Knutson, Lori BSN, RN, HN-BC; Johnson, Pamela Jo MPH, PhD; Sidebottom, Abbey MPH; Fyfe-Johnson, Amber ND
The use and awareness of complementary and alternative medicine (CAM) is growing among the general public and in hospital settings. The percentage of hospitals offering CAM services more than doubled from 7.9% in 1998 to 19.8% in 2006.1 This growth likely reflects the increased use of CAM by the general public, with 38% of adults reporting some CAM use in the past year2 and an even higher prevalence of personal CAM use by those who work in the healthcare industry.3 Hospitals report that patient demand was a major factor in the decision to provide specific CAM therapies.4 Simultaneously, the perceived clinical effectiveness of these programs also appears to be growing.1 As hospital leaders react to these changing perspectives about CAM, respond to increased patient demand, and try to differentiate their organizations in the healthcare market, the integration of CAM therapies in hospital settings will likely grow.4
With the trend toward offering and integrating CAM therapies in conventional medical care settings, there have been attempts to conceptualize this new paradigm. Several terms are currently used to describe this practice, such as integrative medicine, integrated medicine, or integrative health (IH). However, there is debate as to the most appropriate terminology and how it should be defined.5,6 We acknowledge this ongoing debate and recognize that although the term CAM is likely most familiar, our program has successfully integrated the use of CAM therapies provided by IH practitioners in the hospital setting. Throughout this article, we will refer to our program as IH services, our providers as IH practitioners, and the services provided as IH therapies.
Several researchers have articulated conceptual models of IH,7-9 but little has been published to guide the growing use of these therapies in a real-world hospital-based setting.10,11 This article addresses that gap by describing 1 nursing-led model for the integration of CAM services in an inpatient setting resulting in a program of IH.
Abbott Northwestern (ANW) Hospital, the largest hospital in the Minneapolis-St Paul metropolitan area, began providing CAM services to inpatients through a formal program in 2003 when the Institute for Health and Healing (IHH) was established. In the intervening years, this program has become one of the largest inpatient integrative healthcare programs in the country. The growth of our program occurred in a large integrated healthcare delivery system. As such, the IH program has consistently supported and aligned with the system’s overall strategic goals, organizational efforts to achieve the Institute for Healthcare Improvement’s triple aim,12 and goals to achieve meaningful use of health information technology. For example, the IH program supports the system to address pain management aligned with The Joint Commission standards13 and patient experience that is tied to Medicare hospital reimbursement.14
The purposes of this article were to describe the (a) development and growth of an IH program in 1 hospital, sharing lessons learned on the integration of CAM services in an acute care setting, (b) current IH service delivery system for inpatients, and (c) characteristics of typical patients who are referred for and receive IH services.
Development and Growth of a Hospital-Based Integrative Healthcare Program
Rationale for the Creation
Abbott Northwestern Hospital is a 629-bed tertiary-care facility in the Midwest. The hospital has a variety of specialty institutions including the Virginia Piper Cancer Institute, Minneapolis Heart Institute, Sister Kenny Rehabilitation, and the Spine Institute. Before ANW’s inpatient IH program, the hospital had pockets of CAM services provided in several specialty areas, but these were primarily outpatient. At the time of the inpatient IH program conception, ANW had new leadership focused on creating an optimal healing environment, which included integrative medicine. The hospital had a relationship with a philanthropic family interested in supporting the healing environment focus. Awareness of existing CAM programs, general interest in creating and fostering an optimal healing environment, and the availability of financial resources converged to create a culture of readiness.
Development and Implementation
In 2002, a planning process was initiated to develop an inpatient IH program. Needs assessment activities were conducted to gather input from patients, nurses, and representatives of selected specialty areas (eg, orthopedics, cardiovascular, pharmacy). A chart audit of 181 patients admitted for surgical services in 2002 was conducted to examine responses to an intake question about previous use of complementary therapies. Of these, 102 patients (56%) had documentation of complementary therapy use. However, with no dedicated field to collect this information in the nursing intake form, documentation may have been underestimated. A survey of adults at admission to the hospital (n = 260) was conducted to assess self-care health practices. Overall, 32% of respondents reported using complementary therapies in the preceding 3 months, with the most commonly reported therapies being chiropractic (17%), massage therapy (14%), and acupuncture (5%). Surveys, focus groups, and key informant interviews were conducted with hospital staff to assess attitudes and knowledge about CAM therapies and gather input regarding which therapies could best be integrated in the acute care setting.
