ciha syllabus

Leadership in Integrative Health Certification in Integrative Health Administration (CIHA)

Thurs, Oct 30 – Fri, Oct 31, 2014 - San Diego

Course Description Health care is undergoing a transformation toward models of integrative medicine, prevention, sustainability and community collaborations. By exploring key components of an integrative health model, this leadership program will provide essential clinical, financial and administrative tools to respond to the emerging challenges of health care delivery. Utilizing a personalized comprehensive approach to health care, attendees will be joining a unique, rapidly growing group of healthcare executive leaders. This certificate program is offered by nationally recognized experts in integrative medicine and administration, and will utilize an integrative health framework to connect with population health, ACO’s, the impact of the ACA, patient and employee satisfaction and sustainability. Evidence-based practices that address wellness and health with multiple benefits will be explored, preparing participants to become inspired change agents who will make a true difference in health care delivery. Health care transformation will require unprecedented changes in treatment and care models. Whole person approaches to health and wellness have been shown to improve the health of populations and reduce the costs of care. Success stories of engaged institutions will be central to the conversation about how innovations can be shared and implemented.

The Leadership in Integrative Health Certification After the completion of an additional 6 hours of online content and post-tests (included in your registration fee) for a total of approximately 20 contact hours, recipients will receive The Leadership in Integrative Health Certificate. More information will be emailed after the meeting, this email will come from the American Board of Integrative Holistic Medicine. This certification program is the first of its kind, and will establish participants as a new community of leaders in health care transformation.

Faculty Jennifer Blair, LAc, MaOM AHMA Board of Directors Licensed Acupuncturist Penny George Institute for Health and Healing Minneapolis, Minnesota Jeffrey Bland, PhD, FACN, FACB Founder & President Personalized Lifestyle Medicine Institute (PLMI) Seattle, Washington

Diego Coira, MD Hackernsack University Medical Center Hackensack, New Jersey

Daniel Friedland, MD AIHM Chair President-Elect, ABIHM Founder and CEO, SuperSmartHealth San Diego, California Mimi Guarneri, MD, FACC, ABIHM President, AIHM Founder Scripps Center for Integrative Medicine San Diego, California

Robin Guenther FAIA, LEED AP Principal of Perkins+Will Senior Advisor, Health Care Without Harm New York, New York Jamie Harvie, P. Eng Executive Director Institute for a Sustainable Future Duluth, Minnesota F. Nicholas Jacobs AIHM Treasurer International Director Sun Stone Management Resources Harrisburg, Pennsylvania Mary Jo Kreitzer, PhD, RN, FAAN Founder and Director, Center for Spirituality & Healing Professor, School of Nursing Minneapolis, Minnesota

Wayne Miller Nura Health Vashon, Washington

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Tabatha Parker, ND AIHM Director of Education Co-founder and Executive Director NDI NCNM Co-Chair Masters of Science in Global Health San Diego, California Rauni Prittinen King, RN, BSN, MIH, HNB-BC, CHTP/I Founder, Scripps Center for Integrative Medicine President, Holistic & Integrative Medicine Resources, Inc. San Diego, California Emilie Rowan, LCSW Director, Center for WellBeing Atlantic Health Morristown, New Jersey Mark Tager, MD CEO ChangeWell Inc.

Kelly Warshel, MD, ABIHM Medical Director Windber Hospice Johnstown, Pennsylvania Leonard A. Wisneski, MD, FACP Clinical Professor of Medicine George Washington University Medical Center Adjunct Faculty Department of Biochemistry and Molecular Biology, Division of Integrative Physiology Georgetown University Couifer, Colorado

Schedule of Events & Table of Contents Thursday, October 30, 2014 8 a.m. Registration & Breakfast 8:15 a.m. Welcome & Introduction 8:30 a.m. Focused Track (Mission Bay Room)

Transformational Leadership in Integrative Medicine Daniel Friedland, MD, ABIHM F. Nicholas Jacobs, FACHE

Page 5

10:30 a.m. Break & View Exhibits 11 a.m. Focused Track (Mission Bay Room)

Transformational Leadership in Integrative Medicine Daniel Friedland, MD F. Nicholas Jacobs, FACHE

Page 46

12:30 p.m. Lunch (Paradise and Sunset Terrace) 2 p.m. Plenary Session (Paradise Ballroom)

Health as an Economic Strategy F. Nicholas Jacobs, FACHE

Page 107

2:45 p.m. Plenary Session (Paradise Ballroom) Spirituality in Health and Medicine Mary Jo Kreitzer, PhD, RN, FAAN

