Integrative Medicine for Vulnerable Populations: A Clinical Guide to Working with Chronic and Comorbid Medical Disease, Mental Illness, and Addiction

By Julia Hodgson, Kevin Moore, Trisha Acri and Glenn Jordan Treisman

This first-of-its-kind title addresses the failures of an often fragmented healthcare system in managing vulnerable patients with multiple, chronic, co-morbid conditions -- patients who are frequently unresponsive to the methods and approaches used to treat other patients with conditions that are less complicated. The book emphasizes a holistic evaluation to patient care that looks at the whole patient, providing comprehensive formulations that describe the interacting problems that afflict the patient, including elements that are barriers to effective treatment of active medical problems and barriers to recovery. The book begins by defining integrated care, discussing the types of patients who benefit from this approach and some of the models of care, including financing, barriers to acceptance, and advocacy for patients. The second section discusses the structural elements of integrated care, including the building of a team approach, issues of leadership, and role definition, as well as the authors’ experiences in overcoming some of the problems. In the remaining sections, the book discusses major complicating features of the patients seen in integrative care settings, including a description of the kinds of problems, a model for formulation of patient cases, and successful approaches to treatment of these problems. Finally, some of the real-world applications where integrative care provides better outcomes is covered, including in terms of addictions, medically complex patients, and chronic pain patients. Integrative Medicine for Vulnerable Populations - A Clinical Guide to Working with Chronic and Comorbid Medical Disease, Mental Illness, and Addiction is a major contribution to the clinical literature and will be of great interest to health care professionals, administrators, policy stakeholders, and even interested patients and patient advocates. 

• Language: English
• Publisher: Springer
• Release date: Nov 1, 2019
• ISBN: 9783030216115

Book preview

Part I

Foundational Concepts of Integrative Medicine

Terminology around integration is varied, using terms like integrated care, holistic care, integration, and, our preference, integrative medicine. These terms are interchangeable and, for the purpose of this text, we use the term integrative medicine to refer to this concept of bringing together medical and psychological care of a patient. Integrative medicine is a model of medical care in which all elements of healthcare are provided to the patient in a coordinated way that is based on a comprehensive evaluation, a shared diagnostic formulation, and a team-based treatment plan that is flexible, communicated to all of the caregivers, and open to revision as the treatment proceeds to illuminate more of the nature of the patient and their illness. The goal of integrative care is rehabilitative and focuses on improving functioning.

The Agency for Healthcare Research and Quality (AHRQ) has defined standards seen by professionals across this burgeoning field as the gold standard of integration of medical and behavioral health interventions. In their consensus document, the Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus, definitions and explorations of the concepts of integration are laid out in a foundational framework that guides our work. At its most basic, the Lexicon defines integrated care as:

A practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. [1]

The next few chapters are devoted to discussing the principles of integrative medicine, the target populations, different models of integration, and the mindset necessary to implement such a system of treating patients. Early training and setting up a cohesive and comprehensive team is an intentional and thoughtful process. Patients are at the center of a treatment program, but they must be surrounded by a cohesive and communicating team of providers who make every decision with their well-being in mind.

Reference

1. Peek CJ, The National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus, AHRQ Publication No.13-IP001-EF. Rockville: Agency for Healthcare Research and Quality; 2013. Available at: http://​integrationacade​my.​ahrq.​gov/​sites/​default/​files/​Lexicon.​pdf.