In 2003, the IHH was officially formed and began offering inpatient services. The institute was made possible because of a joint financial commitment of $2 million from the George Family Foundation and ANW Hospital committing to fund the program at $1 million per year for 5 years. In 2004, an additional $2 million was donated by the Ted and Dr. Roberta Mann Foundation. As a result of demonstrated improvement in pain management and patient experience scores, hospital leadership committed another 5 years of funding. In 2008, the IHH was renamed the Penny George Institute for Health and Healing (PGIHH). Sustainability is dependent on the ongoing relationship between IH leadership, hospital administration, and philanthropic partners.
The model for delivering IH services was developed using a nursing framework and based on a belief that nursing was fundamental to bridging conventional medicine paradigms and the CAM world. The 1st employee was a board-certified holistic nurse (HN-BC) as the lead of the triad team model, which is also the current model. Triads comprise an IH nurse clinician, a massage therapist, and an acupuncturist. Although practitioners may be trained and/or licensed in a specialty (eg, acupuncture, massage), all team members are called IH practitioners because they are all trained in a core curriculum (ie, guided imagery, acupressure, aromatherapy, Korean hand therapy, massage). Early in the IH program development, the IH nurse clinician—specialized in a clinical service area and HN-BC—was the central figure in the IH team. A key role of the IH nurse clinician was to model working in a hospital setting and in a care delivery team. By the end of 2005, there were 6 IH triad teams (all staff are ≥0.8 full-time equivalent), each devoted to a specific clinical area (ie, cardiovascular, oncology, medical/surgical, neurology/rehabilitation, orthopedics/spine, women care). Teams were also available to cross over clinical focus areas depending on demand. Organizing teams around focus areas facilitated better communication and patient care because IH team members built relationships with staff in specific clinical communities and developed an understanding of the unique needs of patients in those units.
Evolution of Hospital-Based Integrative Healthcare
The PGIHH inpatient program evolved in several key areas over the first 7 years of operation. Areas that experienced important refinements include the referral process, data collection, and nurse training.
Initially, referrals were based on calls to the IH office. In addition, IH practitioners pursued additional patient referrals by visiting nursing units and educating staff about IH therapies available and targeted symptoms. In 2005, the hospital implemented an electronic health record (EHR). With greater awareness of IH services and the ease of electronic referrals in the new EHR, demand for IH services began to outpace available resources. In addition, a review of the types of patients typically referred for IH services revealed that high-acuity patients with multiple complications were disproportionately referred. Many of these referrals were late in the patient’s stay and occurred after other treatments had failed to address symptoms. As a result, the program developed referral criteria and a process to screen and prioritize patients to be served. Current referral criteria include (a) patient able to participate in IH intervention, (b) patient concerns include pain, anxiety/stress, elimination problems, nausea/vomiting, insomnia, coping with change in health/well-being, or maintaining/prolonging a pregnancy, and (c) referral is made within 24 to 48 hours of hospital admission. Criterion C enabled IH practitioners to see patients multiple times before discharge.
Data Collection and Evaluation
Although delivery of inpatient IH services began in 2003, a comprehensive data collection system to track IH service delivery was not implemented until July 2004. An Access database was developed for IH practitioners to document patients served, types of IH therapies provided, and pre-post measures of pain, nausea, and other symptoms. The primary purpose of initial data collection was to demonstrate clinical outcomes. Equally important, however, was collecting data to guide operations, which included patient volume by specialty type and practitioner productivity. In 2005, when the hospital converted to an EHR for clinical documentation, the only IH components included in the new documentation system were a referral for IH services and an IH flowsheet. Because the flowsheet was primarily narrative, IH practitioners continued to use the Access database to document detailed IH service delivery. In mid-2009, a new IH flowsheet was implemented in the EHR to facilitate data extraction for reporting and research. This flowsheet was developed by IH practitioners and continues to be modified to meet both clinical documentation and outcomes research needs.
