Monday, December 5, 2011

13 steps to health

A whole person approach to wellness care:

1) Breathing

2) Sleep, rest, & relaxation

3) Mindfulness & Meditation

4) Prayer & spiritual connection

5) Proper Diet/Eating Hygiene

6) Exercise & Stretching & Bodywork/Massage

7) Self-understanding & Mental Health care

8) Faith, Hope, & Love

9) Feng Shui

10) Body-mind integration (Yoga, Qi-Gong)

11) Herbs, supplements, medications, and homeopathy

12) Holisitic Interventions (Acupuncture, Chiropractic, Energy Medicine)

13) Western Medical Interventions (Surgery)

Saturday, July 16, 2011

The Functional Spectrum of Wellness and Disease

Dr. Len Saputo, M.D. from his book A Return to Healing, has another great tool to asses health and wellness. The Functional Spectrum of Wellness and Disease

0% - 25% - 50% - 75% - 100%

When working with clients, the goal is to help clients move closer to 100%. Any increase in health toward 100% is success. Whether it it something small like reducing smoking from 3 packs to 2 packs, or something large like heart surgery, movement towards 100% is what healthcare and wellness care is about. Keep in mind, however, 100% is different for everyone. 100% for one person may appear as 25% for another. Anything below 50% is where symptoms begin to surface and functionality becomes impacted.

So what is the best way to move a patient towards ideal health? Dr. Len Saputo has also developed a hierarchy of treatment modalities.

1) Lifestyle strategies such as diet, sleep, exercise, stress reduction, weight control, reduction of toxic chemicals, balance, etc.

2) Noninvasive complementary and alternative (CAM) services such as acupuncture, herbal medicine, chiropractic, massage and bodywork, homeopathy, counseling, health coaches, and energy medicine.

3) Natural-medicine approaches such as orthomolecular medicine, functional medicine, bioenergetic research, and advanced testing.

4) Very careful and sparing use of pharmaceutical drugs, surgery and other invasive strategies as a last line of defense.

Seems to me to be a reasonable, cost-effective, patient empowering model of healthcare. It starts with prevention and self care, supplemented with trained medical professional help to encourage and promote the natural healing process. When prevention and support does not work, targeted testing and individualized medicine determines what is going wrong and what needs to be done to move the patient towards a more functional wellness. The use of pharmaceutical drugs, surgery, and advanced procedures in this context can then be used to finally tip the scales towards health and wellness when the disease or condition is unmanageable without further intervention.

Saturday, June 11, 2011

Healing Circles- A Novel Treatment and Diagnosis Method

Imagine you as a patient have searched for years, maybe even decades, for the answer to why you always feel unwell. You have gone from doctor to doctor, and have tried everything from medications to energy healing. Some things help temporarily. At best most things don't do anything and often new treatments make it worse. You have a few doctors or practitioners that you like and you go to see them somewhat regularly, but they certainly have no interest in coordinating your care. You simply see one for the pain, another for information, and another for a medication, and so on.

Dr. Len Saputo has developed a novel way of diagnosis called the Healing Circle. It brings together a team of 3-8 physicians and practitioners from different fields to sit down with a patient in a 2 hour session. The patient shares his/her history (medical, social, spiritual, emotional, etc) with the group and the group subsequently works together to find a treatment plan that is honest about what each field of medicine can and cannot do, is complementary to all healing practices involved, and supports the whole person.

The Healing Circle was developed and born out of more than 15 years of collaboration with the Health Medicine Forum and his subsequent integrative health practices in San Franscisco, CA.

Watch this video of a circle:

To learn more about Healing Circles, visit or you can read Dr. Saputo's many books, including A Return to Healing: Radical Health Care Reform and the Future of Medicine

Friday, May 27, 2011

Major Trends and Health Care Industry Outlook

The philosophy and substantive development of an Integrative Health Care model has been evolving over the past few decades. According to Clement Bezold in his article Evolving Demands and Demographics in Health Care, “90% of the variance in premature death in modern society is related to factors other than the lack of health care. Currently, the vast majority of morbidity and mortality is associated with lifestyle, genetic, and environmental factors.” According to the Center for Disease Control:

• 7 out of 10 deaths among Americans each year are from chronic diseases. Heart disease, cancer and stroke account for more than 50% of all deaths each year.
• In 2005, 133 million Americans – almost 1 out of every 2 adults – had at least one chronic illness.
• About one-fourth of people with chronic conditions have one or more daily activity limitations.

Many of these chronic diseases are preventable through simple diet, exercise, and healthy lifestyle choices. Clearly, there is a need for our health systems to shift from infection and acute and emergency trauma care towards medical and wellness care targeted at our 21st century health problems. While this does not call for an elimination of our evidence-based biomedical health care, it does call for an integration of biomedicine into health systems designed to address lifestyle modification and reduce environmental and genetic risk factors. According to the Institute of Medicine in their February 2009 Summary Report of Integrative Medicine and the Health of the Public, “the interactions between an individual’s social, economic, psychological, and physical environments, and his or her biological susceptibility to illness and responsiveness to treatment; the nature of the care process, as well as its content; and the often greater health benefit to be had from certain “lower tech” interventions, rather than more costly approaches” are part of a bigger picture needed to create this new health care system. Unfortunately, these factors are often overlooked in our current health care system, which are necessary when working with chronic and preventable disease. The tools needed to move our health care system towards one that addresses lifestyle, environment, and genetics and takes into account environmental factors, biological susceptibility and responsiveness, the care process, and lower tech inventions are already at our finger tips. We have the technology to detect early risk factors, know the best preventative measures and lifestyle interventions needed, have a rich array of health care practices and theories of medicine, and we understand the motivations and interventions need to modify human behavior on both an individual and community wide scale.