© Springer Nature Switzerland AG 2020

J. Hodgson et al.Integrative Medicine for Vulnerable Populationshttps://doi.org/10.1007/978-3-030-21611-5_1

1. Fundamental Concepts of Integrative Medicine

Julia Hodgson¹  , Kevin Moore²  , Trisha Acri²   and Glenn Jordan Treisman³

(1)

Sharon Hill, PA, USA

(2)

Philadelphia, PA, USA

(3)

Baltimore, MD, USA

Julia Hodgson (Corresponding author)

Kevin Moore

Trisha Acri

Keywords

High cost utilizerFractured medical careIntegrative medicineCoordinated careMind-brain dualityMind-body duality

Striving to provide the best possible clinical care requires active and thorough consideration of multiple diagnostic possibilities including the complex interplay between biological, psychological, and developmental processes. Integrated medical care requires that all providers caring for the patients have a common understanding of the problems, a common set of treatment goals, and access to the clinical plan for achieving those goals. To maximally care for people with chronic conditions, patients are best managed over many years by a multidisciplinary team with expertise in a variety of healthcare issues and the sophistication to address clinical, organizational, financial, and philosophical complexity. The most ambitious clinicians of every stripe have slowly been coalescing what these best practices look like over the past few decades. These best practices are variously named something along the lines of integrative/integrated medicine/healthcare or individualized/patient-centered care/medical home. There have now been more than 80 randomized clinical trials of integrative medicine versus standard of care, and every single trial shows the superiority of integrative medicine [1].

Because clinical phenomena need to be simplified in order to be quantified and clinical trials are measured by quantified scoring, randomized clinical trials underreport the curative effects of integrative medicine because they miss the clinical complexities best addressed by integrative medicine.

The current model for the provision of clinical care, despite the numerous problems, usually does deliver good care for singular problems. It has evolved over years to accommodate the numerous agendas of those who pay for care, those who need care, and those who deliver care. On the whole, the current healthcare model succeeds for conditions like broken bones, cholecystitis, pneumonia, strep throat, and the like. There are, however, a subgroup of patients with complex conditions that cross medical disciplines and exacerbate each other and sustain comorbidity and chronicity. This subpopulation of patients requires a different approach and may actually worsen with the traditional approach of medical care. They develop patterns of medical care utilization that do not result in improvement but often become costly and burdensome. The reaction of medical administrators to the remarkable waste of resources expended uselessly on these patients has been to try to limit access. This effort is misdirected and further compounds the problem. The first step in the care of this subgroup of patients is to acknowledge that they are sick and not just difficult, and the second step is to develop a better model of care for them. The target for our approach is to provide effective care for these patients, improving their quality of life and function and decreasing the cost of caring for them overall.

For the purpose of this book, integrative medicine is defined as a patient-centered, multidisciplinary approach to diagnosis, comprehensive treatment planning, and coordination of care delivery. The role of the treatment team in this model is complex; it includes expert evaluation and treatment prescription as well as clear communication with the patient and the agencies involved, advocacy, and ongoing efforts to develop a more comprehensive understanding of the case.

Goals of Integrative Medicine

Medical practice boils down to trying to accomplish three goals for its patients: function, quality of life, and longevity. This book will expand upon methodology, interventions, complex conceptualizations, and other techniques that make up integrative medicine. However, all practice ultimately comes back to these three goals.

In order to take care of their health concerns, patients need to be able to function in their lives. This means that patients must make appointments, navigate insurance and finances, juggle medications, and handle everything else that they might need to do to manage their health. Independence is the maximum state of health, but rehabilitation means helping people where they are at and helping motivate them to do incrementally more than they had previously done. When what needs to be done is more than the patient can handle, the team deploys resources to maximize the patient’s quality of life and function. An integrative medicine team is a civil society’s best service to provide for the vulnerable and underserved. Typically, patients will neglect needed healthcare because of a lack of the resources needed to attend or pay for visits with providers. Untreated dental cavities lead to increased inflammation which leads to increased coronary artery disease which leads to heart attacks, coronary artery stents, and coronary artery bypass surgery. Ignoring a problem exacerbates it and complicates it, leading to even higher costs and demands for service in the long run. Patients who are able to have their concerns treated when they attend the doctor are more successful in committing to and maintaining a healthy lifestyle; these visits are rewarding and positive overall. The experience that many vulnerable and complex patients encounter, one of frustration and compounding concerns with each doctor’s visit and insurance bill, feel punished by the healthcare system and are less motivated to commit to their health. Making interactions with the healthcare system rewarding rather than aversive encourages patients to adhere to treatment and maintain significant relationships with their providers, thus maintaining their ability to receive care and better their quality of life.