In 2004, the Minnesota Board of Nursing broadened the scope of practice to include use of CAM. Nurses were required to demonstrate competency to include CAM therapies in their practice. This change provided policy support for the PGIHH program to begin a nurse training program enabling hospital nurses outside the PGIHH team to incorporate CAM therapies into their nursing practice. Attempting to leverage the skills and positioning of the hospital nurses, the PGIHH conducted a survey of the nursing staff to better understand current knowledge, attitudes, and use of CAM therapies. Nurses were asked about both patient care and nurse self-care, as well as what therapies they saw as valid and feasible to integrate into their nursing practice.
In 2005, training for staff nurses began with in-service sessions on nursing units and half-day educational programs. By 2007, the transformative nurse training (TNT) program was implemented. This educational program provides an opportunity for nurses to transform their professional nursing practice by integrating IH therapies. During TNT training, participants learn techniques for relaxation, pain management, and stress reduction to use for self-care and for care of patients. The TNT program has been offered to nurses both locally (eg, ANW Hospital, Minneapolis and St Paul Children’s Hospitals, Mayo Clinic) and nationally (eg, Veterans Affairs hospitals in California). The training is 48 hours for ANW nurses and 32 hours for nurses from other hospitals. Developed and taught by IH nurse clinicians, the TNT is a unique educational offering grounded in holistic nursing philosophy, principles, and theory. It introduces participants to healing and belief systems, human energy systems, and traditional Oriental medicine. The TNT provides hands-on training in massage therapy, guided imagery, relaxation techniques, and aromatherapy. Credentialed practitioners provide instruction in their specific areas of expertise. After completion of the TNT series, newly trained ANW nurses establish a mentoring relationship with an IH nurse clinician. Mentors guide the participants as they identify opportunities for integrating their new skills into patient care routines. The need for additional trainers was identified, and that led to a TNT train-the-trainer program, which has been implemented in numerous local hospitals.
Figure, Supplemental Digital Content 1, http://links.lww.com/JONA/A176, shows the trends in unique patients served and total inpatient visits by IH practitioners through 2010. Data for 2004 represent only 6 months of data collection. From 2005 to 2010, the number of patients served increased by 55% and the number of visits provided increased by 35%. The average number of visits per patient ranged from a high of 3.4 in 2007 to a low of 2.9 in 2010. Clinical communities served were aggregated for reporting purposes based on the nursing unit from which the patient was discharged. The distribution of patients receiving IH services by clinical community from 2004 to 2010 includes 14% women’s care, 15% cardiovascular, 16% orthopedics/spine, 19% neurology/rehabilitation, and 36% medical/surgical/oncology. This distribution did not vary by more than a few percentage points for any area over the 6 years.
Current Service Delivery System
The PGIHH inpatient program employs a total of 21 IH practitioners. The IH practitioner staff consists of 6 registered nurses, board certified in a specialty area and in holistic nursing; 6 licensed Oriental medicine practitioners; 8 certified massage therapists with an emphasis on acute care massage; and 1 certified music therapist. Daily, 10 to 12 IH practitioners are available to provide services, and each will see 5 to 6 patients. The PGIHH maintains 50 to 60 ongoing referrals and receives 25 to 35 new referrals daily.
Integrative health practitioners assess and treat patients based on hospital-wide referrals. A request for an IH consult may be initiated by a physician, nurse, patient, or a patient’s family. A referral to the PGIHH inpatient office is entered into the EHR. The referral is reviewed and assessed by the IH team lead. All referrals are then reviewed by IH practitioners at team rounds. Referrals are triaged and assigned to practitioners based on urgency, patient need, practitioner availability, and practitioner specialty. The IH practitioner who assesses a new patient becomes the primary IH care coordinator for that patient until discharge. The care coordinator does not always provide the treatment but coordinates optimal care for the patient with other IH practitioners. Once all referrals have been assigned, practitioners review their assigned patients and prioritize visits. Priority depends on urgency of the request, patient condition, whether the patient is being discharged that day, the proximity of patients, and patient availability.