The factors needed to refocus our health systems, however, are at times in direct conflict with major trends in health care. In an effort to address them as quickly as possible, often the most effective answer is considered too difficult to achieve (for reasons such as finances or logistics) or is simply missed because the patient interactions with the environment, biological susceptibility and responsiveness, the care process, and “lower tech” interventions are not utilized in solution assessments. Trends in individualized medicine, for example, tends to focus on complex and expensive treatment plans, when often a patient just wants an extra few minutes with the doctor, or just wants the pain to stop which could potentially be managed more effectively with greater cost savings with a service such as acupuncture. Patient demand for maximum level of care, again, also trends towards complex and expensive treatments. Ultimately, a patient wants to be heard and wants the problem to be fixed, and without addressing the root cause and instead focusing on fixing the problem once it has become broken, medical costs and frustration with ineffective and/or slow treatment results become common when treatment and interventions don’t work immediately. Direct consumer advertising of health care interventions and treatment options is also driving up costs because patients are demanding these products and services advertised and providers are at times under pressure to utilize certain products and services. When both provider and patient are under pressure to utilize the same products and services, the result is treatments that may not be the most effective and may be more costly, especially since direct consumer advertising focuses on new innovations and technology which are inherently more expensive. Since current health care financing control is not driven by price and patients are often unaware of the costs of products and services, the trend in direct consumer advertising has few checks and balances. Comprehensive disease management, however, is fortunately a trend that integrative health excels at addressing and this, perhaps, is one of the biggest factors in the growth of integrative health care.

Integration of Complementary and Alternative Medicine is a critical aspect of creating an integrative health care facility; however, the integration of CAM into contemporary western medical facilities, as if they were a few extra silos in the bunch, is not a viable model. CAM is unique is its delivery of care because care encompasses diet and nutrition, spiritual connections, social support, and exercise, just the pieces needed to support this new health care model. The use of CAM modalities without comprehensive wellness and positive lifestyle factors makes these modalities limited. This limited use results in the exclusion of many of the primary reasons CAM is so popular in the first place, ie: patient empowerment and effective treatments from practitioners willing to take the time to listen to their patients. In inclusion of CAM into conventional medical systems often highlights a variety of additional strengths, such as it provides minimalist, non-invasive approaches to early-stage and chronic health conditions, which often confounds the medical industry in an effort to effectively treat without high costs. Many aspects of CAM also meet criteria for safety, efficacy and cost-effectiveness. In addition, CAM is useful in addressing many of the leading trends of healthcare in the United States. CAM, thus, can enter the health care scene as a way to fill in holes that an integrative health system that is focused on lifestyle interventions, environmental factors, and genetic/biological factors, without reinventing the wheel. Looking forward, integrating CAM into current health care systems, therefore, requires a reassessment of our current strengths and weaknesses as a system, and will seek to develop a model where CAM and Biomedicine are complementary. This kind of synthesis, fortunately, is flexible and adept at addressing the complexity of today’s healthcare and health care cost challenges.

Segmenting the Broader Health Care Industry

There are a variety of segments in the health care and wellness industry

Conventional Health Care Industry
• Health care financing
• Physician and Nurses services

Wellness Industry
• Complementary and Alternative health services
• Fitness
• Diet & nutrition

Support Industries
• Public education
• Professional education
• Research & technology innovation
• Institutional services (environmental services, security, design, management, ordering, etc)
• Input factors (natural resources & land, labor, and capital goods)

Health care financing through third party payers and the physician and nurses services that they finance are 18% of the United States GDP, which equals roughly $2.5 trillion dollars. The health care is growing due to a pending increase in health insurance coverage across the nation, population growth, and the aging of the population. Services tend to be clustered in urban and metropolitan areas with use primarily from insured individuals. 83% of the U.S. population is insured in some way. 59% of those insured under the age of 65 are employer insured and 19% under the age of 65 are insured through some sort of government sponsored program such as Medicare, Medicaid, or military health services. All individuals over the age of 65 are eligible for Medicare insurance. Most health services addresses chronic disease and according to the Centers of Disease Control and Prevention, it is estimated that health care costs for chronic disease treatment account for over 75% of national health expenditures. There is a high demand for quality service that is individualized and competition is plentiful. Services are primarily conducted in English and Spanish.

The size of the wellness industry is not as well known. In a 2007 report by the US Department of Health and Human Services, approximately $34 billion dollars was spent on Complementary and Alternative Health (CAM) care, which includes not only visits to CAM practitioners (only 1/3 of money spent) but also CAM products, classes, and materials. This equates to just over 11% of all out of pocket health expenses and to 1.5% of total health care expenditures in the United States. Like the health care industry, the wellness industry is clustered in urban and metropolitan areas but those who frequent these services tend to be wellness and fitness oriented, seeking preventative services, or suffering from chronic illness. According to the US Department of Commerce, nearly 1 in every 2 Americans has a chronic illness, so the wellness industry is certainly not limited to a small percentage of Americans. Based on the amount of growth over the past two decades, and projections for the demand of healthcare services, it is estimated that wellness services, especially CAM, is expected go grow at a fast pace over the next decade. The use of self-care practices has also been on the rise and growth is expected, as wellness and lifestyle interventions become a greater part of healthcare services.

