HEALTH CARE TRANSITIONS: A REVIEW OF INTEGRATED, INTEGRATIVE, AND INTEGRATION CONCEPTS
 
   

Health Care Transitions: A Review of
Integrated, Integrative, and Integration Concepts

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   703–713 ~ FULL TEXT

Claire Johnson, DC, MSEd

National University of Health Sciences,
Lombard, IL 60148, USA.
cjohnson@nuhs.edu


In this article, several views of the terms integration, integrated, and integrative are considered with the hopes that this brief review will help to raise awareness, clarify various uses of these terms, and add to the continuing discussion of integration and how we might improve health care. Models of integrative care, views of integration, and samples of different interpretations and definitions are offered.

KEYWORDS:   Collaboration; Relations, Interprofessional; Role, Professional; Trust



From the Full-Text Article:

Introduction

Our world population continues to increase, and health care resources are strained. The aging population, with its chronic and terminal diseases, weighs heavily on the existing health care infrastructure. [1–3] Preventable diseases (eg, obesity, diabetes, disease due to tobacco use) are out of control, and new diseases or resistant strains of old diseases are reported weekly. We have hope that there is a better way to deliver health care if we only could identify what the perfect model might be. If one health care provider is good, maybe more working as a team would be better. Turning to integration as a means of using resources more wisely and delivering better quality care seems to be a possible solution for our health care crisis.

Traditional medicine and native/aboriginal healing arts have been in existence for centuries before modern Western medical methods; and for the most part, they served their populations well. Yet, over time, we have institutionalized and confined health care in the name of science and with the hope of controlling the upward spiral of costs. Perhaps, in these attempts, traditional healing methods and complementary and alternative medicine (CAM) professions have been dismissed as rubbish to make way for the newfangled methods. This may be due to monopoly or the dominance held by Western medicine. [4] However, each of us should also take responsibility for this situation because we often submit to the belief that technology and science are superior to other methods that have yet to be explained. Although we attempt to ensure that all health care is grounded in science, many still recognize that much of health and healing, Western or otherwise, continues to be partly, if not mostly, an art.

There is an elephant in the room that we seem reluctant to confront. Although some have tried to describe it, only bits and pieces of its description seem to have been put to paper. Some have tried to describe this elephant through honest eyes, trying to avoid political pressures or personal biases to cloud their interpretation of the situation before them. Those who have approached these topics using sociological methods, such as Coulter and Boon, appear to have a clearer and composed view. [5–8] Others have allowed prejudice and political pressures to guide them as they write, resulting in what appears to be the call to battle to fight against other professions. Regardless of the stance one takes, the elephant is still in the room. There are people who need health care, and the question is what should health care look like to best serve our populations and so that our members enjoy what the World Health Organization describes as “physical, mental and social well-being, and not merely the absence of disease.” [9] There are many determinants of health, so we must look beyond the sole practitioner and the professions and investigate these complex models. [10] If we are to solve this puzzle, we must also include the systems and the people in the equation.

The words integrated, integrative, and integration carry a mystique, a feeling that there is something greater to obtain if we are able to accomplish them. Although it is tempting to consider an ideal integrative world, these terms are neither easily understood nor used consistently in the context of health care. It seems that everyone has a unique definition depending upon his or her viewpoint. If we are to join together to accomplish a solution to the health care problem, an understanding of terminology would be useful. In this article, several views of the terms integration, integrated, and integrative are considered with the hopes that this brief review will help to raise awareness, clarify various uses of these terms, and add to the continuing discussion of how we might improve health care.



Models of Integrative Care

Following are summaries of selected models that help describe the concepts of integration. It is possible to have multiple models in existence in the same system, and one may not necessarily be superior to another.

In 2004, Boon et al [6] eloquently provided a model in which they described various stages of integration in health care practices. This model could be used by health care givers or institutions to self-reflect as to which part of the spectrum they belong, or may serve as a guide to set goals for practices and policies. The lowest end of the spectrum is “parallel” care, in which practitioners work with an individual patient in each scope of practice, with little to no communication or coordination among practitioners that a particular patient is seeing.

The next level is “consultative,” in which each practitioner may provide consultation for a patient, but not work together in providing care. Next is “collaborative” care when information is shared between practitioners and would be unique to each patient; not all patients are seen by a provider team. “Coordinated” care is when there is a more formalized structure in which providers freely share information and in which a team is responsible for the care of a patient. “Multidisciplinary” care is when care is overseen by a leader who facilitates care between providers and is an advanced form of coordinated practice. “Integrative” care occurs when there is a non-hierarchical structure in which a variety of practitioners (eg, conventional and nonconventional providers, such as medical physicians, chiropractic physicians, nurses, physical therapists, occupational therapists, mental health care specialists, nutritionists, acupuncturists) work together to care for the whole person with a focus not just on treating disease but also on health and wellness.

