Eastside, Westside: The Bridge toEastside, Westside: The Bridge to

IntegrativeIntegrative Health and HealingHealth and HealingPanelists will explore the variousPanelists will explore the various integrativeintegrative healthhealth and healing and healing practices at their health centers. practices at their health centers.

Steven Chen, M.D.Steven Chen, M.D.Family Physician, Asian Health Services Family Physician, Asian Health Services –– Oakland, CAOakland, CAUCSF UCSF OsherOsher Center Center BravewellBravewell Fellow at the University of Fellow at the University of Arizona Program in Integrative Medicine Arizona Program in Integrative Medicine

KauilaKauila Clark, M.F.A.Clark, M.F.A.Certified Traditional Native Hawaiian Practitioner and Certified Traditional Native Hawaiian Practitioner and Consultant, Waianae Coast Comprehensive Health Center Consultant, Waianae Coast Comprehensive Health Center --Waianae, HI Waianae, HI

Mark W. Frost, M.S., L.Ac., C.M.T.Mark W. Frost, M.S., L.Ac., C.M.T.Professor, American College of Traditional Chinese Medicine Professor, American College of Traditional Chinese Medicine ––San Francisco, CASan Francisco, CA

What is Complementary & What is Complementary & Alternative Medicine (CAM)?Alternative Medicine (CAM)?

National Center for Complementary and National Center for Complementary and Alternative Medicine (NCCAM) definition: Alternative Medicine (NCCAM) definition:

“Complementary and alternative medicine is a “Complementary and alternative medicine is a group of diverse medical and health care group of diverse medical and health care systems, practices, and products systems, practices, and products that are not that are not presently considered to be part of conventional presently considered to be part of conventional medicine.”medicine.”

What is Integrative Medicine?What is Integrative Medicine?University of Arizona Program in University of Arizona Program in Integrative Medicine definition:Integrative Medicine definition:

“Healing“Healing--oriented medicine that takes oriented medicine that takes account of the whole person (body, mind, account of the whole person (body, mind, and spirit), including all aspects of lifestyle. and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship It emphasizes the therapeutic relationship and and makes use of all appropriate makes use of all appropriate therapies, both conventional and therapies, both conventional and alternativealternative.”.”

Integrative Medicine at Integrative Medicine at Asian Health ServicesAsian Health Services

Steven Chen, MDSteven Chen, MD

Asian Health Services, Oakland, CaliforniaAsian Health Services, Oakland, CaliforniaUCSF UCSF OsherOsher Center Center BravewellBravewell Fellow at the Fellow at the

Program in Integrative Medicine, University of ArizonaProgram in Integrative Medicine, University of Arizona

Roadmap to Build IM at Roadmap to Build IM at CHCsCHCsContext: Asian Health Services (AHS)Context: Asian Health Services (AHS)

Why provide Integrative Medicine at AHS?Why provide Integrative Medicine at AHS?

How would IM services be delivered at AHS?How would IM services be delivered at AHS?

Four Potential Models of IM at AHSFour Potential Models of IM at AHS

Support Needed and Anticipated ExpendituresSupport Needed and Anticipated Expenditures

Asian Health Services at a glance…Asian Health Services at a glance…Community Health Center established in 1974 in Community Health Center established in 1974 in Oakland Chinatown, CaliforniaOakland Chinatown, California80,444 visits to 16,773 patients annually80,444 visits to 16,773 patients annually2005 Federal Poverty = $19,350 (family of four)2005 Federal Poverty = $19,350 (family of four)

Limited English ProficiencyLimited English ProficiencyVietnameseVietnameseLaotianLaotianCambodianCambodianTaiwaneseTaiwaneseMandarinMandarinCantoneseCantoneseShanghaineseShanghaineseToisaneseToisaneseKoreanKoreanTagologTagologMienMienChiu ZhouChiu Zhou

AHS Patient Insurance StatusAHS Patient Insurance Status

Why provide Integrative Medicine at AHS?Why provide Integrative Medicine at AHS?

1. Patient Demand1. Patient Demand

2. Enhanced Quality of Care2. Enhanced Quality of Care

3. Social Justice3. Social Justice

4. Provider and Staff Renewal4. Provider and Staff Renewal

5. Pipeline: Recruiting and Sustaining the Next 5. Pipeline: Recruiting and Sustaining the Next GenerationGeneration

Why provide Integrative Medicine at AHS?Why provide Integrative Medicine at AHS?