Along with the growth of the health and wellness industries, the growth of support industries will also expand in order to accommodate and support the health and wellness industries. The need for more public education and better professional health care education will support the evolution of health systems towards comprehensive lifestyle interventions that encompass environmental and biological/genetic factors. Research and technological innovations will continue to drive health care practices, knowledge, and care. Currently, the United States spends approximately $100 billion on medical research alone and is not expected to decline. Technology innovations have always been a hallmark of American health systems, and that trend will not likely stop either. The need for institutional services, essentially, all the pieces of administration and business that keeps health organizations working, will also expand. As more health facilities are established to accommodate growing demands for health services, more people will be employed to design, manage, and upkeep the systems. More health services and facilities will also require more natural resources and land, labor, and capital resources.

Within the Conventional Care Industry, the continuum of care from cradle to grave encompasses 15+ different realms of medicine. These include:

1) Pre-natal care
2) Infant/neo-natal care
3) Pediatric
4) Adult care/primary care
5) Internal medicine
6) Specialists (ie: Oncologists, Urologists, Cardiologists, Endocrinologists, etc)
7) Critical Care & Emergency Care
8) Geriatrics
9) Long-term care
10) Mental Health
11) Behavioral Medicine
12) Environmental Medicine
13) Occupational medicine
14) Rehabilitation
15) Preventative Health (includes wellness care, self-care, and lifestyle management)

The wellness industry fits almost entirely into the last category. Support industries mirror the same set of realms of medicine.

The challenge of health care today is managing systems that streamline delivery of the entire continuum of care. 30 years ago, medicine went in the direction of institutionalized delivery of care. The entire industry became institutionalized. However, in the 80’s, the American health system entered into a transition phase attempting to demystify and deinstitutionalize health systems. This has produced a staggering array of delivery systems. To a large degree, we are still in this transition period trying to find effective delivery systems that address the complexity of health in American society. Some of these delivery methods are:

1) The “Medical Home” or “Health Home”
2) Integrative Health
3) Functional Medicine
4) Community Clinics & Satellite Hospitals
5) Conventional biomedical “silo system”
6) Home Health Care
7) Patient Centered

The diversity in Integrative Health systems, in part, is a result of Integrative Health combining different delivery systems together to produce new ideas and results.

Factors that Drive the Health Care Industry

The health care industry is the largest and easily the most complex industry in the United States. Every person at one point in their lives is touched by the system. Political factors, environmental and ecological issues, economics, social factors, and technology all play a huge role in the industry, often creating cycles of patterns or directing attention towards or away from trends and information.

Perhaps more than any other factor, and often the most overlooked, the environment and the ecological niches in which we live in have the biggest impact. Humans are more attuned to the rhythms of the earth than many of us would like to believe. Despite our modern society, these deep associations play a huge role. Weather patterns trigger cycles of aches and pains; the full moon guarantees the maternity ward will be packed solid; the seasons will cause the Emergency Department to code red because of influenza patients in the winter or injuries and accidents from kids breaking their arms and families in car accidents during their vacation in the summer. As drought and heat waves, ice storms and hurricanes sweep the nation each year, medical service crisis’s always follows. Beyond the natural environment, the ways in which we alter our environment are also challenging our health systems. Pollution chokes asthma patients and chemicals from pesticides and building materials wreak havoc on our bodies. Over-sterilization and over use of antibiotics are creating superbugs which make infection rates skyrocket. Hospitals and health systems are designed to operate at near capacity, which results in facilities that are chronically over-utilized and maxed out. Each day and week brings unpredictable challenges that simply cannot be ignored, even if our society is removed from the natural cycles of the earth.

Politics, on the other hand, is not so unpredictable; rather it is a constant battle that must be met. Legislation can change health systems and their futures of success or failure literally overnight once the dust settles after the long, hard fight. Federal legislation in particular can create and obliterate entire markets and professions. The 1996 HIPAA and 2010 Affordable Care Act both have had a deep effect on the nature of health systems. A large majority of large health facilities in the United States also participate in the Medicare system, which is constantly being reworked. Thus, health systems must always keep abreast of recent developments and plan extensively in order to ensure success of their businesses. Regulatory bodies and government policies on all levels of government, as well as the private sector, place significant limits on heath care too. Party politics and power struggles between the Republican and Democrats creates cyclical change in support of programs and funding. And an ever expanding number of lobby groups constantly work to keep things moving smoothly between government and the industry. Internationally, shifts in populations, immigration, global health epidemics, and terrorist threats all put a huge burden on the system.

Since health care in the United States is essentially big business, the economy impacts on health care can be both devastating and extremely profitable. Even though the United States health system is a reactionary system and largely removes choice when a patient is in need of services, when the economy is slow, health systems struggle to make ends meet. In hospitals, 80-90% of admissions come from the ER, so when the ER is low, hospital beds become empty. During a recession, for example, people travel less and thus have fewer car accidents. Sports funding also goes down and so fewer kids are getting sports injuries. Elective surgeries get put off and operations get delayed because patients cannot afford the co-pay. Sometimes people choose to travel to other countries for medical services instead because they are cheaper. Since most hospitals also get capital funding from endowments or bonds, both of which are interest based investments, equity can be severely impacted during recessions as well. The market also cycles with a constant new stream of drugs, research studies, and technologies. When it comes to distribution of services, there is a huge gap between wealthy communities and poor communities. Hospitals and clinics supported by insured and wealthy patients have more services, more doctors, and better equipment. The lack of insurance or quality insurance significantly impacts reimbursement rates for health systems, with the resulting cash flow problems significantly impacting services.