Integrative medicine teams focus on functioning in patients’ lives because this is what leads to the behaviors and the adherence to medical care that ultimately increases quality of life. A person whose pain is under control, whose depression is subsiding, and whose hepatitis C is being cured will not only be healthier, but he/she will feel better too. Without the looming presence of these sorts of conditions, patients are more able to engage in other aspects of their lives, like work, volunteering, and school as well as building up relationships with their partners, children, and other social supports. The integrative medicine team is able to intervene in a way that alleviates some of the burden and allows the patient to build up a meaningful life for themselves.

One of the goals of this model is long-term intervention and sustained care; integrative medicine patients are cared for continuously, consistently, and long-term. Unlike care where the panel of doctors caring for patients is constantly changing and therefore patients face a new doctor frequently, the collaborative and coordinated nature of integrative medicine allows the patient to be protected from losing their treatment if there are changes in providers within the team. Because there are still multiple members of the team who will know the patient, care is ongoing and able to shift more seamlessly when staffing changes occur. Furthermore, because the team is treating the patient holistically, the same team will manage changes or concerns as they arise instead of the patient bouncing from specialist to specialist to attempt to receive care. In this way, integrative medicine is uniquely able to provide long-term consistent care for patients, despite what ailments may arise.

The patient in an integrative medicine practice not only increases their functioning and quality of life but is able to do so in a sustained and long-term way with continuous and consistent care by the entire team.

Who Needs Integrative Medicine?

Most patients do well with the current medical system which has evolved to be successful in most cases. During an attack of appendicitis, a patient comes to the emergency department, gets a diagnosis, is admitted, has surgery, and goes home. The system selects the most appropriate plan for the patient through a series of gated triage steps, and single problems require little coordinated input from more than one discipline. Many people are able to navigate going to separate doctors, therapists, and specialists for annual checkups and follow-ups and to handle simple problems or maintenance. These patients are not the targets of integrative medicine. The targets of integrative medicine are more complicated; they are the sliver of the population that have chronic and comorbid conditions. The ideal candidates for integrative medicine are those with some combination, two out of three at least, of complex medical, psychological, and addiction issues.

A different patient might come to the emergency room with a complaint of abdominal pain but also be addicted to opioids and in withdrawal; for this patient, the appendicitis might get missed or the addiction might not get addressed. Each additional level of comorbidity increases the need for a coordinated approach that involves complicated decision-making. Increased complexity requires more communication between different types of clinicians. The target population of integrative medicine is those patients with severe, chronic, and complex health problems; not only are these the patients who need the most support from coordinating providers, but they also need the most help navigating the healthcare system.

The more the patient’s comorbidities differ in kind, such as behavioral problems, mental illness, psychological issues, and medical issues, the more integrated medicine is needed. Most patients with coexisting hypertension and diabetes can get these problems addressed in the usual medical setting. The explanations are disease-oriented and the treatments are medication. Add in obesity and the importance of behavior change becomes critical. This complexity moves treatment beyond the realm of medication-based treatment and requires input from behavioral health, psychology, and/or social work. The addition of psychological evaluations, behavioral interventions, and mapping the course of therapy for comorbidity requires a team of communicating clinicians for success.

Patients may not understand or accept the need for the disciplines beyond the traditional medical doctor giving them a pill, and this confusion on the part of the patient leads to resistance against more effective interventions and, consequently, to poorer outcomes. However, consider the difference between integrative medicine and specialty referral care in the treatment of a patient with chronic back pain. A neurologist managing a patient with chronic back pain might obtain an MRI, increase the patient’s pain medications, and refer the patient to a surgical specialist; this could provide some information or temporary relief, but is a very narrow view of what might be going on for this patient. In contrast, as long as there are no serious signs or radiologic findings indicating need for urgent surgical intervention, a primary care physician and a psychologist in an integrative medicine team might be able to discern that the patient has had increased stresses in her home life, as well as depression and anxiety that make the pain less manageable. Psychotherapy, physical therapy, and a home exercise program might lead the patient to decrease his/her use of pain medication and improve his/her quality of life. Often, the patients who most need and benefit from integrated care are those in need of psychological and behavioral interventions in addition to medical care.

