Healing environment

Models of Integration
Ines von Rosenstiel
Head of Pediatrics, Slotervaart Hospital
Director IM program, Slotervaart Hospital
Chair NIKIM
Content
Definition IM
Situational facts NL
Framework IM
Consequences of integration
Challenges of integration
Different models
Tips
Future
The great change
CAM to Integrative Medicine
‘Integrative Medicine is
the practice of medicine that reaffirms the
importance of the relationship between
practitioner and patient, focuses on the whole
person, is informed by evidence, and makes use
of all appropriate therapeutic approaches,
healthcare professionals and disciplines to
achieve optimal health and healing.’
Integrative Approach
Bioenergetic therapies:
Acupuncture/Acupressure, Healing/Therapeutic
Touch, Prayer, Homeopathy
Biomechanical
Therapies:
Surgery,
Osteopathic/
Chiropractic;
Bodywork/Massage
Patient-centered,
compassionate care
Biochemical
Therapies:
Medications, Herbs,
vitamins, minerals,
dietary supplements
Lifestyle Therapies:
Mind-body; Environment; Exercise/Rest;
Diet/Smoking/Drinking
The Integrative Medicine movement
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Article “Twice as Strong”
H ilary E . M acG regor, T imes S taff W riter , A ugust 07, 2006
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The “New Medicine" television show, 29 march 2006
(9 million viewers)
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Social phenomenon worldwide
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Grass- root populist movement and/or led by
conventionally trained physicians?
IM Expertise in the Netherlands
Slotervaart Hospital & NIKIM 2003-2009
Best Practices
Education
Research
Advocacy
Tangiable IM elements in Dutch Hospitals 2009
Ziekenhuis
Modaliteiten
AMC Amsterdam
•Meditatie bij pijn, stress en angst via ademhalingsoefeningen en yoga
•Hypnose voor pijnklachten en ter voorbereiding van operaties
Brandwondencentrum Rotterdam
•Therapeutic touch
Diaconessenhuis Utrecht
•Geleide visualisatie ter voorbereiding van operatie of chemotherapie
Erasmus MC Rotterdam
•Healing environment
Flevoziekenhuis Almere
•Geleide visualisatie ter voorbereiding van operatie of chemotherapie
•Acupunctuur tegen misselijkheid en braken na ingreep of chemo
•Massage voor pijnverlichting en ontspanning
•Healing environment
Laurentius ziekenhuis Roermond
•Acupunctuur tegen misselijkheid en braken na ingreep of chemo
Lentis Groningen
•Meditatie bij pijn, stress en angst via ademhalingsoefeningen en yoga
Maaslandziekenhuis Sittard
•Healing environment
Martini Ziekenhuis Groningen
•Healing environment
Máxima Medisch Centrum Eindhoven
•Geleide visualisatie ter voorbereiding van operatie of chemotherapie
Máxima Medisch Centrum Veldhoven
•Therapeutic touch
Medisch Centrum Alkmaar
•Geleide visualisatie ter voorbereiding van operatie of chemotherapie
Orbis Medisch Centrum Sittard
•Healing environment
Slotervaartziekenhuis Amsterdam
•Geleide visualisatie ter voorbereiding van operatie of chemotherapie
•Massage voor pijnverlichting en ontspanning
•Hypnose voor pijnklachten en ter voorbereiding van operaties
St. Annaziekenhuis Geldrop
•Massage voor pijnverlichting en ontspanning
St. Antoniusziekenhuis Nieuwegein
•Hypnose voor pijnklachten en ter voorbereiding van operaties
UMC St. Radboud Nijmegen
•Meditatie bij pijn, stress en angst via ademhalingsoefeningen en yoga
•Acupunctuur tegen misselijkheid en braken na ingreep of chemo
Verpleeghuis Mariaoord Rosmalen
•Therapeutic touch
Vumc Amsterdam
•Geleide visualisatie ter voorbereiding van operatie of chemotherapie
Implications of integration
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Clinical care
Research
Education
Communication:
open, non-judgmental
Discuss potential benefit and risks, as well as interactions and risks with
other medications/therapies
The approach to evidence
B . K ligler/R . L ee
D . R akel
Textbooks, Databases, Journals
M .
L oo
How do you negotiate a treatment plan?
Effective
Safe
Yes
No
Yes
Use/Recommend
Tolerate
No
Monitor closely
Advise against
Ethical framework
Cohen M. Pediatrics, 2005
Both camps have to step in the
integrative circle
IM Practices
Achievements
 Unifying conceptual framework
 Development of an international network
Obstacles
 No unifying objectives training standard
 No unifying scope of practice
Who practices IM?
Conventional physicians and practitioners
Now
Interim
Future
Selfdetermined
Bilateral peer
approved
Bilaterally
certified
Certification
Now
Interim
Future
unregulated
Self-regulated
Co-regulated
Don’t fix a broken system
Transform health care
Holistic philosophy

Good medicine
The philosophy/values are shared but are not
implemented in:
 Structure
 Process
 Outcome
Focus on prevention