Societal trends are perhaps the most diverse and difficult to manage. American lifestyles are isolated, sedentary, fueled by a poor diet and lack of sleep, and are increasingly dependent upon mental energies rather than physical work. Combined, these factors put Americans at high risk for dozens of chronic diseases and mental and behavioral health challenges. As populations are aging, growing, and shifting, access to healthcare can be stressed because the services of the local health systems no longer fit the demographics of the area. Our society has a “fix it NOW” mentality and often has no time for wellness care, self care, or preventative care. Those who have chronic health conditions tax the system the most. Nearly 80% of health care resources are used to manage chronic health conditions, yet a vast number of Americans with chronic health conditions don’t even have health insurance and access to medical care. These patients not only tax the system, also rely on self-care and out-of-pocket services to manage their health. Preventative medicine, however, is opening new doors in choices about health care spending. Consumers who are insured tend to use primary care when they get sick. But those who are uninsured tend to wait until they are so sick that they need to go to the ER. Ethnic and religious factors can also impact service and care. Different cultures and ethnicities often have a different perspective and values on care and the course of treatment. Some cultures value large families, so in turn, when a family member ends up in over night care, accommodations for larger families must be made. Language barriers, companions, and interpreters can all complicate easy and speed of service. Religion, at times, can also create logistical nightmares when the need for kosher food, last rights, or specific protocols for handling the deceased for burial is at odds with normal protocol.

The media at times can also impact the system with constant updates of new studies, lawsuits, or stories of when something screwy happens, like a sponge is sewed into a patient. Fortunately, the media does not play as important of a role in health care decisions as other national issues because most people place a higher value on personal experience and opinions of family and friends. Despite this, most major health facilities will have a designated public information officer to play as intermediary with the press. Over the past few decades, health care has increasingly been branded. At one time, it was considered unethical to advertise health services. But with a change in laws, hospitals and major health facilities play off their strengths against competitors to increase revenues and retain patients. Hospitals have become highly competitive and heavily use billboards, radio and TV ads, and print media to get their message and brand image out. The increasing direct consumer advertising for medications and services further brings health decisions into the everyday lives of Americans. The increasing use of advertising, however, adds to healthcare costs, which requires an increase in patient volume, which means stronger pushes for consumer loyalty through advertising and branding.

Last, but not least, technology makes an impact on our health systems in many ways. Competing technology developments constantly produce innovations in drugs, treatments, equipment, design, and robotics. Despite intellectual property rights on drugs, treatments, and biological units like genes, which limits access, Health systems are under a lot of pressure to keep up with innovations. Ultimately, however, what makes the difference is not the innovation, but whether or not health facilities choose to embrace innovations. Those who do often see better outcomes in care and more accurate diagnosis which then leads to lower risk. It is often faster, more efficient, creates better access and communication, and precision. The replacement of technology, however, and the innovation of new solutions creates a chronic problem. How often do you upgrade? And at what point does it become a liability if you don’t? And sometimes, technology is too good. For example, imaging can now pick up micro cysts in breast tissue during mammograms that are part of the normal tissue and not necessarily a health risk. This begs the question, how early should intervention be when intervention itself may be more risky than the cyst that may or may not actually become a health risk? The actual technological innovations of healthcare are not the only technologies that affect the industry. There are a variety of technologies associated and dependent upon the health care industry, such as clinical information systems, imaging, and health billing and accounting operations. The recent and growing transition to electronic health files is somewhat “revolutionary” in the field. Many systems are struggling to make this transition. But, clinical info is critical to care and electronic records makes diagnosis and medical oversight easier and more efficient. As a benefit, electronic systems allow patients to access their own files on the internet or their doctors via a simple email.

Wednesday, May 25, 2011

Fields within Integrative Medicine

Integrative Medicine is a whole person approach to medicine that integrates conventional evidence-based medicine (ie: Western Medicine) with CAM. Integrative Medicine is the clinical application and integration of Integrative Health. The following are examples, but certainly not a complete list of therapies. Many can actually placed in more than one category.

Conventional Western Medicine

This type of medicine is what you will find when you go to your primary care physician or the Emergency Room at the hospital. It is sometimes called “Allopathic Medicine”, “Biomedicine” or “Evidence-Based Medicine”. The majority of the American Healthcare system is composed of this type of medical system. Doctors, nurses, and other healthcare providers diagnose and treat based on rigorous scientific evidence and utilize medications and surgery to address illness and disease. There are many specialties such as Cardiology, Dentistry, Oncology, Endocrinology, Infectious Disease, etc. This is a highly regulated field in all states and requires a high level of education to practice.

- Primary Care Physicians/Family Medicine
- Acute Care & Emergency Care
- Specialties (Oncology, Cardiology, etc)
- Hospice
- Laboratory & Imaging
- Surgery

Alternative Medical Systems

These alternative medical systems are built upon an independently complete system of theory and practice and can stand alone as an entire medical discipline. Many have a rich historical tradition that is thousands of years old and are considered pre-modern medical systems. They often incorporate aspects of manual medicine, energy medicine, natural medicine, and body-mind techniques. In most states, these alternative medical systems are highly regulated and require a high level of education to practice.