1. Patient Demand1. Patient Demand

“Extrapolations to the US population suggest a “Extrapolations to the US population suggest a 47.3% increase 47.3% increase in total visitsin total visits to alternative medicine practitionersto alternative medicine practitioners, from 427 , from 427 million in 1990 to million in 1990 to 629 million in 1997629 million in 1997, , thereby exceeding total thereby exceeding total visits to all US primary care physiciansvisits to all US primary care physicians.” .” (1)(1)

“Estimated expenditures“Estimated expenditures for alternative medicine professional for alternative medicine professional services increased 45.2% between 1990 and 1997 and were services increased 45.2% between 1990 and 1997 and were conservatively estimated at conservatively estimated at $21.2 billion$21.2 billion in 1997in 1997, with at least , with at least $12.2 billion paid out$12.2 billion paid out--ofof--pocket. pocket. This exceeds the 1997 outThis exceeds the 1997 out--ofof--pocket expenditures for all US hospitalizationspocket expenditures for all US hospitalizations..”” (1)(1)

“57% of older Chinese adults used one or more CAM services “57% of older Chinese adults used one or more CAM services despite having access to primary care servicedespite having access to primary care service.” .” (2)(2)

Cultural fit with patient explanatory models of health and disease

1.1. JAMA.JAMA. 1998 Nov 11;280(18):15691998 Nov 11;280(18):1569--75.75.2.2. Alex Li, Complementary and Alternative Medicine Use Among Older Alex Li, Complementary and Alternative Medicine Use Among Older Chinese Adults in San Francisco, 2005Chinese Adults in San Francisco, 2005

Why provide Integrative Medicine at AHS?Why provide Integrative Medicine at AHS?

2. Enhanced Quality of Care2. Enhanced Quality of Care

Patients prefer to get services from providers and clinics they Patients prefer to get services from providers and clinics they already already know and trustknow and trust

IM IM expands number of treatment optionsexpands number of treatment options offered offered (musculoskeletal conditions, asthma, rheumatoid arthritis, etc.)(musculoskeletal conditions, asthma, rheumatoid arthritis, etc.)

Research demonstrates qualityResearch demonstrates quality (GAIT trial for (GAIT trial for glucosamineglucosamine + + chondroitinchondroitin, acupuncture for osteoarthritis, Mindfulness Based , acupuncture for osteoarthritis, Mindfulness Based Stress Reduction programs, etc.)Stress Reduction programs, etc.)

Empiric experienceEmpiric experience of patients and cliniciansof patients and clinicians

Why provide Integrative Medicine at AHS?Why provide Integrative Medicine at AHS?

3. Social Justice3. Social Justice

“Integrative Medicine is for everyone, not just “Integrative Medicine is for everyone, not just the rich”the rich”

Patients have Patients have difficulty payingdifficulty paying for servicesfor services

Patients get Patients get limited coveragelimited coverage of services by of services by Medicaid (service limit = 2 acupuncture visits Medicaid (service limit = 2 acupuncture visits per month)per month)

Why? 4. Provider and Staff RenewalWhy? 4. Provider and Staff RenewalProvider and staff burn out from “hamster Provider and staff burn out from “hamster medicine” (Morrison and Smith, BMJ 2000)medicine” (Morrison and Smith, BMJ 2000)

Provider interest and skill building to develop Provider interest and skill building to develop expertise in IMexpertise in IM

Provider and staff selfProvider and staff self--care servicescare services

Why? 5. Pipeline: Recruiting and Why? 5. Pipeline: Recruiting and Sustaining the Next generationSustaining the Next generation

AHS as a model teaching site for advanced students, AHS as a model teaching site for advanced students, residents residents

Blend integrative medicine with social justice medicineBlend integrative medicine with social justice medicine

Develop cultural competency skills while working with Develop cultural competency skills while working with limited English proficient immigrants, refugees, lowlimited English proficient immigrants, refugees, low--income patientsincome patients

Cultural affirmation of healing systems of origin Cultural affirmation of healing systems of origin ((AyurvedicAyurvedic, , CuranderasCuranderas, Indigenous, Traditional Chinese , Indigenous, Traditional Chinese Medicine,etc.)Medicine,etc.)

How would Integrative Medicine How would Integrative Medicine services be delivered at AHS?services be delivered at AHS?