Page 175

3:30 p.m. Break & View Exhibits 4 p.m. Plenary Session (Paradise Ballroom)

Global Health Tabatha Parker, ND

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4:45 p.m. Plenary Session (Paradise Ballroom) Personalized Integrative Health Care: A Look Ahead Jeffrey Bland, PhD, FACN, FACB

Page 284

5:30 p.m. Closing Remarks 6 – 9 p.m. Exclusive reception at Pacific Pearl La Jolla

Goldfield Stage will pick up/drop off in front of the Conference Center at Paradise Point

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Schedule of Events continued

Friday, October 31, 2014 (All functions will be held in the Mission Bay Room) 7:30 a.m. Breakfast 8 a.m. Organizational Transformation: Guiding the Metamorphosis

Mark Tager, MD 38

8:40 a.m. Administrative Implementation of Integrative Health in Your Health System F. Nicholas Jacobs, FACHE

Page 362

9:10 a.m. Leading from the Heart: Reconnecting to Your Mission Mimi Guarneri, MD, FACC, ABIHM

Page n/a

9:50 a.m. Break 10:20 a.m. Integrative Health and Medicine: Navigating Policy Trends

Leonard Wisneski, MD, FACP Page 374

11 a.m. Integrating Clinical and Behavioral Health Units –Solutions to Difficult Problems Diego Coira, MD, FAPA

Page 434

11:30 a.m. Dying with dignity: End of Life conversations in an ACO context Kelly Warshel, MD, ABIHM

Page n/a

12:10 p.m. Lunch 12:50 p.m. Healthy Food from the Clinic to the Community – Lessons of

Success through Integrated Operations Jamie Harvie, P Eng

Page 469

1:20 p.m. An Evolving Narrative: Learning Lessons from Integrative Health Implementation Jennifer Blair, LAc, MaOM

Page 504

1:50 p.m. The Business Case for Sustainable Healthcare Buildings: Supporting Community Health and Resilience Robin Guenther, FAIA, LEED AP

Page n/a

2:25 p.m. Panel: Billing and Paying for Integrative Health and Medicine F. Nicholas Jacobs, FACHE Mimi Guarneri, MD, FACC, ABIHM Rauni Prittinen King, RN, BSN, MIH Emilie Rowan Wayne Miller

Page n/a

3:30 p.m. Adjourn

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We’d like to Hear from you We value your feedback, please take some time following the program to complete an online evaluation.

1. After the conference, visit http://cmetracker.net/SCRIPPS/Login?FormName=getCertificate to complete the conference evaluation.

2. Enter your username and password. Please note your email address must match the email account you

previously used to register for the conference. If a new user, follow instructions to log in and set up your password for your online account.

3. Enter CME Activity Code 35422 The evaluation will only be available for four weeks after the conference and must be completed by November 18, 2014.

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http://cmetracker.net/SCRIPPS/Login?FormName=getCertificate

Transformational Leadership(Engaging Conscious Leadership)

Daniel Friedland, MDChair, AIHM

CEO, SuperSmartHealth

© SuperSmartHealth® 2014

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Qualities of High Performance Leaders


Qualities of Low Performance Leaders


Low Performance Leader High Performance LeaderAchievement Oriented• Purpose and Vision• Strategically Focused• Decisive • Gets Results

Relates Well• Cares• Fosters Team Play• Collaborates well• Mentor

Authentic• Integrity • Courage

Systems Aware• Concerned for Community• Sustains Productivity

Self-Aware• Personal Learner• Composure• Balance• Selfless Leader

CreativityReactivity

Complying• Pleasing• Conforming• Conservative• Passive

Protecting• Arrogant• Cynical and Critical • Distant

Controlling• Autocratic• Driven to Prove Self Worth• Ambitious to Get Ahead• Perfectionistic

Adapted from The Leadership Circle © SuperSmartHealth® 20148

© 2011 The Leadership Circle, All Rights Reserved. Company Confidential 5

Leadership Circle Profile™ Graphic

Low Balance

90

80

70

60

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Inter

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Lead

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90 80 70 60 50 40 30 20 10 90 80 70 60 50 40 30 20 10 10 20 30 40 50 60 70 80 90 10 20 30 40 50 60 70 80 90

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CREATIVE

TASK

RELA

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REACTIVE

Critical

ArroganceDistance

Conservative

Pleasing

Belonging

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Ambit

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Drive

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Perfe

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Self-A

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Authenticity

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Protecting

Complying

Achieving

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Personal

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SustainableProductivity

IntegrityCourageousAuthenticity

CommunityConcern

10 20 30 40 50 60 70 80 90

Leadership Effectiveness

Low High

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High Balance

Relationship-Task Balance

10 20 30 40 50 60 70 80 90

ReactiveCreative

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Identity

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Leadership Effectiveness Scale

• I am satisfied with the quality of leadership that he/she provides.

