomesandaccountablecareorganizations.MoreinformationonreimbursementstrategiesforintegrativecareandtheHOPEvisitcanbefoundonmywebsiteatdrwaynejonas.com.

CONCLUSION

Weareenteringanewworldofmedicineandhealthcare.Aworldinwhichattentionisincreasinglybeingpaidtoallthedeterminantsofhealth,notjustthephysicalmanifestationsofdisease.Inthisemergingworld,incentivesarebeingrealignedtopromotehealthandwellnessratherthanjusttreatthedisease.

Nowit’stimetorebalanceourpractices.Asprimarycarephysicians,weareonthefrontlinesoftheUShealthcaresystem,withnearlyeverypatientinthesystempassingthroughouroffices.Learningtoaddresstheirissuesholistically,listeningtopatientsandpracticinginaninterdisciplinarymannerwithprovidersoutsideoftraditionalmedicinearetheelementsrequiredtobesuccessfulinthenewnormal.

TheHOPEmodeloffersonewaytogetthere.Ihopeyou’lltryit.

PAYING FOR HOPE


JonasWB,ChezRA,SmithK,SakallarisB.Salutogenesis:thedefiningconceptforanewhealthcaresystem.Glob Adv Health Med.2014;3(3):82-91.

JonasWB,RakelDA.Developingoptimalhealingenvironmentsinfamilymedicine.In:RakelRE.Textbook of Family Medicine.7thed.Philadelphia,PA:Saunders;2007:15-24.

Lehman R . Sharingasthefutureofmedicine . JAMA Intern Med.PublishedonlineJuly3,2017.doi:10.1001/jamainternmed.2017.2371.

LongP,AbramsM,MilsteinA,etal.Effective care for high-need patients.NationalAcademyofMedicine;2017.

RESOURCES

http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2635331


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2. CohenSB.The concentration and persistence in the level of health expenditures over time: Estimates for the US Population, 2011-2012. Statistical Brief 449.AgencyforHealthcareResearchandQuality;2014.

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4. CentersforDiseaseControlandPrevention.LeadingCausesofDeath.2016;https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.AccessedDecember11, 2017 .

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6. InstituteofMedicine.Best Care At Lower Cost: The Path to Continuously Learning Health Care In America. 2012 .

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8. LorigK,RitterPL,LaurentDD,etal.Onlinediabetesself-managementprogram:arandomizedstudy.Diabetes Care. 2010;33(6):1275-1281.

9. WennbergJ,BrownleeS,FisherE,etal.An Agenda for Change: Improving Quality and Curbing Health Care Spending:. The Dartmouth Institute for Health Policy & Clinical Practice. 2008 .

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11. CentersforMedicare&MedicaidServices.RFI on Physician Payment Reform” (CMS-3321-NC) External FAQ.

12. KnowlerWC,Barrett-ConnorE,FowlerSE,etal.Reductionintheincidenceoftype2diabeteswithlifestyleinterventionormetformin.N Engl J Med. 2002;346(6):393-403 .

13. CentersforMedicareandMedicaidServices.MedicareDiabetesPreventionProgram(MDPP)ExpandedModel.2017;https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/.AccessedDecember11,2017 .

14. QaseemA,WiltTJ,McLeanRM,ForcieaM,fortheClinicalGuidelinesCommitteeoftheAmericanCollegeofP.Noninvasivetreatmentsforacute,subacute,andchroniclowbackpain:Aclinicalpracticeguidelinefromtheamericancollegeofphysicians.Ann Intern Med. 2017;166(7):514-530.

15. ShanafeltTD,DyrbyeLN,WestCP.AddressingPhysicianBurnout:TheWayForward.JAMA. 2017;317(9):901-902.

16. CornellProgramforHealthyLiving(CPHL).2017;https://hr.cornell.edu/benefits-pay/health-plans/endowed-health-plans/cornell-program-healthy-living-cphl.AccessedDecember12,2017.

17. DatacourtesyofCornellUniversityandAetna2017.

18. HermanPM,AndersonML,ShermanKJ,BaldersonBH,TurnerJA,CherkinDC.Cost-effectivenessofMindfulness-basedStressReductionVersusCognitiveBehavioralTherapyorUsualCareAmongAdultsWithChronicLowBackPain.Spine (Phila Pa 1976). 2017;42(20):1511-1520.

19. HermanPM,PoindexterBL,WittCM,EisenbergDM.Arecomplementarytherapiesandintegrativecarecost-effective?Asystematicreviewofeconomicevaluations.BMJ Open. 2012;2(5).

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21. LongP,AbramsM,MilsteinA,etal.Effective care for high-need patients.NationalAcademyofMedicine;2017.

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https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/

https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/

https://hr.cornell.edu/benefits-pay/health-plans/endowed-health-plans/cornell-program-healthy-living-cphl



To access more information on integrative health, including tools and resources for patients and providers, visit DrWayneJonas.com

ABOUT THE AUTHOR – DR. WAYNE JONAS

Dr. Jonasisapracticingfamilyphysician,anexpertinintegrativehealthandhealthcaredelivery,andawidelypublishedscientificinvestigator.Dr.JonasistheExecutiveDirectorofSamueliIntegrativeHealthPrograms,aneffortsupportedbyHenryandSusanSamuelitoincreaseawarenessandaccesstointegrativehealth.Additionally,Dr.JonasisaretiredlieutenantcolonelintheMedicalCorpsoftheUnitedStatesArmy.From2001-2016,hewaspresidentandchiefexecutiveofficerofSamueliInstitute,anonprofitmedicalresearchorganizationsupportingthescientificinvestigationofhealingprocessesintheareasofstress, pain, and resilience .

Dr.JonaswasthedirectoroftheOfficeofAlternativeMedicineattheNationalInstitutesofHealth(NIH)from1995-1999,andpriortothatservedastheDirectoroftheMedicalResearchFellowshipattheWalterReedArmyInstituteofResearch.HeisaFellowoftheAmericanAcademyofFamilyPhysicians.

Hisresearchhasappearedinpeer-reviewedjournalssuchastheJournal of the American Medical Association, Nature Medicine, Journal of Family Practice, Annals of Internal Medicine, and The Lancet.Dr.Jonasreceivedthe2015PioneerAwardfromtheIntegrativeHealthcareSymposium,the2007America’sTopFamilyDoctorsAward,the2003PioneerAwardfromtheAmericanHolisticMedicalAssociation,the2002PhysicianRecognitionAwardoftheAmericanMedicalAssociation,andthe2002MeritoriousActivityPrizefromtheInternationalSocietyofLifeInformationScienceinChiba,Japan.

http://drwaynejonas.com/

DrWayneJonas.com

@DrWayneJonas

http://drwaynejonas.com/

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