In preparation for the patient encounter, practitioners review the patient’s EHR and may consult with providers. If the patient is new, time is spent on education about IH services available. Practitioners discuss treatment options with the patient, explain specific treatments they are able to provide, and make recommendations for treatment during that session. Type of treatment is a shared clinical decision between the patient and the IH practitioner. At the initial visit, the treatment decision is based on a combination of the following factors: the initial referral request, IH practitioner’s assessment of the patient and the patient’s medical history, and patient preference. After the initial visit, a plan of care (POC) is established by the IH practitioner. The POC includes the types of therapy and the frequency of treatments. Because acupuncturists are licensed through the Minnesota Board of Medicine, acupuncture requires a physician order and a signed consent, which are recorded in the EHR.
Average IH treatment time is 25 minutes, not including assessment, intake, or education. Before beginning treatment, the IH practitioner asks the patient to verbally rate (on a scale of 0-10) his/her current levels of pain, anxiety, nausea, and well-being. At the completion of treatment, the IH practitioner asks the patient to rate pain, anxiety, nausea, and well-being as he/she did during the pretreatment assessment. In some cases, the patient is asleep after the treatment; therefore, ratings may not be obtained. If the patient is awake, the practitioner discusses additional treatment and/or discharge goals. Immediately after the session, IH practitioners document in the EHR the IH treatment provided and the prereatment/posttreatment ratings or the reason for not obtaining ratings.
Description of Inpatients Served by Integrative Healthcare Program
Figure 1 shows a 1-year snapshot of referral and receipt of IH therapies during hospitalizations at ANW Hospital. In 2010, there were 34608 inpatient admissions with a length of stay of at least 24 hours. Of these, 15% were referred to the IH program for therapies. Of those referred, 78% were seen by an IH practitioner and received a therapy. For those who were referred but did not have an IH practitioner visit, some were admitted over the weekend and had hospital stays that were too short, whereas others did not meet referral criteria. Patients who received IH services had, on average, 2.9 visits with IH practitioners during a hospitalization. On average, patients receive 1.8 different therapies during a typical IH practitioner visit, with the most common combination being aromatherapy and massage therapy.
Table 1 presents the descriptive characteristics of all hospitalizations lasting 24 hours or more by IH referral status (those referred and not referred) during 2010. Those with an IH referral were significantly more likely to be female, white, and privately insured than those without a referral. Hospitalizations with an IH referral had significantly longer length of stay, averaging 3.9 days longer than those not referred. Moreover, significantly more referred patients were classified as high severity based on Medicare Severity Diagnosis Related Group coding, with 49% categorized as major or extreme compared with 33% of nonreferred patients. In contrast to Table 1, which represents all hospitalizations, Table 2 presents the characteristics of unique patients referred for IH services during 2010 by whether they received IH services. Women were more likely to receive services than men were. No differences in IH services received were found by age or race. Those who received IH services had more hospital visits and referrals for IH services during the year.
The development of the PGIHH inpatient program began with planning efforts in 2002 and has grown to an integrated program serving around 3600 unique patients annually. In addition, through the TNT program, nurses learn to integrate IH therapies into their nursing practice so IH therapies can be delivered to a broader group of patients than those served solely by the PGIHH practitioners. Achieving the integrated program required a paradigm shift on the part of both medical providers and IH practitioners. Medical providers learned to incorporate IH services into the care of their patients. At the same time, IH practitioners learned to work as part of a multidisciplinary team and in the context of an inpatient setting. The holistic nurse-led model facilitated the relationship between conventional providers and IH practitioners, supported integration of IH practitioners into the acute care setting, and fostered referrals for integration of IH therapies.
Nurse administrators have an opportunity to optimize the healing environment and meet the challenges of an evolving healthcare landscape. Growing evidence for the efficacy of IH therapies and increasing consumer demand for these services means that IH has never been more relevant for the hospital setting. The PGIHH program flourishes because of the unique relationship between IH leadership, hospital administration, and philanthropic partners. Institutional buy-in is a key component in the development and successful growth of the program. However, critical to this success is the unique skill set of those who lead IH. Nurses approach patient care from a whole person perspective. The leadership required for the new field of IH must view healthcare from a whole person/whole systems perspective. Nurse administrators can play a critical role in setting the stage for success of IH in the hospital setting. This requires them to be conscious of the unique leadership approach required, a willingness to invest in the development of these leaders, and support for the cocreative process necessary to leverage IH for the transformation of hospital settings into optimal healing environments.
© 2013 Lippincott Williams & Wilkins, Inc.