- Homeopathy (including Bach Flower Remedies)
- Naturopathy
- Traditional Chinese Medicine & Acupuncture

Manual Medicine/Bodywork

This is a part of the traditional CAM (Complementary and Alternative Medicine) field and is composed of several unique disciplines, but not entire medical systems. Manual Medicine is the practice of manual manipulation of the body. It encompasses some of the oldest medical traditions from around the world and in some cases predates many alternative medical systems such as TCM and Ayruveda. There are also many newer bodywork disciplines that have been incorporated into conventional evidence-based medical systems. This field is regulated in most states and requires moderate to high educational requirements to practice.

- Massage Therapy
- Chiropractic
- Applied Kinesiology
- Cranial Sacral

Energy Medicine

This is also is a part of CAM and incorporates many different disciplines. There are two major categories in the Energy Medicine field. The first is biologically produced energy fields, known as Biofields and commonly referred to as Subtle Universal Energy. The second category is Bioelectromagnetic medicine which uses measurable waves such as in magnetism, light, and electricity. Energy Medicine, especially the use of Biofields, was used as a form of primary healthcare in ancient and traditional cultures, predating the formation of alternative medical systems. In many cases, the use of Energy Medicine became an integral part of ancient traditional medical systems such as Traditional Chinese Medicine and Ayruvedic Medicine. Many aboriginal and other traditional cultures still use Energy Medicine as a part of their primary healthcare system. This field is largely unregulated in the United States. In most cases there are relatively low educational requirements to practice these disciplines, outside being taught them.

- Qi-gong
- Reiki
- Therapeutic Touch
- Polarity Therapy
- Magnetic Therapy
- Light Therapy

Biological/Natural Medicine

This is also a CAM field and refers to the use of natural substances for health. For most Americans exploring complimentary and alternative health practices, this is the first thing they are exposed to. Most natural medicine is available to the consumer at the grocery market or over the counter at pharmacies. Examples include healthy food choices, vitamin supplements, and using herbs to maintain good health. Occasionally it is useful to see a practitioner or advisor when putting together a diet or herbal regimen. There is a significant amount of federal and state regulation on the quality of food, vitamins, supplements, and herbs. Practitioners and advisors vary in the amount of education required to advise but in most cases do require a moderate amount of education. Regulation of herbal and nutritional advisors and practitioners vary by state.

- Herbology
- Nutritional Therapy
- Vitamin Therapy
- Aromatherapy

Body-Mind Medicine

This is also a CAM discipline and includes the use of techniques to boost mental abilities to control the body. Many Americans are familiar with body-mind techniques which include guided imagery, meditation, and prayer. This is the second most common form of complimentary and alternative medicine that Americans are exposed to. Some techniques require a moderate to high amount of training to practice or advise in but in most cases educational requirements are low to none. There is no regulation for practitioners of body-mind medicine.

- Biofeedback
- Guided Imagery
- Hypnotherapy
- Trauma Touch Therapy
- Somatic experiencing
- Rapid eye desensitization
- Emotional freedom technique
- Trauma release exercises
- Meditation
- Prayer, Spirituality & Religion
- Yoga
- Breath/Breathing Therapy
- Behavioral Therapies (CBT, DBT)
- Autogenics
- Progressive Muscle Relaxation

Tuesday, May 24, 2011

Massage for the poor

From the way I am seeing the health care situation, the next few years is going to open a flood gate of innovative ideas. Here is one of several that I have been working on.

It is commonly said that the secret to business is finding a solution to a problem that needs fixed. The poor tend to have the most problems, yet for some reason, most businesses chase after only the rich or those that are willing to pay. The richest people in the world have always been those who have found a solution for the masses, not the wealthy. So, my question becomes.... how can we use massage to help the poor?

In a few short years, nearly every American will have health insurance, thanks to the Affordable Care Act. The problem is, already, the health care system is maxed out. An influx of new patients is predicted to create a demand on the system significantly beyond any reasonable capabilities. Already, a huge push is starting to train more primary care physicians. The nursing industry is ramping up Nurse Practitioner graduates to fill in the gap where primary care doctors are unable to (in terms of numbers). But both require graduate level degrees and beyond. Keep in mind, the majority of health problems in the United States are chronic diseases. For a large portion of the patients in health systems, when they go to the doctor, they leave without an answer or a clear path of what to do next. Or, they would leave not knowing how to do what they need to do (like eat better or exercise more), even if they do know what needs to be done.

Currently, in areas where most people do not have health insurance, one of two things happen. Either they are constantly utilizing public and community health clinics or they wait until they are so sick that they end up in the ER. Once these people have insurance, the clinics and primary care facilities will likely not be able to sustain the load. On the other hand, based on anecdotal evidence, those who regularly receive massage are more stable and better able to manage illness, thus reducing demand on the health systems. Individuals that truly do have a medical issue are more likely to seek help because the massage therapist will encourage them to do so, but then they will recover or get through what ever they are dealing with quicker, as well. According to the body of research on massage, massage is also very good at a few very specific things, like reducing depression, dealing with pain management, and reducing recovery times, which there are currently few other effective solutions for. Therefore, what would happen if massage therapists, dually trained as health coaches, worked in these at risk neighborhoods?