Super-Utilizers and Fractured Healthcare

Chronic health conditions create organizational confusion due to the variety of clinical needs and the demands of the health insurance and healthcare referral systems. As any cancer patient can explain, attending multiple appointments and taking multiple medications can tax the most diligent planner. After correct diagnoses are established, typically multiple interventions are recommended by the treatment team and are most effective when engaged in concert. While patient responsibility and adherence is always paramount, even the patient who is well versed in the medical system often requires assistance navigating diverse healthcare systems. If you have ever attempted to read the fine print of a health insurance plan, it comes as no surprise that attempting to understand and attain insurance benefits causes great confusion to most people. Imagine trying to navigate this while simultaneously managing chronic and comorbid conditions, like an opioid addiction and a recent prostate cancer diagnosis; these are the patients who need the sophisticated level of support that integrative medicine can provide.

An analysis of the distribution of healthcare resources in the United States reveals that the majority of the population uses a relatively small amount of the funding allocated every year. However, there is a small group of people (referred to as super-utilizers, high-utilizers, chronics, problem patients) whose medical, psychological, and addiction problems end up using a large share of healthcare costs in the United States. For example, in 2013, Medicaid covered about $440 billion of expenditures in healthcare; about half of this spending could be attributed to the 5% of individuals with the highest costs [2]. Similarly, the National Institute for Health Care Management (2012) reports that the top 1% of utilizers of healthcare accounted for over 20% of spending in 2014 and the top 5% accounted for half of spending in healthcare (see Fig. 1.1) [3]. Other data from the National Institute for Health Care Management break down expenses by the average cost per person in 2014 (see Fig. 1.2); as can be seen, the top 1% of healthcare utilizers cost a mean of about $107,000 per person annually. The top 50% of healthcare users averaged about $9000 per person, while the bottom 50% averaged $264 per person [3].

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Figure 1-1.

Healthcare spending is highly concentrated among a small portion of the US non-institutionalized population [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://​www.​nihcm.​org/​topics/​cost-quality/​concentration-of-us-health-care-spending)

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Figure 1-2.

Mean spending per person varies dramatically across spending groups [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://​www.​nihcm.​org/​topics/​cost-quality/​concentration-of-us-health-care-spending)

Because healthcare interventions are often limited in their effectiveness, these same patients return time and time again to emergency rooms, new doctors, and endless specialists to try to resolve their problems. The more chronic conditions a person is diagnosed with, the more often they end up in the hospital [4]. Many of these people are not getting better. In fact, Jiang et al. (2015) found that readmission rates to hospitals are four to eight times higher for super-utilizers than other patients within a 30-day period, totaling over half of all readmissions in that period [4]. It is important to note that while chronic conditions are a trademark of super-utilizers, acute conditions like pneumonia and urinary tract infections are often in the top conditions being treated in this subset of patients [4]. Overall, super-utilizers are significantly more likely to report poor health (see Fig. 1.3).

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Figure 1-3.