In 2004, Mann et al [11] discussed 7 models of integrative care, moving from the simplest to the most complex system.

The first model (Informed Clinician) is one in which an allopathic medical provider learns accurate information about various other nonconventional therapies. This may include knowing what the practice or therapy procedures may provide to a patient and if there are any side effects or interactions with medical treatments (eg, herb and drug interactions).

The second model (Informed, Networking Clinician) is grounded in the first model, but the practitioner has a functioning network of providers available and is able to offer more treatment options to patients.

For model 3 (The Informed, CAM-Trained Clinician), a medical practitioner does not necessarily have a network of other providers, but instead chooses to train himself in selected CAM modalities (eg, takes a course in acupuncture).

Model 4 (Multidisciplinary Integrative Group Practice) is described as when both conventional and complimentary therapists form a partnership to focus on specific clinical issues. In this model, providers collaborate and cross refer; but patients see separate providers.

Model 5 (Interdisciplinary Integrative Group Practice) is similar to model 4; however, the patient is seen by a team of providers, each providing his/her area of expertise (eg, for a patient with chronic spine pain, there may be a neurologist, acupuncturist, doctor of chiropractic, and pain management specialist).

Model 6 (Hospital-Based Integration) integrates conventional and CAM services within a hospital setting.

Model 7 (Integrative Medicine in an Academic Medical Center) is very complex and includes integration of services in addition to including them in teaching, research, and clinical care settings.


In 2005, Kaptchuk and Miller [12] described 3 potential relationships between CAM and allopathic medicine.

The first model is the “opposition” model. In this model, both camps denigrate the other, suggesting that the other is harmful, unfounded, or lacking in some manner. Interactions with providers from the other camp are discouraged (eg, doctors of chiropractic refusing to work with medical doctors, neurologists refusing to work with acupuncturists, physical therapists refusing to work with chiropractors).

The second model is described as the “integration” model. This model incorporates CAM modalities into conventional medicine; but in this model, the foundation is shaky, and it is suggested that the “… integration model risks undermining not only the ethos of CAM, but also that of biomedicine.” Thus, in this description, integration of methods by one provider may result in a loss for all professions as well as potential harm to delivery of care.

The third model is the “pluralism” model, in which there is cooperation between medical and CAM providers. This model allows for tolerance of epistemological differences and recognizes that both allopathic medicine and CAM have the potential to offer valuable treatment options for patients. This model promises to maintain integrity for those participating and offers improved communication and better patient choices.


In 2004, Leckridge [13] proposed a unique series of models based upon how patients approach health care.

The “market” model allows the patient to choose whatever health care service that he/she wishes; however, services are not integrated. Thus, the patient must access each provider separately; and each provider may be unaware of the other (eg, patient will see the doctor of chiropractic as well as their primary care medical doctor without telling either one).

The “regulated” model is the same as the market model; however, access and delivery of care are regulated by a body such as by the government or professional body. As with the market model, the regulated model provides services; but they are still separate and described as “chaotic.”

The “assimilated” model is one in which a medical practitioner attempts to offer and apply the CAM therapies himself or herself. A fault of this model that the authors point out is that one medical practitioner cannot learn all possible therapies that a patient may want or need.

The fourth mode is the “patient-centered” model that supersedes the other models by being focused on the patient instead of the provider. In this model, teamwork between medical and CAM providers uses a biopsychosocial model of health in the approach to patient care. As patients become active participants in health care, considering health care models from the patient's viewpoint may be helpful.


In 2006, Gamst et al [14] described several models to include CAM services in health care systems in Denmark and Norway. Model 1 is when a conventional medical practitioner uses both conventional and CAM methods. In this model, the authors raise issues with the lack of bridge building and the potential lack of proper training. Model 2 occurs when various types of health care practitioners cooperate together and refer to one another. In this model, practitioners practice independent of one another; and care is not necessarily coordinated for the patient. Model 3 occurs when a team of conventional and CAM practitioners works together at an institutional level. In this model, they are focused more on providing best patient care instead of focusing on a profession or treatment modality.

Based upon these various models, it appears that there are several themes. One theme is the use of CAM modalities by medical doctors and the development of “integrative medicine” (“IM”) specialties within medicine. [15, 16] It appears that there are a variety of motives and risks raised with this model. Another theme focuses on cooperative or coordinated health care delivery between services and providers and focuses on providing the most clinically and cost-effective care to the patient in which multidisciplinary teams work together. And finally, there are models that focus on the person/patient who is the ultimate end-user of the health care provided. In our quest to develop a better health care system, we should perhaps focus on what is best to restore or maintain the health of our population. Although the health care system and patient-focused models are more complex and would take the investment of emotional and financial resources, the rewards may also be great.