My hunch is that it would mitigate and modulate the flow of patients into the primary health and mental health system. Those who do enter into the primary health and mental health system would be less likely to over-utilize the system and would speed up recovery times. Even if the benefits reduced patient volume by only a few percentage points, it still might be worth the effort. Current research on massage therapy focuses on ancillary benefits, or tries to prove how massage is better than current methods and therefore should replace current treatment programs. No matter how hard we push, however, the health industry is not likely to simply get rid of decades worth of current practice. Massage, however, has several things that it can do for health that NO OTHER TREATMENT does as well, or is as easily administered. These strengths could be leverages in massage outreach programs in neighborhoods with high health risk factors. If the programs were subsidized by primary and mental health systems, then an effective public health monitoring program could be developed that many people in the community would likely be willing to participate in voluntarily. There are few other medical interventions as pleasurable as receiving massage, especially a massage that would cost you personally only a few dollars. Since these massage therapists are trained as health coaches, knowledgeable and reliable sources of information on health can be spread through the community at a deeper level than the typical public health campaign. Currently, public health and community clinics serve that role, but are limited in their ability to effectively carry this duty out, due to limitations in time and resources being at odds with work load and job responsibilities (ie: treat patients!).

Certainly, a large body of research would need to be conducted on something like this to verify its feasibility. As far as I know, the massage literature has not explored this type of role in the health system. Thus, I believe that a call to action is overdue in the massage industry. We are already working to redefine our role in the health system, but I don't think we are thinking outside the box enough. Ultimately, we are a health industry that has existed for centuries outside of conventional western medical boxes. Our role needs to leverage our strengths as an industry to redefine our role in the future of healthcare, instead of trying to stuff ourselves within the conventional medical system box that already exists.

Sunday, May 15, 2011

Integrative Mental Health Program- Dialectical Behavioral Therapy

Integrative Chronic Disease Management Programs are being developed to address the growing number of hard to manage chronic diseases and illnesses in the United States. Many of these programs have structural similarities focused on support systems, patient buy-in, lifestyle modification, symptom management, and risk factor reduction. Dialectical Behavior Therapy (DBT) is an integrative program designed to reduce risk factors associated with Borderline Personality Disorder, but is currently used to effectively address a wide range of mental illnesses.

Dialectical Behavior Therapy encompasses many of the core tenets of Integrative Health and Integrative Medicine (12 out of 14), utilizing the necessary methods of integration (all 8) and incorporating the four realms of integration within three specific types of care. Clients are enrolled into a group and individual therapy sessions, must make a commitment towards change, track specific behaviors and risk factors daily through the use of diary cards, and participate in weekly homework assignments. Group sessions focus on four subjects concerning Interpersonal Effectiveness, Mindfulness skills, Distress Tolerance/Crisis Management skills, and Emotional Regulation. Individual sessions are used to reinforce the group session, monitor individual risk factors via the diary card, and provide individualized care on subjects beyond the scope of the group.

Integrative Tenets (12/14)
DBT is inclusive of Mind, Body, and Spirit by utilizing Eastern and Western techniques in patient care. It is personalized and prevention oriented, and embraces wellness care, lifestyle management, and self-care. Mental Health Professionals work in teams to facilitate groups and individual care, and cultivate relationships with clients in order to effectively reduce risk behaviors. This in turn encourages patients to learn about themselves and take responsibility for their own health/wellbeing. It is evidence based, focuses on what works for the client, puts emphasis on the process of care, and ultimately is a valuable cost effective tool with a high rate of success. Most DBT groups are composed of patients with similar family, societal, and cultural factors.

Integrative Methods (8/8)
Due to the nature of small group management combined with individualized sessions, DBT emphasizes the patient as the center of care and is highly personalized. The inclusion of family and love ones in individual sessions is encouraged so that patients have an opportunity to share their new skills and smooth over potential difficulties in application. Individual sessions focus on reinforcing skills learned in group that are effective and offer opportunities to trouble shoot ways to reduce factors preventing skill applications outside the scope of DBT within the patient's environment. A solid base of research behind DBT allows for a focused, evidence-based program. Records are kept for each client consisting of therapist notes, diary cards, and homework. Through the course of the program, patients are encouraged to integrate and utilize all the skills together to build an interdependent network of self-care and positive lifestyle management. Providers refer out and connect patients with resources as needed, so that patients are supported as much as possible through the course of the program in order to achieve positive outcomes.

Realms of Integration (1/4)
There is a vast synthesis of knowledge from a variety of Eastern and Western practices. Providers are also placed in a "lead by example" role, demonstrating use of the skills in their own lives. The extent of administrative integration and provider-system organization and the resulting clinical practice integration depends upon the organization in which DBT Providers practice.

Types of Care
DBT is a Chronic Disease Management Program, a rehabilitation service, and part of Self Care/Wellness & Lifestyle Management.

Saturday, May 14, 2011

Integrative Health Foundations

The following 14 tenets form the foundation of an comprehensive Integrative Health system. The Institute of Medicine believes we can develop and support these tenets by a focused cultivation of research, practice, education, and policy. This foundation ultimately creates a broader definition of health and health care, one that more fully supports the American guarantee of life, liberty, and the pursuit of happiness. The ultimate goal is a personalized, predictive, preventative, and participatory health care system, that moves away from the "find it and fix it" model.