• He/she is the kind of leader that others should aspire to become.

• He/she is an example of an ideal leader.• His/her leadership helps this organization to thrive.• Overall, he/she provides very effective leadership.

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Correlations to Leadership Effectiveness

0.830.580.810.730.79

0.760.41

0.79

0.410.65

0.710.63 0.59

0.700.69

0.65

0.700.85

0.720.72

0.720.77

0.85

0.08

-0.28

-0.37

-0.60

-0.55-0.51

-0.50

-0.49

-0.13

-0.11

0.04-0.57

-0.59

-0.43

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Lead

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Total Creating ScoreR = 0.93

Rsq = 0.86

5.0

4.5

4.0

3.5

3.0

2.5

2.02.5 3.0 3.5 4.0 4.5 5.0

Leadership Effectiveness & Creating

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Lead

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Total Reactive ScoreR = -0.66

Rsq = 0.44

5.0

4.5

4.0

3.5

3.0

2.5

2.01.0 1.5 2.0 2.5 3.0 3.5

Leadership Effectiveness & Reacting

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ReactivityFight & Flight

CreativityFulfillment

Low Performance Leadership

High Performance Leadership

Your Brain and Leadership

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Autonomic Nervous System

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Mirror Neurons

Evolution of Neonatal Imitation. Gross L, PLoS Biology Vol. 4/9/2006, e3

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Fight Flight Trigger

1 2

Fight Flight

Trigger

Give Receive

1 2

GiveReceive

Cycle of Reactivity

Cycle ofCreativity

Social and Emotional Contagion





Actively DisengagedEmployees

Cost

Actively EngagedEmployees

Benefit


The Importance of Leadership


Perceived Leadership Integrity and Burnout

• 287 family medicine and general internal medicine respondents (68.3% response rate)

• Correlated burnout to Perceived Leadership Integrity Index (PLII):1. Support for physician’s core values

2. Prioritizes quality over costs

3. Positive response to physicians raising quality issues

4. Interest in patient care above self-interest

5. Honesty

• Low PLII associated with physician burnout (p = 0.0001) and intention to leave (p = 0.026)

Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med. 2005;20:S182.


The Cost and Benefit ofEmployee Engagement

Employee Engagement. What’s Your Engagement Ratio?http://www.gallup.com/strategicconsulting/121535/Employee-Engagement-Overview-Brochure.aspx

• Absenteeism 40%• Turnover 25-50%• Patient Safety Incidents 41%• Safety Incidents 49%• Quality Defects 60%

• Customer Satisfaction 12%• Productivity 18%• Profitability 16%

Difference between top and bottom quartile of employee engagement:

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Leadership Effectiveness & Business Performance

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Leadership Effectiveness

R = 0.612Rsq = 0.3752

7.5

7.0

6.5

6.0

5.5

5.0

4.5

4.0

3.5

• Sales/Revenue Growth• Market Share• Profitability/ROA• Quality Products/Services• New Product Development• Overall Performance

2.0 2.5 3.0 3.5 4.0 4.5 5.0

http://www.theleadershipcircle.com/wp-content/uploads/2011/05/12_OrgPerformance.pdf22


Aggregate Profile of Those Leaders Whose Businesses’Were Evaluated as Highest Performing

Top 10%

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Aggregate Profile of Those Leaders Whose Businesses’Were Evaluated as Lowest Performing

Bottom 10%

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CostGrowth andProfitability


BenefitGrowth andProfitability

SAFETY

BELONGING

SELF-ESTEEM

SA


How Do You Shift?


The 4 in 4 Framework™ to Engage Conscious Leadership

IntegratingMental Emotional Social Spiritual

Intelligence


Make the Turn intoWhat’s Truly Important

Cultivate Creativity By Reflecting on

What’s Truly Important

Reappraise Stress and Self-Doubt

Recognize Reactivity



The 4 in 4 Framework™ 1 2

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A practice of paying attention with a sense ofopenness, curiosity, acceptance, and compassion,

of whatever is arising in the present moment





The 4 in 4 Framework™ 1


Recognize Reactivity:

1. Physical Sensations

2. Feelings

3. Thoughts

4. Behaviors

1Is it doing more harm than good?


Recognize Reactivity:

1) Pause – 3 breaths and/or exit

2) Assess hunger, thirst and fatigue

3) “Name it to tame it!”

4) Consider best response

1Is it doing more harm than good?

