Tuesday, February 14, 2017

CUIn May of 2013, Colorado Governor John Hickenlooper declared his commitment to make Colorado the nation’s healthiest state. Two years later the chancellor of the University of Colorado Anschutz Medical Campus, Don Elliman, backed an initiative from a CU integrative health and medicine group to explore the potential for a campus-wide integrative health strategy. At a one-day conference on November 16, 2017, these two lines of pursuit converged. In his opening remarks, Elliman suggested that meeting Hickenlooper’s goal may require embracing the core philosophy of holistic and integrative health.

The context was a one-day summit at the Anschutz Medical Campus entitled “Future Trends in Healthcare: An Integrative Approach to Health and Wellness.” The meeting was organized by nationally-prominent integrative medicine leader, Leonard Wisneski, MD and his colleague, philanthropist Pamela Bard.  Wisneski, chair of the Integrative Health Policy Consortium, is an adjunct faculty appointment at CU and is also a principal backer of the medical school’s Strauss-Wisneski Indigenous and Integrative Medicine Collection.

Running through the day’s formal program –  all of which was recorded and available to the public -- was an exploration of whether, how, and in what ways adopting integrative medicine practices and perspectives might assist the state in reaching Hickenlooper’s goal. The answers, while hopeful, also underscored challenges. That all presentations are available to the public invites expanded exploration.

EllimanColorado University Anschutz Medical Campus chancellor Elliman, pictured, provided a suggestive, affirmative answer in his opening remarks. He spoke to Hickenlooper’s goal, acknowledging that, while many of his fellow Coloradoans think the state has already hit that pinnacle, that it wasn’t true and “there are some areas where we are quite far off.” Then he reflected: “The fact of the matter is that for us to really achieve the state of wellness that we want for the citizens of the state of Colorado, we have to encompass the concept that medicine is not all about the curative.”

Elliman saluted the value of the high-tech medicine for which CU Anschutz is known then added that there are “elements that go beyond that.” A broader perspective is required: “On the flip side of that, we need to understand that treatment has to be holistic.” He spoke to the need for “the combination of traditional and non-traditional – of holistic medicine.” This, Elliman said, “is something that we as an academic medical center need to be playing a leading role in pushing forward.” He added: “I am thrilled that this conference is here.  We hope we as a campus can be a leading force in understanding integrative medicine and improving outcomes of our citizenry through the use of it.”

Wisneski brought in three big gun integrative health leaders to engage the audience in examining what this direction might mean. Courtney Baechler, MD, MSCE, is the vice president of Penny George Institute for Health and Healing at Minnesota’s multi-hospital delivery organization Allina Health. Allina, where Baechler also chairs of the Prevention and Wellness Clinical Service Line, has the most thorough inpatient-outpatient use of integrative services of any system in the United States. Her topic was “Sustainable Integrative Models of Care.”

BaechlerIn Baechler’s presentation she provided data from multiple studies showing the clinical value to patients from integrative services. Most were related to reductions in stress, anxiety and pain relief. Knowing that adoption of such an integrative model begs questions on financial impact, she provided three kinds of data. Some 80% of their services are covered by insurance. In fact, they convinced Medicaid in their state to cover acupuncture for pain. Baechler then spoke to the competitive interest of delivery organizations: “We have data to show that 35% of people who use [our integrative services] are new to Allina and they go on to use other health services. This is a good market share offering for those who care about those numbers.” Baechler also had something for those who are focused on the numbers associated with overall costs. The research team performed a retrospective review of those hospitalized patients who had received in integrative medicine consult for pain. On average, they saw “an average savings of $905 per hospitalization” compared to those with usual care.

Baechler shared that Allina’s plans to keep more care out in the community is provoking an expansion of integrative services into six additional community clinics. The experience with inpatient services led to an adjustment to focus on specialties where there is strong practitioner and consumer interest. Oncology, childbirth and maternal care, and joint replacement are the top three lines with a focused plan with cardiology also in exploration.

ChesneySpeaker Margaret Chesney, PhD brought listeners into some of the research-related directions needed to shift toward the more integrative perspective. The former deputy director of what is now the NIH National Center for Complementary and Integrative Health (NCCIH) and past chair of the Academic Consortium for Integrative Medicine and Health first reinforced Elliman’s message: “The disease driven approach to care has resulted in spiraling costs as well as a fragmented health system that is reactive and episodic as well as inefficient and impersonal.”