Lifestyle Clinics
T heroleof O ptimal H ealing E nvironments in the
M anagement of C hildhood O besity.F reedman
M R , S tern J S , 2004
Healing environment
Evidence:
Elements of nature
Mind-body skills
Music therapy
Aromatherapy /diffuser
Massage/yoga/healing touch
Healing environment
Evidence based design, scientific research
UNDERSTANDING HEALING ENVIRONMENTS:
E ffects of physical environmental stimuli on patients. H ealth and
W ell-B eing
K arin D ijkstra, 2009
Key articles: conclusion
There is no single model of Integrative Medicine practice
Instead, there appear to be many different responses to
common challenges
No “one size fits all”
IM Practices Organization
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Key themes:
Dimensions of health
Selection of therapies used
The practices approach to evidence
Their adaptations to financial concerns
Dimensions of IM patient care
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Patient centered care
Time 30-45 minutes
Shared decision making
Whole person care (mind/body/emotions)
Integration of CAM therapies
Healing environment
A viable business plan
Selection of the therapies:
 Chiropractic
 Massage
 Acupuncture
 Mind-body medicine (counseling, stressreduction)
 Nutritional service
Adaptation to financial concerns

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Forgo third party reimbursement, charging for
extended visit “consulting practices”
Practice income through sale of supplements
Growing role of Philanthropy in
Integrative Medicine
Case study: T heI nstitutefor H ealth and H ealing atabbot
N orth W estern H ospital
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Over $ 15.000.000 raised to date (2009)
Donors expect to partner with the
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Commitment to change the model of care
Integrating CAM in to the standard of patient care, Liver
Bend, Eugene, Oregon
Create a comprehensive Integrative Medicine
Program that blends the best evidenced-based
conventional therapies and healing therapies and
optimizes whole-person patient-centered standards
of care across all of the hospital’s centers of
excellence, both inpatient and outpatient
Objectives
 Become a national model
 Achieve a new standard of patient care
 Create educational opportunities
 Training for nurses and physicians
 Support clinical research
 Establish self-care programs
 Create an eventual self-sustaining program
Funding
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Create healing environment
Programmatic support
Training/education
Clinical outcome research
Steering committee in institutions: patients and donors
Does an integrative approach improve
outcome?
J Altern Complement Med 2005 Apr 11(2)219
Integration of complementary and alternative medicine in a major
pediatric teaching hospital: an initial overview.
H ighfield E S , M cL ellan M C , K emper K J , R isko W , W oolf A D
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RESULT: Over 5.5 years, CHPER staff provided over 2100
consults: acupuncture, massage, holistic pediatrician,
relaxation therapies, biofeedback, hypnosis, and biopharmaceutics. Acupuncture and massage therapies were
incorporated into a Clinical Practice Guideline
Does an integrative approach improve
outcome?
Integr Cancer Ther.2007 Jun;6(2):174-84.
Patients' experiences and perceptions of a consultative model
integrative medicine clinic: a qualitative study.
K oithan M , B ell I R , C aspi O , F erro I , B rown V
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77% women expressed overall satisfaction with IM
(1) expansion of treatment options with lower perceived
toxicity than conventional therapies
(2) positive experiences of the IM physician as caring and
taking time to listen, and
(3) improved self-care skills and sense of empowerment
 30% reduction in consultation rate
 44% reduction in prescription
Dissemination of successful Integrative
Medicine practices models and evaluation
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University of Michigan IM Clinic
SF-12, Holistic health questionnaire
 High patient satisfaction
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Different Models
Philosophy
 Emphasis on whole person, diversity of health care
philosophies, determinants of health considered increase
 Reliance on the biomedical scientific model decreases?
BMC Health Services Research 2004, 4:15
Different Models
Structure
 Complexity increase
 Reliance on hierarchy and defined roles decreases
BMC Health Services Research 2004, 4:15
Different Models
Process
 Communication, of participants involved,
individualization, synergy & the importance of consensus
increase
 Practitioner autonomy decreases
BMC Health Services Research 2004, 4:15
Different Models
Outcomes
 Complexity and diversity of outcomes increase
BMC Health Services Research 2004, 4:15
Focused consultatory model
Conventionally trained physicians as direct
providers (using existing staff), target CAM to
specific conditions
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Slotervaart Hospital
Lentis
Consultatory model
CAM providers as consultants, employs CAM
practitioners
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Sloan Kettering
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Mc Anderson Cancer Center
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Children’s Hospital and Clinics of Minnesote
Primary care model
Traditional medical care-CAM
Joop de Vette, family physician
Hygiëa Integraal Gezondheidscentrum
Spa models
As an integrative medicine person, you have to
think like a medical and a business person
Arizona, A. Weil
E. Guarneri, MD co founder/medical director
the Scripps Center for IM in San Diego
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Point person: multiple hats
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Liaison between
administration and the board
The medical staffs
Patients and the public
CAM champions
Bear trap
Medical staff hostility, “educate them”
Referrals should be two-way!
 Strict follow-up
 Consult letters and accurate charting
Bravewell collaborative
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Transformation of the conventional healthcare system
Expansion of access to diverse CAM therapies
 4 possible outcomes