The term ‘integrative health care’ gets used a lot. Having been a student of the term–and the movement–for more than half of my professional life in chiropractic, I think it’s important to lay out some ‘design principles’ to help establish what should be a more commonly held understanding of what it really means for chiropractors and those we interact with.
The word ‘integrative’ crops up in health care a lot, but it means a lot of different things. ‘Vertical’ integration in a system (hospital, clinic, etc.) is a way of describing a kind of service delivery hierarchy and includes the acknowledgement that connecting different parts of a delivery system (from ER to inpatient care to outpatient care to…etc.) offers the prospect of improving efficiencies and lowering costs. ‘Horizontal’ integration can be used to describe a networking effort of clinics and services to create a more thorough degree of coverage–geographic coverage for providers, for instance, or combinations of types of professions (specialty and generalist, pediatric through geriatric, for example).
Integrative health care offers the prospect of a kind of ‘one-ness’ (Latin root integrat, or ‘made whole’). So how do you take a bunch of separate professions and mash them together to make them one? And–more fundamentally–should you?
My single-question litmus test of integrative health care efforts is this: Integrative health care means that I don’t do something because someone does it better. Integrative health care means that those involved make a focused and distinct clinical contribution to the health of a population–n of 1 or n of millions. It does not mean that I take someone and put them through my complete examination and therapeutic process, then refer them to someone else who does the same thing, and on to the third person, etc. There are too many redundant elements in the process of examining, assessing, testing, treating and evaluating patients to consider that sequential multidisciplinary approach to be integrative. “Made one” it’s not. It can be effective health care, but from my perspective it’s not integrative. (In similar fashion, ‘integrative medicine’ sounds appealing, but from my view it seeks to make medicine ‘one,’ not health care. And it orients everything to medicine’s paradigm, but that’s not necessarily a good fit. See below…)
Why do I think this way? Because every profession operates with a distinct and notable professional paradigm of healing. That paradigm, or professional cosmology, determines a number of things about the process an individual goes through as they ‘become’ a patient. Each profession’s paradigm creates a kind of distinct ‘energetic container’ for the therapeutic relationship being established that facilitates healing, change, or transformation. After all, if people didn’t need facilitation, providers would be out of business. The relationship a chiropractor has with an individual is different than that created by a naturopath, a massage therapist, an acupuncturist, a medical physician, and so on. It’s not just that the people are different: it’s more deep than that. The basis for the effectiveness of the services a chiropractor offers someone is philosophically different that what is available from others. Some are aligned, but many are not. All are arguably valuable to the right person at the right time. In all likelihood all contribute to a ‘wholistic’ and complete paradigm of health and healing. But there are some important distinctions. Those distinctions offer the promise of some wonderful diversity in care and approach. And just as biodiversity strengthens an ecosystem, the ecology of health care can be immeasurably stronger if we take advantage of the range of contributions out there.
What are our contributions–and distinctions?
Chiropractic has deep and immutable roots in vitalism, the understanding and acknowledgement that our physical beings are innately capable of self-directed growth, development, health and healing. The role DCs play in facilitating the optimal function of those capacities centers on removing interference; that interference can come from a number of sources (physical, emotional, environmental, etc.). Our therapeutic contribution is based on our unique understanding and appreciation of the central importance of optimal neurologic function. Those who address vertebral subluxation see that clinical entity as a sole or primary source of restricting optimal function; those who see other avenues of input into normalizing neural system performance see validity in those as well. Those who view the body purely from a structural or symptomatic perspective also depend on the inherent restorative capacities of the body–mediated by the central nervous system and directed by whatever version of innate intelligence that one is willing to recognize. The central professional paradigm, regardless of therapeutic approach, really has to do with optimal neurologic function. It’s wonderful that it can include both mechanistic and non-mechanistic phenomena. In terms of a focused contribution to population health, that is chiropractic’s principal contribution. (And ‘principle’ contribution as well.) For health and healing, optimal neurologic function isn’t a minor consideration. It’s a contribution of potentially enormous significance.
Important or potentially critical contributions are available from other professions as well. A number of these also have roots in vitalism, and a resurgence of academic interest has fueled a new examination of vitalism in light of quantum mechanics theory (see the work at the LIFE Octagon; links to materials on a conference on vitalism are here). Each has what might be called a professional ‘signature therapeutic contribution’ to supporting health and healing. As I would frame them (not as a member of their professions, so forgive me if I poorly represent these, and please correct me), naturopathic medicine seeks to use beneficent natural substances to correct and enhance normal function; homeopathy uses specially-prepared natural substances to trigger/activate a healthy or healing response on the part of the body; Oriental medicine uses various tools to restore energetic balance to the body; Ayurveda uses a complex model of interplay among various energetic, physical and environmental sources and symptoms, using natural substances and healthy practices to improve health and support healing; and massage therapy supports health and healing by restoring physical function, where soft tissue problems have imposed limitations, restrictions, or imposed altered function. Many in medicine speak respectfully of the tenets of vitalism, but outside of their relationships with patients their therapeutic paradigm is substantially different, based on the imposition of drugs and surgery, which although often necessary and life-saving, also assert control over the body’s natural processes. That, too, is not a minor consideration. But it is as different philosophically from vitalistically-grounded professions as you can get.
Taken together, a spectacular array of options is available for consumer/patients. A seemingly endless menu of different approaches, models, interventions, and explanations is possible to choose from. Without a good model of integration, that diversity might be the source of some real problems. With a good model of integration, imagining the improvement in population health management that’s possible is breathtaking.