If so:





The 4 in 4 Framework™ 2Recognize

ReactivityIs it doing more

harm than good?

1


Reappraise Stress and Self-Doubt:

• What if…• If only...• Judgment and Criticism• Rejection and Abandonment• Neglect and Abuse• Standards and Expectations• Loss• Transition

Triggers of Stress and Self-Doubt:

2


Reappraise Stress and Self-Doubt:

2

Appraise Reappraise

1) What happened (just the facts)?

2) What is my belief about what happened?

3) Is my belief true or what is the evidence this should be so?

4) How could I view this differently?

Adapted from Albert Ellis et al. Rational Emotive Behavior Therapy. Amer Psychological Assn; 3 edition 2011. © SuperSmartHealth® 2014

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The 4 in 4 Framework™ Recognize Reactivity

Is it doing moreharm than good?

1Reappraise Stress

and Self-DoubtIt’s nothing more than

psychic gas!

2



3




• Learning• Connecting• Expressing Potential• Being of Service• Creating Opportunity• Experiencing Significance• Leaving a Legacy

3




3

VSIR Process

Implementation ResultsStrategyVision


SpecificMeasurableAligned with your VisionRealisticTime Framed

SMART Results


Health Relationships Work



3




The 4 in 4 Framework™ Recognize Reactivity


1Reappraise Stress

and Self-DoubtIt’s nothing more than

psychic gas!

2


What’s Truly ImportantLearning

ConnectingExpressing Potential

Being of ServiceCreating Opportunity

Experiencing SignificanceLeaving a Legacy

3Make the Turn into


4


1

3

Find

Frame

Apply

Evaluate

1

3

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4








The 4 in 4 Framework™


It’s nothing more thanpsychic gas!

LearningConnecting

Expressing PotentialBeing of Service

Creating OpportunityExperiencing Significance

Leaving a Legacy


Frame1

2

3

4Apply

Evaluate

Find

1 2

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CostGrowth andProfitability


BenefitGrowth andProfitability


An Inspired Shift in Conversation


For More Information and Resources see:

http://supersmarthealth.com/leadership

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Thank You!Daniel Friedland, MD

Chair, AIHMCEO, SuperSmartHealth

[email protected]

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Making the Change

AIHM Leadership 2014

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“The only thing that is always consistent in life is

CHANGE”

Redesigning Your Future

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A different place a different time

New ways to see opportunities, produce sustainable growth

and reshape organizations for consistent innovation

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“This Business Model Doesn’t Work Anymore!”

Saddle makers- automobiles

Watch makers – the quartz watch

Newspapers

Music

Movies

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What is the Reality of Change?

“Change or Die”

50

What do leaders do?

Create a vision and direction for the organization, and

mobilize to accomplish that vision and direction.

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Transformation

It should NOT be our goal to create what people will LIKE.

It should be our goal to create what people will LOVE!

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Chaos provides opportunity

People who are security dependent won’t change.

Surfing the wave doesn’t mean fighting the ocean. (Don’t resist it.)

53

What Kind of Future Do YOU Want to Occupy?

You have the ability to design your future.

Half the time work in areas that you don’t know

Half the time work in areas that you do know,

And you will GROW.

54

Worst of Times and Best of Times

Collaboration vs. Competition

Healing vs. Curing

Bottom-up vs. Top Down

Patient Centered vs. Employee and Physician Centered

What you focus your attention upon IS YOUR reality!

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There are NO lines . . .WE MADE THEM!From Outer Space:

Township

County

State

Nation

Work all sides.

Nothing has to be the way it is.

We can INVENT or PREVENT our future

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The Pale Blue Dot CArL Sagan

We succeeded in taking that picture from deep space, and, if you look at it, you see a dot. That's here. That's home. That's us.

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The Calf Path

by Sam Walter Foss

10/7/2014An Army of ONE!13

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10/7/2014An Army of ONE! 14

One day, through the primeval wood,A calf walked home, as good calves should;

But made a trail all bent askew,A crooked trail as all calves do.

Since then two hundred years have fled,And, I infer, the calf is dead.

But still he left behind his trail,And thereby hangs my moral tale.The trail was taken up next day

By a lone dog that passed that way,And then a wise bell-wether sheep

Pursued the trail o'er vale and steep,And drew the flock behind him, too,

As good bell-wethers always do.

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And from that day, o'er hill and glade,Through those old woods a path was made;

And many men wound in and out,And dodged, and turned, and bent about

And uttered words of righteous wrathBecause 'twas such a crooked path.

But still they followed—do not laugh—The first migrations of that calf,

And through this winding wood-way stalked,Because he wobbled when he walked.