Views of Integration

It is interesting to see how many different interpretations and definitions of integrative, integrated, and integration there are in the literature. These range from a focus on the integration of delivery of health care services and focus on the patient instead of the practitioner, to a view of the allopathic delivery of CAM modalities. Appendix A offers samples of the wide variety of uses that various sources have used for these terms.

      Practitioner Centered

The reports by Eisenberg et al [17, 18] in 1998 and 2001 seemed to stimulate a surge of interest in the medical community to find out why consumers were spending money on CAM therapies. Since that time, there has been a scramble in conventional medicine to crack the code and identify what is behind the lure of using health care outside of what Western medicine offers.

Of special interest is the use of the term IM or sometimes called complementary and integrative medicine or CIM. Integrative medicine is used by some to mean the incorporation of practices, such as those modalities and methods traditionally used by CAM practitioners, by the medical doctor. [19] For example, Rees and Weil [20] promise that IM will imbue “orthodox medicine with the values of complementary medicine.” Others may choose to incorporate CAM modalities instead of values. In some cases, there has been an interest in including CAM therapies in medical curricula (eg, acupuncture, manual therapies, mind-body training). [21]

Using the term IM does not imply that the medical doctor has necessarily had formal training in CAM. For example, a medical doctor who uses herbal remedies in addition to conventional Western medicine may consider himself worthy of practicing IM. I have observed several medical facilities advertising themselves as being “holistic” and offering CAM therapies in the hopes of getting more patients through the door. The interesting thing is that there are no CAM practitioners within these facilities. The “CAM” therapies being offered were simply modalities taken from CAM practices such as hypnotherapy (eg, labeled as mind-body techniques) or acupuncture offered by one or two of the medical staff. Is it possible that “corporate commercial interests” or marketing tactics are behind these actions rather than a true understanding of the concepts of integrative care and practices of the system from which these treatments originated? [22]

It may be that one of the primary drives of the medical industry to incorporate CAM modalities into practice and give it the moniker IM is to benefit from the public's interest and willingness to spend money on alternative therapies. [4] Is the creation of IM a commercial response to the rise in popularity and use of other methods that a provider does not learn in the traditional curriculum (eg, CAM)? Is IM an attempt to compete with CAM for a patient's desire for nontraditional methods? Is IM a means for some providers to keep CAM at a 10-foot–pole distance so that they do not need to refer or cotreat patients with traditional medicine or CAM practitioners? [16] These are questions that need to be considered when using the term integration in our discussion of health care.

From a practitioner-centered viewpoint, allopathic practices are at the center of the health care model. Some have stated that all scientific procedures are owned by conventional medicine and that all unscientific procedures fall into the realm of CAM. Phil Fontanarosa, MD, and George D Lundberg, MD, stated “There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.” [23] It may seem that orthodox medicine claims to own anything that is considered pure and good; anything otherwise is left to the fringe professions. This is an interesting viewpoint; however, I disagree that one profession can legitimately stake claim to all procedures that are scientific. Does one profession have the right to “own” science? I think not.

There is a demand in Western medicine for all things CAM to be put through the intense scrutiny of evidence-based procedures and leave all untested practices aside. However, all procedures in medicine should also undergo the same scrutiny. [24] Yet, not all procedures and practices used in medicine are evidence based [25–29]; so there seems to be a double standard. All health care practices should be given the same level of testing as well as tolerance.

The medical community also appears to be interested in incorporating only those CAM modalities in their “IM” practices that have shown to stand up to scientific rigor. However, it does not seem to take into account that the delivery of a modality outside of its regular practice environment, used by someone who is only trained in a short course (such as acupuncture needle insertion instead of the philosophy and art of acupuncture), may not provide the same results to the patient as described in the scientific literature. [7] If medicine is serious about incorporating CAM modalities into regular practice, it should also perform clinical trials in that particular setting to ensure that medical doctors are delivering safe and effective treatments.

An additional concern may be that some practitioners are dabblers, in that they wish to call themselves IM practitioners so that they may advertise and receive financial benefit from accessing the consumers who are seeking more natural or holistic therapies. This type of practitioner may attempt to plug in a modality (eg, prescribing St John's wort or sticking a few acupuncture needles) that has been borrowed from a more complex healing model so that he or she can feel validated in calling himself or herself an IM practitioner. However, taking one modality from a more complex set of practice procedures may not necessarily be effective. [16] As well, because no single entity currently controls what is considered IM or regulates IM, [30] the results might possibly become a mishmash of therapies, not consistent from one IM medical doctor to another. It will be interesting to see how the medical profession resolves this problem.