The 14 tenets

1) Inclusive of Mind, Body, and Spirit
2) Care is from cradle to grave
3) Personalized
4) Prevention oriented, using healthcare promotion and comprehensive disease management programs
5) Embraces wellness care, lifestyle management, and self-care
6) Care providers work as a team
7) Patient/Provider Relationship is restored
8) Patients learn about and take responsibility for their own health/wellbeing
9) Uses evidence-based practices
10) Care is focused on what is working for the patient
11) The care process is just as important as the care content
12) Quality of care at the greatest value/lowest cost is the ultimate goal
13) Sensitive to family, societal, and cultural factors
14) Utilizes all health systems and scientific bodies of knowledge, including Genomics/Proteomics, Complementary and Alternative Medicine, and current research


1) Place the patient at the center
2) Individualize care
3) Welcome family and loved ones
4) Maximize healing influences within care
5) Maximize healing influences outside care
6) Rely on sophisticated, disciplined evidence and information delivery systems
7) Use all relevant capacities- waste nothing
8) Connect helping influences with each other

Realms of Integration

1) Knowledge base
- Evidence of all the healing systems
- Personal initiative and drive from each provider

2) Administration
- Organizational mission, plan, and leadership
- Information Technology
- Quality Management
- Professional & Staff education
- Financial Management
- Human Resources
- Marketing Plans
- Reimbursement system
- Facilities and space planning
- Regulatory factors
- Risk Management
- Qualification and Credentialing of Providers
- Other administrative functions that support clinical functions

3) Provider-System relationship
- Financial incentives
- Marketing support
- Access to facilities and services
- Access to practice management services (support staff, shared revenues/practice/loss, etc)
- Participation in governance & policy making
- Shared mission/vision
- Process for developing organization informed consensus
- Community involvement
- Relationships with other organizations and external providers
- Provider communications
- Conflict resolution and biases
- Positive and negative sanctions

4) Clinical practice
- Clinical protocols
- Clinical outcomes
- Patient satisfaction
- Cost effectiveness
- Quality of service (well trained and experienced practitioners, and services are evaluated using the benchmarks of the discipline and not biomedicine)
- Inpatient admissions and lengths of stay
- Clinical culture
- Educational Programming
- Care management strategies, case management strategies, and clinical pathways
- Practice organization and collaboration
- Coordination of care

Types of Care Needing Innovation & Integration

1) Emergency Care
2) Acute Care
3) Primary Care
4) Chronic Disease Management
5) Rehabilitation
6) Home based Care
7) Long Term Care
8) Self Care/Wellness & Lifestyle Management
9) Medical/Health "Home" model

Success Factors (From Integrating Complementary Medicine into Health Systems by Nancy Faass)

- Establish access to clients (demographic)
- Identify sources of reimbursement
- Devise a flexible & portable payment system that does not compromise the length of visit or the quality of care (because insurance rates are too low)
- Obtain sufficient capital (long-term, min 3-5 years wait before return on investment)
- Develop an effective infrastructure to manage risk
- credentialing to high standards
- ongoing monitoring
- quality assurance initiatives
- minimize risk of litigation
- Form friendly alliances with conventional medicinal facilities and practitioners (formal linkages)
- Recruit a stable of loyal practitioners willing to cross-refer to one another in-house
- Position the organization advantageously in it’s particular market
- Develop a relationship with a research facility
- Provide the therapies most desired in the organizations market, offering a carefully chosen selection
- Empower patients
- Consider healthcare a business, and guide operation with that in mind
- Identify one or more champions in the organization who are highly regarded by all constituents and looked up to by all physicians
- Obtain a strong endorsement from the board and top management
- Develop an extensive education program that serves all stakeholders
- Emphasize effective communication
- Use media to link staff and stakeholders
- Grounded in detailed market and competitor analysis
- Incorporates wellness AND fitness
- Best placed in the for-profit unit, in partnership with a hospital
- expand the scientific paradigm via the scientific method & evidence-based treatments

Friday, May 13, 2011

Accountable Care Organizations

The Affordable Care Act (ie: Health Reform Bill) is full of new changes for our current health care system in the United States. Innovations within the act are designed to increase market competition, increase access and quality of care, and decrease costs. Every few months between Jan 1, 2010 and Jan. 1, 2015, something new happens. One new and exciting program is the development of Accountable Care Organizations, which goes into effect January 1, 2012. What is an Accountable Care Organization you may ask? It is an incentive for health care providers to reorganize their delivery systems and care management pathways into INTEGRATIVE Health systems. ACO's are projected to save as much as $960 million over the first three years alone!

So who does this effect and what does it mean?

ACO's are programs designed to incentivize Medicare health providers. Group practices, networks of individual practices, and partnerships/joint ventures between hospitals and professionals are the primary organizational structures eligible for ACO status, and thus shared savings benefits. Each ACO must meet quality measures in patient/caregiver experience of care, care coordination, patient safety, preventative health, and population risk management for Medicare patients.

This is a huge step in the right direction for Integrative Health, but still leaves much room for improvement. First, Integrative Health systems don't guarantee Integrative Medicine on a clinical level, only integrated administration and a change in the relationship of providers (ie: Doctors, Nurses, etc) with the system. However, both of these aspects are the critical foundation for creating integrated medical care within the integrative health system. One of the major hurdles for Integrative Health and Medicine is a lack of successful models and research into what works and what doesn't. Integrative Healthcare requires a very different thought process and approach towards care. Providers and Payers (ie: insurance companies) want to know if an investment into this kind of radical reorganization of our health systems is worth it; is there an adequate return on investment? For the past 20 years, payers and providers have been playing hot potato and insisting someone else "go first". The government, in this case, is stepping in and saying they are willing to bet that this not only works, but is better. They are putting the money and time into a program that will give the information private health systems and insurers/payers need to go forward and support and create Integrative Health systems and reduce the investment risk of doing something "unproven".