Highest spenders are much more likely to report being in worse health [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://​www.​nihcm.​org/​topics/​cost-quality/​concentration-of-us-health-care-spending)

Mood disorders and addiction are among the top diagnoses facing super-utilizers [4]. Addiction alone causes a significant increase in the number of emergency room visits—both by patients seeking drugs and to deal with the increased medical problems that arise from chronic use. Add in chronic medical conditions like hepatitis C or HIV, or suicidality linked to depression, and the number of hospitalizations, medications, and doctors’ visits multiplies. Especially when patients must visit numerous specialists or doctors for each aspect of their complex conditions, the costs pile up. However, the patient who is able to visit one integrative medicine practice to simultaneously deal with their depression, suicidality, HIV, and addiction has fewer medical visits each year and gets better more consistently, resulting in fewer hospitalizations and fewer resources needed. For these patients, integrative medicine is more cost-effective for the healthcare system in the long run and, in addition, brings about better outcomes (see Figs. 1.4 and 1.5).

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Figure 1-4.

Inpatient care drives high spending, but highest spenders spend more on all types of care [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://​www.​nihcm.​org/​topics/​cost-quality/​concentration-of-us-health-care-spending)

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Figure 1-5.

Care for highest spenders dominated by inpatient services, prescription drugs, and outpatient and ED care [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://​www.​nihcm.​org/​topics/​cost-quality/​concentration-of-us-health-care-spending)

Philosophical Barriers: The Problem with Mind-Body Dualities

There are legions of philosophical barriers to successfully practicing integrative medicine. One of them is mind-body duality. The belief that the mind and body are different or separate is a widely criticized fallacy. Almost no one would dispute the idea that the mind influences the body and the body influences the mind. Yet, even the most holistic practitioner has to resist the constant urge to attribute physical symptoms to a physical cause and mental symptoms to a mental cause.

A stark example of the interaction between mind and body is in Charles Bonnet syndrome. Charles Bonnet syndrome is a medical condition related to changes found in visually impaired people, especially in older patients, which causes complex visual hallucinations, usually silent and often amusing [5]. An example of this condition is a patient reporting seeing tiny cartoon people walking up and down the walls which they may or may not know are hallucinations. Despite knowing that these little people are not real, the experiences of the hallucinations are very real to the person; the brain thinks that they are seeing these images in front of them. Hallucinations from Charles Bonnet syndrome are usually related to macular degeneration in the eye and a misinterpretation by the brain of sensory noise from the decaying retina. However, they are not the same as hallucinations caused by psychotic disorders which have a different etiology. This distinction is difficult for patients and physicians to recognize. Patients will often not report these hallucinations because of the fear they have regarding having a mental illness or the stigma that might be associated with admitting they have visual hallucinations [5]. Furthermore, medical physicians may not be aware of Charles Bonnet syndrome , or they may fall in the trap of the common assumption that all seemingly mental symptoms have a mental cause. Yet, this well-documented syndrome proves that the mind and body are not so simple.

A much less dramatic example, yet significantly more common, is the impact of stress on both physical and mental symptomatology in patients. Stress is described as the response to threat or demand and is a part of all normal life. In patients with different histories, intense stress may occur in response to mild threats or demands, and mild stress may occur in the face of intense threats or demands. Stress is a common cause of worry, fear, and fatigue in the patients that we see. When life is overwhelming or negative events or thoughts are looming, it is unsurprising that people are distracted and less able to focus on other aspects of their lives. However, stress impacts more than just the psychological. When we are stressed, our sympathetic nervous system within the autonomic nervous system is activated; this is the part of the body that evolved to protect us in times of grave danger. Commonly called the fight or flight instinct, our body reacts to alarming situations by giving us a burst of energy to fight external threats; back in the days when our early ancestors were living in the wilderness, these bursts were vital for surviving when a bear or a lion was chasing them. Heart rate, breathing, muscle tension, metabolism, and blood pressure increase, vision and hearing become sharper, and hormones like adrenaline are released to facilitate this survival reflex [6]. In the process, other internal systems, like our immune system, may be inhibited or disordered. In short bursts, and in the face of a threat like a bear, these fight or flight body reactions are incredibly important. However, modern humans continue to have these reactions not just when our lives are in danger, but when we are nervous about a test or are driving during a snowstorm. Again, short bursts of sympathetic arousal can be useful in helping us to manage taxing situations; after the situation goes away, our body functioning returns