Some seem to view CAM and the traditional health care professions as if they were simply a reservoir with a set of practices from which modalities can be plucked and then incorporated into conventional medical care.

For example [31]:

“In closing, I would like to share with the Subcommittee my vision of where I expect complementary and alternative medicine to be in the years to come. I am confident that NCCAM's [National Center for Complementary and Alternative Medicine's] leadership will stimulate both the conventional and CAM communities to conduct compelling scientific research. Several therapeutic and preventative modalities currently deemed elements of CAM will prove effective. Based on rigorous evidence, these interventions will be integrated into conventional medical education and practice, and the term ‘complementary and alternative medicine’ will be superseded by the concept of ‘integrative medicine.’”


None of these descriptions seem to address the building of bridges or the development of cooperative relations or strategies between health care professions. This particular model of IM seems to be similar to the practice of buying cars and stripping them down piece by piece to sell their parts. These parts will be installed into other models with the hopes that they will work as they did in the original one; however, this may not be the case. The use of a CAM modality in another system may not necessarily achieve the same results or be as safe as if it were used in a CAM setting. Once stripped, the carcass goes to the smelter. This is similar to the suggestions made by Strauss [31] that the CAM professions will eventually go away and Winnick [4] predicting the absorption of CAM by conventional medical care. In this scenario, it is assumed that the person who is doing the stripping is able to accurately recognize the valuable from the invaluable parts. But what if the most valuable parts are not recognized, or what if they only hold their value when incorporated into their original whole? There is still much to be explored. This model may be a dangerous approach to the evolution of health care practices.

How can one profession view another profession as a source of modalities to strip and use? One possible reason may be the philosophical approach to patient care. Medical training may result in a different style of thinking and problem solving than those who use traditional, aboriginal, or CAM methods. If the primary focus in medical training is disease oriented [32] and a patient presents with a headache or runny nose (diagnosed disease/symptom), the logical action is to prescribe a pill (use a modality). If the patient presents with a tumor (diagnosed disease/symptom), then perform surgery (use a modality). Therefore, if a provider, who perceives himself or herself as the center of health care and ultimate decision maker, wishes to incorporate other tools to approach patient care, he or she might logically view other nonmedical professions or CAM tools as modalities to harvest and use in his or her practice instead of working with the members of the other professions. However, if these tools are used as modalities to address diseases and symptoms instead of addressing the patient in the larger context, it is possible that nothing more may have been gained by the incorporation of these modalities into medical practice. In this case, the medical doctor may have simply shifted from “take 2 aspirin and call me in the morning” to “take 2 acupuncture needles and call me in the morning.” The question, of course, is “Will this particular IM model (ie, conventional medical doctors applying CAM therapies) work?”

      Cooperative and Systems Centered

Another manner in which integrative and integrated have been used is to describe health care delivery systems that integrate or coordinate various providers and services that address the health of the patient from cradle to grave. This may be described in various ways, such as horizontal or vertical integration, or focusing on a disease and integrating care around the disease entity [33, 34] or merging various programs and acute and long-term care. [35] These terms have been used to describe health care delivery systems that combine various professional disciplines so that patients' access to care is more coordinated and cost efficient. The patient may enter the health care system and experience the time savings and stress reduction of accessing all needed care, in that all needed services and providers can be found or accessed through one location or venue. Constructs such as “patient-centered medical home” promise to provide continuity of care and coordinated services. There are proponents of providing integrated care in which various forms of health care delivery are provided to the patient. [36, 37] In the study of Barrett et al, [36] it is suggested that an integrated system, delivering both CAM and conventional care, could better address health care needs over the course of a patient's lifetime and that prevention and health maintenance would be a priority.

Other authors have described multidisciplinary teams working together in various health care settings [38, 39] and ways of helping CAM practitioners better communicate with conventional doctors. [40] These models seem to offer the best of what health care can provide, although it does not come without effort. Those who have studied integrated health care models have used a variety of approaches from a systems approach [41] to reviews of various models. [37]

Integrative health care models are complex and take proper planning and cooperation to be successful. Some of the factors that should be considered include but are not limited to the following: physical building/facilities, informed/cooperative practitioners, cultural competence, health care records, reimbursement structure/process, provider interaction/respect, clinical and cost effectiveness, and assessment programs. Complex systems can be addressed with forethought, planning, and measurement. [42, 43]