Tuesday, May 10, 2011

What is Integrative Health?

Integrative healthcare is so much more than the bringing together of CAM (Complementary and Alternative Medicine) with contemporary western evidence-based medicine. You can call that Integrative Medicine. But "Integrative Health" is an umbrella term also referring to the inclusion of patient AND provider self-care, health promotion, disease prevention, a patient centered return to healthcare management, and an over-arching concept of lifestyle change and wellness. It is about finding the most effective and efficient solution for a health problem for the least amount of cost. It is also about seeing patients as part of communities and as a sum greater than a person's bodily parts; re-merging the mind and body back together and encompassing spiritual and emotional aspects too.

Its a new kind of system that reinforces and supports the idea of health and wellbeing through health coaches and multiple sources of primary care. It is about making sure that doctors are being doctors, administrators are administrating, and nurses are being nurses, instead of expecting the doctor to care for us and the administrator making medical decisions and the nurses overseeing everything without time to care and interact with the patients. It is about leaving the doctors office with a plan and a support group to see you through it and a coach to guide the way, all under one roof. When your doctor says you need more exercise, you can get a your own personal trainer, and then get head to the kitchens where your own personal chef teaches you how to cook hearty and healthy meals. Doctors no longer have incentives to see you in the least amount of time and order the greatest number of tests possible to get reimbursements. Your doctors have incentives based on whether you actually get better. The system is about celebrating what you already do and intrinsically know to be the best person you can possibly be! It's your health home. Your doctor's diseases no longer define who you are because your healthcare system is about health, not dis-ease!

Kind of sounds to good to be true. The crazy thing is that a health system like this is already being used in hospitals and clinics around the country, and many of these systems are the most financially stable programs in the nation with some of the highest patient satisfaction numbers. Programs in these facilities are saving tens of thousands of dollars in health care costs, per person. And not only are they achieving health outcomes comparable to normal procedures, but in some cases have better health outcomes. Count me in for this kind of health care evolution!

Monday, May 9, 2011

I guess All I really need to know (about the best health care system) I learned in Kindergarten!

Wouldn't it be cool if all the different departments of the hospital saw us as whole people instead of carving us up into specialties? Imagine if we applied the simple logic that every part of us is connected. I guess All I really need to know (about the best health care system) I learned in Kindergarten!

Ezekiel cried, "Dem dry bones!"
Ezekiel cried, "Dem dry bones!"
Ezekiel cried, "Dem dry bones!"
"Oh, hear the word of the Lord."

The toe bone connected to the heel bone,
The heel bone connected to the foot bone,
The foot bone connected to the leg bone,
The leg bone connected to the knee bone,
The knee bone connected to the thigh bone,
The thigh bone connected to the back bone,
The back bone connected to the neck bone,
The neck bone connected to the head bone,
Oh, hear the word of the Lord!

Dem bones, dem bones gonna walk aroun'
Dem bones, dem bones, gonna walk aroun'
Dem bones, dem bones, gonna walk aroun'
Oh, hear the word of the Lord.

The head bone connected to the neck bone,
The neck bone connected to the back bone,
The back bone connected to the thigh bone,
The thigh bone connected to the knee bone,
The knee bone connected to the leg bone,
The leg bone connected to the foot bone,
The foot bone connected to the heel bone,
The heel bone connected to the toe bone,
Oh, hear the word of the Lord!

Monday, May 2, 2011

Why not Integrative Health? Medicine for today, not yesterday.

There is a rise in chronic disease which is stressing the healthcare system beyond capacity, because our healthcare system was designed for the infectious disease and acute-traumas of the 20th century. We have done so well in overcoming acute trauma and infectious disease that we have shifted the nature of human disease, illness, and morbidity. We no longer die of cholora and smallpox. When there is an accident, there are machines that keep us alive until we can get back on our feet. Today, it is lifestyle, and danergous environmental factors that trigger many genetic conditions, that ultimately determines how long each of us lives. Yet we continue to look for answers for autism, cardiac disease, diabetes, and depression and so many other chronic conditions with the tools of 20th century healthcare, despite having 21st century tools at our fingertips.

Take ADHD for example. According to integrative health specialists, early childhood trauma disrupts the organization of the brain stem, causing symptoms mimicking ADHD.

We are living in a world where we are increasingly subjected to global traumas (politically, environmentally, and otherwise) in a way humanity has never had to face before, beyond the scope of the family and community unit. If one of the most frustrating childhood diseases is a result of envrionmental factors mixing with genetic predisposition, the end result will only be an increasing number of ADHD and autistic spectrum children.

So my question then becomes, when will be move towards an integration of all the systems of health and wellness designed to treat these conditions? Will it only be when we have destroyed our planet and in the process, ourselves, because we cannot accept that we are from the earth, and to the dust we shall return?!?!? We have the power to create our environment. We have proven that over and over throughout histroy. Lets create an evironment that we can live in and listen to our bodies for the answers. As a massage therapist, I have learned to do that. And from my experience, our bodies are already screaming out the answers. You just have to listen and learn the language.