Delivery of IM services on 3 levels Delivery of IM services on 3 levels

PatientsPatients

StaffStaff

ProvidersProviders

Delivery of Delivery of Current IMCurrent IM services toservices toPATIENTSPATIENTS

EMDR EMDR (Eye Movement Desensitization and (Eye Movement Desensitization and Reprocessing) for Post Traumatic Stress Reprocessing) for Post Traumatic Stress Disorder, done by Social WorkerDisorder, done by Social Worker

NutritionNutrition counseling and group classes by counseling and group classes by Registered DieticianRegistered Dietician

Delivery of Delivery of NEW IMNEW IM services to services to PATIENTSPATIENTSAcupuncture PLUS Health/Advocacy Education (1/2 day of Acupuncture PLUS Health/Advocacy Education (1/2 day of clinic/week)clinic/week)

New patient visit = 15 min. intake + 15 min. needling + 30 min. New patient visit = 15 min. intake + 15 min. needling + 30 min. leave leave needles in patientneedles in patientFollow up visit = 15 min. + 30 min. leave needles in patientFollow up visit = 15 min. + 30 min. leave needles in patientHealth/Advocacy Education during 30 min. when needles in patientHealth/Advocacy Education during 30 min. when needles in patient33--4 rooms per provider4 rooms per provider

Osteopathic Manipulative Medicine (1/2 day of clinic/week)Osteopathic Manipulative Medicine (1/2 day of clinic/week)

New patient visit = 30 minutesNew patient visit = 30 minutesFollow up visit = 15 minutesFollow up visit = 15 minutes2 rooms per provider2 rooms per provider

Referral Directory to Acupuncturists/Osteopaths for complicated Referral Directory to Acupuncturists/Osteopaths for complicated casescases

Delivery of IM services to Delivery of IM services to STAFFSTAFF

SelfSelf--Care Services for staff:Care Services for staff:

ShaolinShaolin QiQi Gong class (weekly, after hours)Gong class (weekly, after hours)

Yoga class (weekly, after hours)Yoga class (weekly, after hours)

Massage (annually, during clinic hours)Massage (annually, during clinic hours)

Reiki treatments (in development)Reiki treatments (in development)

Delivery of IM services to Delivery of IM services to PROVIDERSPROVIDERS

InIn--Service Provider Training on:Service Provider Training on:

Nutrition, supplementsNutrition, supplements

Osteopathic Manipulative MedicineOsteopathic Manipulative Medicine

Acupuncture and Traditional Chinese Acupuncture and Traditional Chinese MedicineMedicine

4 Potential Models for 4 Potential Models for PROVIDERPROVIDERTrainingTraining

1. Provider “Mini1. Provider “Mini--Fellowship Model”Fellowship Model”

2. Student Model2. Student Model

3. Provider + Student Mixed Model3. Provider + Student Mixed Model

4. Allopathic + CAM Practitioner Model4. Allopathic + CAM Practitioner Model

1. Provider “Mini1. Provider “Mini--Fellowship” ModelFellowship” ModelMiniMini--fellowship: fellowship:

Interested providers will rotate under the guidance of Master Interested providers will rotate under the guidance of Master osteopath/acupuncturist (1/2 day per week)osteopath/acupuncturist (1/2 day per week)Providers will do intake of patientsProviders will do intake of patientsProviders will present patients to Master Practitioner and otherProviders will present patients to Master Practitioner and other providersprovidersProviders will do treatment with support of Master Practitioner Providers will do treatment with support of Master Practitioner as needed as needed

Advantages:Advantages:Based on successful model currently employed for AHS Procedure CBased on successful model currently employed for AHS Procedure CliniclinicIM services are FQHC Reimbursable services if provided by MDs, IM services are FQHC Reimbursable services if provided by MDs, DOsDOs, , PAsPAs, , NPs, NPs, RDsRDs, , LCSWsLCSWs, Dentists, DentistsSupports provider renewalSupports provider renewalIntensive mentoring between Master Practitioners and AHS provideIntensive mentoring between Master Practitioners and AHS providersrsProviders eventually able to incorporate modalities into regularProviders eventually able to incorporate modalities into regular primary care primary care clinic visits clinic visits

Challenges:Challenges:Primarily a physician model vs. collaborative model with other pPrimarily a physician model vs. collaborative model with other practitionersractitionersExpenditures for Master Practitioner’s timeExpenditures for Master Practitioner’s timeFewer services provided to patients due to fewer providers trainFewer services provided to patients due to fewer providers traineded

2. Student Model2. Student ModelIM services provided by students from acupuncture, osteopathic IM services provided by students from acupuncture, osteopathic schools. Students under guidance of Master teachers serving as schools. Students under guidance of Master teachers serving as interpretersinterpreters

Advantages:Advantages:Collaborative relationships with local schools, leveraging, and Collaborative relationships with local schools, leveraging, and sharing of sharing of resourcesresourcesPotential for more services/access to be provided (e.g. evening Potential for more services/access to be provided (e.g. evening clinics)clinics)Low cost (AHS provides training site/patients/interpreters; theyLow cost (AHS provides training site/patients/interpreters; they arrange arrange malpractice/preceptors/students)malpractice/preceptors/students)

Challenges:Challenges:Services not easily FQHC reimbursable unless through MDs, Services not easily FQHC reimbursable unless through MDs, DOsDOs, , PAsPAs, , NPs, NPs, RDsRDs, , LCSWsLCSWsSeparation & less communication between allopathic and CAMSeparation & less communication between allopathic and CAMSome patients may not want to be seen by studentsSome patients may not want to be seen by studentsSpace considerationsSpace considerations

3. Provider + Student Mixed Model3. Provider + Student Mixed ModelAHS providers work alongside students under guidance of Master AHS providers work alongside students under guidance of Master Practitioner. Practitioner.

