Project for Integrative Health and the Triple Aim (PIHTA) - Examples in Practice
Integrative Patient-Centered Medical Homes, Key Findings
The Academic Collaborative for Integrative Health through the Project for Integrative Health and the Triple Aim (PIHTA) conducted a three-part series focusing on naturopathic doctors serving as primary care providers in integrative patient centered medical homes (PCMHs). The convergence of “values-based medicine” under the Affordable Care Act and the rise of integrative health and medicine have increased opportunities for integrative health providers. Naturopathic doctors are modeling these new forms of care. This project, sponsored by the North American Board of Naturopathic Examiners (NABNE) and Visual Outcomes, is intended to create a series of resources for all stakeholders in understanding these contributions of naturopathic doctors.
The project has 3 significant purposes: 1) educate members of the naturopathic profession to these roles for naturopathic physicians; 2) provide guidance for naturopathic doctors who wish to pursue a professional role in a PCMH or Federally Qualified Health Center (FQHC); and, 3) most importantly, substantially increase awareness that naturopathic physicians have significant roles to play as leaders, and as part of teams, in meeting the nation’s primary care needs. Profiles on three separate clinics in Vermont and Oregon have been designed for clinicians, educators, administrators, and other stakeholders to better understand the skills and behaviors needed to successfully work in medical home environments. Each individual clinic profile offers tips, strategies and is based on its own unique context. While many lessons are contained within these in-depth profiles, this summary distills some of the key findings and themes that emerged across all cases.
1) Naturopathic medicine is patient-centered primary care
Naturopathic medicine places patients at the center of care, provides individualized approaches to treatment, and uses non-invasive and preventative therapeutic methods. The components of PCMHs are closely aligned with the values of integrative health and medicine because they represent a comprehensive, collaborative, team-based approach to care while focusing on accessibility and coordinated services.
2) Naturopathic participation in a PCMH expands availability of services to diverse patient populations
Naturopathic doctors participating in PCMHs demonstrate that integrative care is affordable and accessible to diverse patient populations. By increasing access to care for low-income patients with a variety of chronic conditions, naturopathic doctors serving in these primary care roles routinely treat underserved populations thereby dispelling the myth that integrative medicine is for the affluent.
3) Integrative PCMHs exhibit many traits and behaviors associated with interprofessional collaboration
Interprofessional communication is a signature feature in integrative PCMHs and is evidenced by open lines of communication among providers to lessen confusion for patients being seen by multiple providers. The structure of PCMHs requires providers to work with individuals of other professions to maintain a climate of mutual respect and shared values. The inclusion of integrative providers as well as community health teams highlights PCMH clinics’ commitment to interprofessional practice. Lastly, team-based strategies for managing patient populations involves a significant amount of collaboration to ensure that care is safe, timely, efficient, effective and equitable.
4) A team based environment enhances patient experience
The PCMH team-based environment leads to better patient care, satisfaction and outcomes. Because integrative PCMHs rely on the skills of different types of providers, patients have access to a wide range of services that support and extend primary care. As examples: integrative health coaches educate patients on special diets prescribed by their primary care provider;, social workers help connect patients to other services to combat some of the social and cultural barriers to health;, and acupuncturists work with patients manage chronic pain. With access to many onsite specialists and services, integrative PCMHs offer convenient and comprehensive care to patients.
Patient experience is also enhanced by group activities that support and reinforce a commitment to team work. Holding regular staff meetings to discuss complicated patients, clinic policies, quality measures, or emergent opens the lines of communication among providers and ensures that patients are receiving superior care. Peer-based strategies for assessing population health metrics creates transparency in quality and safety aspects of care within the PCMH model.
5) MYTH - Naturopathic doctors are not able to Implement care that is consistent with their values within a PCMH environment
Because of the many organizational and bureaucratic rules associated with PCMH membership, many assume that the PCMH structure would restrict how naturopathic doctors deliver care. The PCMH structure in fact supports naturopathic doctors’ decisions to implement care that is consistent with their values. There is a great deal of flexibility and choice regarding the selection of quality measures to track, but also how to manage patients. Naturopathic doctors can remain true to the values and practices of naturopathic medicine while working within a PCMH environment.
6) Patient satisfaction and evaluative measures
PCMH clinics regularly utilize a variety of strategies to gauge patient satisfaction and to evaluate patient experience. Some clinics participate in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to rate patients’ health care experiences, while others launch their own surveys to elicit feedback on patient satisfaction. Informal qualitative methods are sometimes used to elicit positive and/or negative feedback from patients onsite which enables the clinic to improve specific processes or systems.
7) Experience with institutional healthcare culture and practice facilitates the transition to a PCMH environment.
Clinics in transition often benefit from staff members and clinicians who have prior work experience in conventional clinics or hospitals. PCMH clinics can take advantage of this expertise by applying the best practices found in these settings. Having a background or training in conventional medicine helps to develop or enhance systems and processes in existing or evolving PCMHs. For example, hiring staff who can serve in multiple roles (nurse and panel manager, site specialist and data specialist, acupuncturist and IT) builds bridges and in roads between conventional and integrative healthcare.
8) Due diligence and planning facilitates the process of becoming a PCMH
Clinics considering whether to become a PCMH may benefit from some of the lessons learned by the integrative clinics profiled in this study. Prepping staff well in advance and creating organizational scaffolding facilitates the transition to a becoming a PCMH. Setting expectations early on for both clients and staff helps foster a culture that embraces accountability. Becoming a PCMH introduces a number of changes to daily operations, and as result, most clinics need to reconfigure existing staff or hire new support to cover the roles and responsibilities associated with PCMH membership. It is also helpful to anticipate changes with patient composition. Some clinics saw an influx of patients with acute and/or chronic conditions representing a departure from the types of patients typically seen in practice.
9) Expect challenges using Electronic Health Record Systems (EHRs) and tracking data
Clinics transitioning to a PCMH model should expect challenges with EHRs since most systems are not designed to capture or report data that is useful, or easily mined, for integrative clinics. Most often, the EHRS that are available to clinics are incongruent or incompatible with integrative practice, so data managers often need to perform their own manipulations to produce data that is useful and relevant.
10) Professional development
Naturopathic doctors profiled in the 3 individual case reports expressed a desire to receive more education and training in billing, coding and insurance procedures and also felt a need to gain more experience working with data and quality measures. Clinicians stressed the importance of making residency programs more available to graduates and identified a need for more experience with acute patients.
11) Strategic Partnerships with state and local organizations support the development of PCMH clinics
Strategic partnerships with local and state organizations can provide financial resources to PCMH clinics. In one case, a collaborative grant from Oregon Health Authority improved access to care, and provided consultants and coaches to facilitate monthly trainings and onsite learning collaboratives to learn from other clinics' best practices. Another clinic received financial support from CareOregon which enabled the clinic to launch a number of strategies to enhance patient experience. The Vermont Blueprint for Health funds the creation of Community Health Teams provide additional services and reinforce doctors’ treatment plans.
Beyond financial support, strategic partnerships may also assist with patient satisfactions surveys, conduct research on cost-effectiveness and patient outcomes, and provide resources and trainings to help with PCMH organization and management. Strategic partnerships also help clinics with panel management and sometimes assist with data collection processes and procedures. Overall, these partnerships expand a clinic’s organizational capacity to effectively manage membership in a medical home.
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