      Patient Centered and Person Centered

Another trend in health care is to focus on each person as a unique individual and in a holistic manner. [13, 42, 44] With the patient at the center, the health care providers and system may provide more holistic services. The patient is seen as an entire entity and not just a case or a disease. A patient is cared for from before birth to growing up, to adulthood, and through the aging years and the process of dying. The patient is seen as having a combination of physical, emotional, mental, social, and spiritual needs. The ultimate goal is to prevent illness in addition to helping the person reach his or her maximum potential. This model may be a good match for those professions that have this holistic philosophy built into their foundations. [45] Providing education and behavior modification skills would help the patient to stay healthy, through activities such as proper diet, exercise, social activities, and work habits. Because no single provider is able to care for one patient for all needs, coordination between systems, services, and providers is necessary, such as public health, mental health, primary care, specialties, etc.

In a patient-centered model, the patient's/person's needs and preferences are considered. A patient-centered component is one of the essential pieces of evidence-based practice: evidence, clinical experience, and patient values. Thus, it fits nicely in the evidence-based practice paradigm. [46] When a patient's/person's needs are considered, this also empowers the patient/person to become an active participant in health and healing processes instead of relying totally on health care providers for his or her “health.” As Lekenridge [13] suggests, this model requires teamwork from health care providers. In this type of model, coordination must occur on multiple levels, such as at the caregiver, funding, and administration levels. [42] Trends in patient-/person-centered care include the way we think and the vocabulary we use for the recipient of care. [47] For example, the “people-first” concept has been an attempt to focus on the person instead of his or her disease or disability (eg, instead of blind person, using the phrase person who is blind). [48] The tradition of the medical model to focus on disease management reinforces the use of the term patient. As we move from labeling patients, such as the spinal stenosis case, to a more holistic, health-conscious, and person-oriented manner, our terminology used in practice and in publications will change. If we are to transition to prevention and wellness models of health care, models in which we see people having the potential to be healthy, we may also wish to revise our day-to-day use of the term from patient to person. As part of an integrated health care system, if health is our goal, then one of our goals may also be viewing people as whole and healthy, not as perpetual patients. When we focus on the person/patient, we may also have a tendency to focus less on ourselves as health care providers. We have the potential to transition from doctor-centered health care models to person-centered models. It is up to us to make this happen.

      Where Does CAM Fit?

What about integration of various systems that wish to include CAM? What is actually being integrated? What is CAM? Coulter and Willis [7] raise the issue that CAM was defined by Western medicine as what it is not instead of by what it is. Can some professions or therapies be called CAM anymore? Now that there is an established scientific basis for some of the CAM professions, does this mean that they no longer should be called CAM? Maybe it is time that we revisit how we label various health care practices. Unclear terminology also creates varying degrees of confusion and leaves room for turf battles in which the patients are caught in the middle. Hopefully, we will find a way to evolve beyond this.

The chiropractic profession provides a good example of a profession that was once considered CAM that may no longer fit in the old paradigm. [49] Now that chiropractic has been tested in various scientific ways, including blinded, randomized controlled trials, the evidence is present. Does this mean that chiropractic is now no longer considered CAM? If it is not recognized as part of conventional Western medicine, nor as CAM, how should one classify the chiropractic profession? Chiropractic has typically defined itself as separate and distinct from medicine as a reaction to attacks from organized medicine to survive early 20th century legal attacks on practicing medicine without a license. [4, 32, 50] Has the need for this survival method passed? Are we able and willing to work together with other professions for the benefit or our patients?

I have hope that there will soon be a time in which various health professions will work together, in harmony, to serve the best interest of the people. We are beginning to see some of these examples before us. [38, 51–56 These integrated settings would not have been possible several decades ago because our culture was not ready to test these new models. Through improved education and cultural competency skills, we seem to be more willing to work together for a common good. Some of these integrated health care environments have demonstrated effective care in addition to cost-saving benefits, which may be a primary driving force in what our health care system will look like in the future.



Conclusion

Although this article has reviewed a portion of the literature on integrated/integrative care, there may be other viewpoints and models that exist and should be considered as we approach the future of health care. As well, this discussion does not necessarily imply that one model is superior to another or that in some circumstances multiple models cannot exist at the same time. Somewhere among the multitude of definitions and models, there must be a truth that we will eventually realize. How we reach that state, either by a path of dominance and marginalization or by way of holistic patient-centered approaches, will be up to the stakeholders. I hope that this brief review will help to raise awareness, clarify various uses of these terms, and add to the continuing discussion of integration and how we might improve health care.



Appendix A.

Samples of Different Interpretations and Definitions of Integrative, Integrated, and Integration
See page 710.




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