Scientific literature for CAM on safety, efficacy and cost effectiveness in those identified populations
(HAIG-2002): #1 Stress management, Pain, Anxiety, Back pain, Headache/migraine, Depression.
Computerized testing available in clinic rooms Improved function standardized instruments or ask set up data collection, outcomes at the very beginning
Developing an Integrative Health Clinic and Program VASLCHCS
Developing an Integrative HealthDeveloping an Integrative Health
Clinic and Program VASLCHCSClinic and Program VASLCHCS
Sandra J W Smeeding PhD, CNS, FNP-BC
Associate Director Integrative Health
VA Salt Lake City
Learn the research needed prior to proposing
an Integrative Health Clinic.
Understand the people to involve in the
Learn the steps needed to establish an
Integrative Health Clinic and Program.
Describe strategies to overcome the challenges
and organizational barriers.
Formative ResearchFormative Research
Readiness 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
Formative ResearchFormative Research
Readiness to changeReadiness to change
• Is there commitment from institutional leaders?
• Analyze the supporters and barriers, identifying potential
• Assemble a powerful team to lead the change- steering
• Create and communicate a compelling vision of change-
• Experiences of other VA organizations with similar
• Readiness criteria that needs to be satisfied before
Timing- External Market AnalysisTiming- External Market Analysis
• 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
Prevention of chronic disease, health promotion,
Internal and External supportInternal and External support
#1.#1. Administrators:Administrators: Director, Chief Nurse, Chief of Staff, ACNS,Director, Chief Nurse, Chief of Staff, ACNS,
Chief of Services: Anesthesia, Mental Health.Chief of Services: Anesthesia, Mental Health.
#2. Providers Known to offer CAMProviders Known to offer CAM (VA CAM Practice(VA CAM Practice
20022002),), Psychologist, Nursing, DO/MD, PT, LCSW, Clergy
#3#3.. VA Integrative & CAMVA Integrative & CAM:
#4.#4. VA Acupuncture:VA Acupuncture:
#5#5.. VASLCVASLC email@example.com
Timing Internal Market AnalysisTiming Internal Market Analysis
• VASLC Integrative Health Proposal (1997 ) approval
• 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
• Understand local Veterans CAM use.
- Dissatisfied: reliance on pharmaceuticals ,lack of whole person
Institutional AssessmentInstitutional Assessment
Informal SurveyInformal 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.
Medical Staff,Medical Staff,
Clinical Executive BoardClinical Executive Board
• Physician resistance-safety, control.
• Budgetary constraints. & limitations of insurance
• Credentialing and Privileging of providers and therapies.
• Efficacy /Effectiveness of particular modality for specific
medical conditions. Evidence-based practice.
• Office and Clinic space.
Positioning in a servicePositioning in a service
Patient PopulationsPatient Populations
• Service positioning:
Primary care Mental health
Preventive Cardiology Integrative
Anesthesia Chronic pain End of life/palliative care
• VASLC: Anesthesia: Chronic Pain & Stress, Depression,
Anxiety, Health Promotion.
• Outpatient or Inpatient - best opportunity, most
New Model of HealthCareNew Model of HealthCare
VASLC GoalsVASLC Goals
• Improve health related quality of life, reduce pain & stress
related depression and anxiety, non pharmacological.
• Focus on health promotion-lifestyle, self-management,
minimizeminimize “facility and equipment dependent” treatments.
• Whole person: healing vs. cure, mind/emotion/body/spirit,
avoid the disease management model or mechanistic pathophysiologic
• Choice: patient is the center of the decision making-in
charge vs. hierarchical orders.
• Active participation vs. passive recipient: coaching.
Outcome MeasuresOutcome Measures
• 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
• Pain reduction
• 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.
Credentialing and PrivilegingCredentialing and Privileging
• Standardized the Process for provision of therapies
and privileging of providers. (Appendix A & B).
• Utilize the same process as conventional therapies and
• VA provider applied for credentialing and privileging in
• 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
• 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
• 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
Selection of CAM ServicesSelection of CAM Services
• Target population: Supported by research evidence ofSupported by research evidence of
effectiveness - for particular indications.effectiveness - for particular indications.
• Non-controversial, critical initial acceptance.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
Program Business Plan*Program Business Plan*
Approved by Clinical Executive BoardApproved by Clinical Executive Board
• Executive SummaryExecutive Summary: Summary of VA, current CAM and IH literature
• 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.
Multidisciplinary SteeringMultidisciplinary Steering
NeurologyNeurology Interested staffInterested staff
Primary CarePrimary Care ChaplainChaplain
Pt. EducationPt. Education Mental HealthMental Health
Pain MedicinePain Medicine Staff EducationStaff Education
PM & RPM & R Phys. TherapyPhys. Therapy
RheumatologyRheumatology Social WorkSocial Work
Integrative Health Outpatient ClinicIntegrative Health Outpatient Clinic
and Program Modeland 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
Marketing Integrative HealthMarketing Integrative Health
Education of ProvidersEducation 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.
Strategies to overcome resistanceStrategies 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
Administrators: policy, fiscal
• Monthly Education series in primary care.
• Visibility, Accessible, Communication!
Factors to Ensure aFactors to Ensure a
Successful ProgramSuccessful 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.
Greatest barriers andGreatest barriers and
reasons for failurereasons 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
• Lack of communication within the facility
What would we do differently?What would we do differently?
• More consultation on:More consultation on:
Data management & Program evaluation.Data management & Program evaluation.
• Clinic staff support.Clinic staff support.
• Unable to get massage approved.Unable to get massage approved.
• Unable to get chiropractic approved.Unable to get chiropractic approved.
• Unable to get Energy work approved for clinic, was usedUnable to get Energy work approved for clinic, was used
in nursesin nurses under their license on the medical floor to aunder their license on the medical floor to a
limited extent.limited extent.
• Limited personnel to introduce inpatient programs.Limited personnel to introduce inpatient programs.
• Obtain permanent staff-FTE from startObtain permanent staff-FTE from start ..
VASLC – CEB Modality Application
VASLC - PSB Provider Application
Examples of Business plan content
CAM ModalityCAM Modality
Clinical Executive Board (CEB)Clinical Executive Board (CEB)
1. A description of the therapy and the mechanism of action.
2. Literature review of effectiveness/efficacy of therapy.
3. List of medical conditions proven to benefit by the researched
evidence base or patients to refer.
4. Describe any adverse effects.
5. List medical conditions to exclude, contraindications, patients not to refer.
6. Expected duration/numbers of treatments and the benefits.
7. References from the literature review.
CAM Professional Standards BoardCAM Professional Standards Board
(PSB) Application(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.
6. References from the literature review.
7. Training, certification, licensure for the therapy.
• The intent is to develop an interdisciplinary, collaborative Integrative
Health Program at the SLC VAHCS involving physicians,
nurses, pharmacists, dietitians, psychologists, and other health
• 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 therapies will 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
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.
• 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
• A CAM initiative would allow the SLC VAHCS to develop
collaborative relationships with nationally known research
organizations, academic centers, to conduct outcome research.
Business PlanBusiness Plan
• 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.