Chesney highlighted the practical and economic challenges of shifting from this fragmented approach through a story that demonstrated how the research community is itself structured around, and invested in maintaining the status quo.  While affirming value in 5 year studies, she spoke to the greater urgency: “We need research that is much quicker.  The public needs more answers. We need to do things that cost less. I am a real advocate of how we can gather data that can inform policy.” To leverage change, Chesney urges an elevated focus on the health services research, on examining data from electronic medical records, and on more “evaluation studies instead of randomized trials.”

Chesney concluded with a theme that shows how far the puck of health creation shifts the focus away from reductive research.  “If you want to be the healthiest state,” she charged, “you need to move beyond the clinic’s one-to-one care, to the communities and neighborhoods. We need to expand the idea of personalized medicine, to more to zip code from genetic code.” Her perspective aligned with the commitment Baechler described at Allina to focus integrative resources on the community.   

JonasSpeaker Wayne Jonas, MD proceeded Chesney at the NIH. He served as the director of the office that became the NCCIH in 1998. For the past 15 years, Jonas directed the Samueli Institute where he led a research program that proved instrumental in moving integrative care into military medicine. Another key project was to promote optimal healing environments in medical delivery organizations.

Jonas followed Chesney with a somewhat brusque opening: “That was good. And now for the real world.” He argued that what is going on at places like Allina is “not the norm.”  To create significant change in Colorado and elsewhere “there needs to be a conceptual change that has to penetrate into our culture.” Otherwise, he said, “we will have wonderful examples like this that will eventually die.”

The conceptual change recommended by Jonas was aligned with the direction Chesney recommended for research. He promoted a shift is from “the science of the small and particular” - associated with the high medical specialization and addressing of acute condition - to “a science of the big and the whole.” The shift reflects the need to address chronic diseases, and particularly the powerful social determinants of health.  “It’s not just about the body,” explained Jonas, “it’s about the hard to measure things, the brain, the mind -  it’s about your social environment, the spirit.”  To add to the S.O.A.P. note format for clinical encounters – subjective, objective, assessment and plan – practitioners must add a H.O.P.E. note: Healing Oriented Practices and Environments.

RuthA way to think about these new priorities was offered by philanthropist and “accidental activist” Ruth Westreich. In a presentation on how such activist can be most attractive to foundations and policy makers, she led with a framework of a “therapeutic order.” At the broad base are social determinants and ways to “stimulate the healing power of nature.” At the top and optimally least utilized are the most invasive approaches such as pharmaceutical medicines that take over natural processes, and surgeries.

The big shift, in Jonas’ view, is from “a sole interest in ‘pathogenesis’ to a focus on ‘salutogenesis” or health creation. He needled his audience a bit, dismissing the transformative leverage of integrative health if that term only means adding a few modalities to conventional practice. The integration must go beyond the clinic, into the community, and include the social determinants. If Colorado really wants to hit its target, it might start by creating a “well-being index”, he suggested, to begin to development measurable markers. He described how he has participated with the leaders of military health who are “getting out of the box” and beginning to embrace the whole person and whole system perspective.

Jonas posed a question that is central to Colorado Governor Hickenlooper’s ambitious initiative: “Is our nation really ready to make that bus turn? Or do we have so much invested in this science of the small and particular and all the things that have come behind it so that the resistance to turning that bus means it’s not going to happen.” He paused: “The recent election make that question even more important.”

So, can the commitment of Chancellor Elliman and the University of Colorado Anschutz Medical Campus to exploring roles for integrative medicine help Governor Hickenlooper reach his goal for the people of Colorado?

Anyone expecting quick answers at this conference would likely feel both teased by potentials while also head-scratching about how to frame the contribution. Baechler offered clear-cut guidance on how integrative healthcare delivery can advance patient experience and outcomes in both inpatient and outpatient clinical settings. Jonas pointed to the work in military medicine as additional exemplars. Yet Baechler, Chesney and Jonas each urged, in an ascending crescendo, that “integrative medicine” must open its application of its whole system approach. They urged the field to consider embracing a self-definition that moves beyond the clinic and into communities.

Jonas’ frame may be useful here. If “integrative medicine” is conceived as an exploration of new therapies and practitioners, the engagement is a sort of integration of the small and particular. The potential can be useful in enhancing health in those served. Yet what these talks suggest is that for the movement for integrative health and medicine to maximally assist Colorado, and communities elsewhere, toward salutogenesis, this integration must be reframed around the big and the whole represented by actively engaging the social determinants. Good marriage changes all parties.

This reporting of the conference was supported by the Bard Family Foundation.

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