By way of describing what good practices are, it’s probably important to expand on what integrative health care is not, because by my criterion much of what passes for integrative health care out in the marketplace actually isn’t. It’s much more common to find multidisciplinary or interdisciplinary health care. Integrative health care is actually quite rare, in part because of the economics of how health care is paid for, and in part because we haven’t yet had the cultural bravery required to explore it.
Multidisciplinary, multi-provider or multi-specialty care isn’t integrative. Having a handful of different providers practicing in the same building, the same office, or the same room even isn’t integrative just because of their proximity. It’s certainly convenient, so that consumers don’t have to go to different places to get different services. But it’s not integrative in my view because providers in these situations tend to operate to the limits of their scope, and commonly refer when they’ve either exhausted their therapeutic armamentarium or it becomes apparent after some time that their best contributions have not resulted in the outcomes that patients were seeking. There are certainly exceptions, but it’s rare to have a provider refer for a focused clinical contribution by another provider. Referrals tend to be for ‘evaluate and treat’, because there is the intention to respect the professional autonomy of the provider being referred to. That may or may not be necessary, though. And that’s where the opportunity for integration comes in.
System-side economics aren’t integrative. Our current financial model of rewarding providers for volume of services (rather than outcomes) is a barrier to integration. Thanks to the Affordable Care Act, there’s a real chance that outcome-based population health compensation will come into broad use. We can only benefit from this.
Academic accreditation requirements aren’t integrative. When we transitioned Northwestern College of Chiropractic to become Northwestern Health Sciences University by adding professional and academic programs, we thought and assumed that there would be cultural benefits, clinical opportunities and economic efficiencies achieved through putting different professions together in the classroom and clinic. Our surprise was that professional accrediting standards actually imposed barriers for any experimentation with this. Silos, there we went.
So, what IS integrative? Well, first and foremost, consumers are integrative. Consumers commonly seek out a focused clinical contribution from a variety of different providers. They just don’t call it that. I would argue that many simply put up with the extra junk we add to their experience in terms of patient education, compliance-based therapeutic plans, etc. It’s not that we’re wrong for doing those things. We’re just not normally interested in asking consumer/patients what it is they want to do in terms of assembling a clinical team. Because rest assured, most are. And most cannot articulate what it is they want without help, nor explicitly plan how to achieve their goals. But through experimentation, missteps, peer-to-peer referrals and other means, they are functioning as their own integrative case managers.
So how can we help foster integration? By beginning to have discussions about what our clinical contributions are in the area of population health. If we had the opportunity to make one significant professional, paradigmatic, relational or therapeutic contribution to global population health, what would that be? If our answer is ‘everything we do,’ and we insist on that being true for every patient we treat, then I believe we’ll end up marginalized (further) by the emergent system. If our answer is that we do several things exceptionally well and truly uniquely, then a role will emerge as the needs we claim to address come to be more widely understood. In chiropractic, we can’t point to wide acceptance and adoption of the concept, problems and challenges imposed by vertebral subluxation. We can make a case for being back and neck docs, but no one’s listening. But what might happen if we really focused on optimal neurologic function, and could point to the lessening of pathologic processes as a result?
If we all understood our central and peripheral contributions, it would become much easier to design a system that makes those contributions available, prioritizes them (read: customizes them) to individuals’ needs, supports them through outcome-based financial reward models, and does all this respecting the professional autonomy that is required for effective participation. In my opinion, this pluralistic model is where we have to go. Any profession that thinks in monopolistic or exclusionary terms is, in my view, doomed to failure. And perhaps extinction.
A great case in point of this is the issue of Northwestern having a nurse practitioner in one of its clinics. I happen to believe that NPs are amazing providers, rooted in the historical relational strengths of nursing and with a foot in science-based contributions to health. If anyone needs a service-based model for health care, we don’t need to look any further than nursing.
In fact, while at Northwestern we created an integrative clinic in collaboration with the Advanced Practice Nursing program at Metropolitan State. An NP was the clinic director; she operated under a physician’s license who never set foot in the clinic and whom we never saw; and with chiropractic, nursing, acupuncture and massage care we had a collaborative primary care delivery model for low-income populations. No one’s scope was compromised or impinged; no one’s autonomy or philosophy was excluded or even prioritized. Why was it integrative? Because we each made a focused clinical contribution to the needs of people who came in the door. Not everyone received every contribution; not everyone needed it. But the model was elastic enough to accommodate the diversity (customization) of needs.
So for me, whether or not a NP is in a clinic is immaterial. It’s more about the preparation, relationship connections, algorithms governing patient care and decision support, the degrees of evidence that we accept to inform clinical decisions and patient social contracts, outcomes measurements and an understanding of how to identify, track and acquire measurements of the variables that go into them. Oh…and communication might play a little role, too. In integration, there are no losers. Everyone wins. Especially the patient/consumer.
Whatever our orientation is to integrative health care, I strongly suggest that we as a profession need to begin to have just the conversation I point to earlier in this piece: beginning to define and seek consensus on what our focused contribution to population health might–should–must–be. It does not mean that we restrict ourselves to a single intervention; it doesn’t mean we subjugate ourselves to systemic limitations. It means we explore how best to meet the needs of those we serve. Because those we are serving are already shopping around. We just don’t know it.