Advantages:Advantages:Collaborative relationships with local schools, leveraging, and Collaborative relationships with local schools, leveraging, and sharing of sharing of resourcesresourcesLow cost (we provide training site/patients/interpreters; they aLow cost (we provide training site/patients/interpreters; they arrange rrange malpractice/preceptors/students)malpractice/preceptors/students)IM services are FQHC Reimbursable services if provided by MDs, IM services are FQHC Reimbursable services if provided by MDs, DOsDOs, , PAsPAs, NPs, , NPs, RDsRDs, , LCSWsLCSWs, Dentists, DentistsPotential for more services/access to be providedPotential for more services/access to be provided

Challenges:Challenges:Teaching to different cohorts of learners (physicians vs. studenTeaching to different cohorts of learners (physicians vs. students)ts)Less communication/separation between allopathic and CAMLess communication/separation between allopathic and CAMSome patients may not want to be seen by studentsSome patients may not want to be seen by studentsSpace considerationsSpace considerations

4. Allopathic + CAM Practitioner 4. Allopathic + CAM Practitioner ModelModel

CAM Practitioners and Allopathic providers work CAM Practitioners and Allopathic providers work together in same clinictogether in same clinic

AdvantagesAdvantagesCollaborative modelCollaborative modelOnOn--site fully trained CAM practitioner(s)site fully trained CAM practitioner(s)More patient services providedMore patient services provided

ChallengesChallengesServices not easily FQHC reimbursable unless Services not easily FQHC reimbursable unless through MDs, through MDs, DOsDOs, , PAsPAs, NPs, , NPs, RDsRDs, , LCSWsLCSWsCommunicating across different healing paradigms Communicating across different healing paradigms

What decision support is needed What decision support is needed for IM services?for IM services?

Leadership from the top (CEO, ED, Leadership from the top (CEO, ED, Medical Director)Medical Director)

Provider “champion(s)” for Integrative Provider “champion(s)” for Integrative MedicineMedicine

Fiscal team to “run the numbers”Fiscal team to “run the numbers”

What are the Anticipated What are the Anticipated Expenditures?Expenditures?

Master practitioner reimbursementMaster practitioner reimbursement

Training courses in Acupuncture and Osteopathic Manipulative MedTraining courses in Acupuncture and Osteopathic Manipulative Medicine icine for interested providersfor interested providers

Osteopathic Manipulative MedicineOsteopathic Manipulative MedicineSpecial exam tablesSpecial exam tables

Acupuncture PLUS Health/Advocacy EducationAcupuncture PLUS Health/Advocacy EducationNeedlesNeedlesElectroacupunctureElectroacupuncture equipmentequipmentEducation/advocacy materials (video, handouts, educators)Education/advocacy materials (video, handouts, educators)

StaffingStaffing

Malpractice coverage for providersMalpractice coverage for providers

Roadmap To Build IM at Roadmap To Build IM at CHCsCHCsContext: Asian Health Services (AHS)Context: Asian Health Services (AHS)

Why provide Integrative Medicine at AHS?Why provide Integrative Medicine at AHS?1. Patient Demand1. Patient Demand2. Enhanced Quality of Care2. Enhanced Quality of Care3. Social Justice3. Social Justice4. Provider/Staff Renewal4. Provider/Staff Renewal5. Pipeline for Next Generation5. Pipeline for Next Generation

How would IM services be delivered at AHS?How would IM services be delivered at AHS?Patients, Staff, ProvidersPatients, Staff, ProvidersAcupuncture + Osteopathic Manipulative MedicineAcupuncture + Osteopathic Manipulative Medicine

Four Potential Models of IM at AHSFour Potential Models of IM at AHS1. 1. MiniMini--Fellowship Provider ModelFellowship Provider Model2. Student Model2. Student Model3. Provider + Student Model3. Provider + Student Model4. Allopathic + CAM Model4. Allopathic + CAM Model

Support Needed and Anticipated ExpendituresSupport Needed and Anticipated Expenditures