This forest path became a lane,That bent, and turned, and turned again;

This crooked lane became a road,Where many a poor horse with his load

Toiled on beneath the burning sun,And traveled some three miles in one.

And thus a century and a halfThey trod the footsteps of that calf.

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The years passed on in swiftness fleet,The road became a village street;And this, before men were aware,

A city's crowded thoroughfare;And soon the central street was this

Of a renowned metropolis;And men two centuries and a halfTrod in the footsteps of that calf.Each day a hundred thousand rout

Followed the zigzag calf about;And o'er his crooked journey went

The traffic of a continent.A hundred thousand men were led

By one calf near three centuries dead.They followed still his crooked way,And lost one hundred years a day;

For thus such reverence is lentTo well-established precedent.

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A moral lesson this might teach,Were I ordained and called to preach;

For men are prone to go it blindAlong the calf-paths of the mind,And work away from sun to sun

To do what other men have done.They follow in the beaten track,

And out and in, and forth and back,And still their devious course pursue,

To keep the path that others do.But how the wise old wood-gods laugh,

Who saw the first primeval calf!Ah! many things this tale might teach—

But I am not ordained to preach.

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And still their devious course pursue,

To keep the path that others do.

But how the wise old wood-gods laugh,

Who saw the first primeval calf!

Ah! many things this tale might teach—

But I am not ordained to preach.

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Reinventing the Patient Experience

Best of a Hotel – Hire a hotel manager

Best of a Spa – Add Integrative Medicine

Best of a Hospital – Become the employer of choice

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THE FUTURE BECOMES A DESIGN FUNCTION

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Living on the Edge The world that is or the world that

will be.

Idealsim vs. Realism


No one way is the Right Way

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Edge Runners are World Creatures

Power to change reality

Let’s make it be some other way.

We have the capacity for self-design.

We can modify our environment.

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What Kind of Future Do YOU Want to Occupy? You have the ability to design your

future.

Half the time work in areas that you don’t know . . .

Half the time work in areas that you do know,

And you will GROW.

68

The Universe

If you look into an electron microscope you see infinitely lesser.

If you look into a telescope you see infinitely greater.

There are Endless Possibilities

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Science Follows Science Fiction

Discovery comes from fiction.Discovery comes from FANTASY.What limitations do you accept?Money will follow ideas.

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Where is YOUR future?

Excite yourself to get your imagination moving to design your future.

If there are limitations in your frame of reference . . .you are keeping yourself in BONDAGE!

71

There are NO lines WE MADE THEM! Township

County

State

Nation

Work all sides.


We can invent or PREVENT our future

72

Boundaries

There are NO boundaries but the boundaries YOU make.

All limitations are self imposed. The universe is ONE CONNECTED

fabric. What is your vision of the future?

ONLY YOU KNOW. We can empower ourselves to create

a new world.

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The Key to Change

Once you have totally accepted it, you can change it.

74

What is the conversation you have with yourself? Everything makes sense in a large

enough context.

Sense what is trying to happen and let it happen.

Be alert to changing environmental conditions.

Reframe any limitations to become opportunities.

Tremendous limitations breed success. They open doors.

75

Steps to the change

Explain the depth of the problem.

Offer nontraditional solutions

Introduce them as a package

Work to ensure they will actually happen

76

The WIFM for the Organization?

Increase innovation and creativity Improve service to peers and

patients Inspire passion and performance Increase retention of top

performers

77

What we CAN DO!

We cannot change the human condition – but we can change the condition under which humans live and work.

78

First Two Weeks as CEO

Met with every employee in my office one on one for approximately seven minutes each non-stop.

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WHY?

It was an effort to begin to BUILD TRUST by being:

OpenHonestAttentiveSincereKindInterested (Hawthorne

80

Employee CommunicationsNick’s BlogOpen Door PolicyNewsletterBirthday Pizza with the PresidentTown Hall MeetingsManagement by wandering aroundCaught You Caring

81

What was the purpose of these initiatives?

Keep everyone informed – The secret was “there was no secret.”

Opportunities to “Accentuate the Positive”

Opportunities to re-direct energy when things had gone wrong.

82

Employee Physical Wellness

Osteoporosis ProgramSmoking CessationEat Well for Life ProgramStrength Training Cardiac RehabWalking Trails

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Employee Fitness HealthStyles – Nearly 50% of employees were

members

Open approximately 90 hours per week.

Employee costs approximately $10 per month

Includes classes in kick boxing, aerobics, water aerobics, yoga, tai chi

84

Mr. Hawthorne AGAIN!

This effort demonstrated that the employees were valued that they were, in fact, THE MOST VALUED

ASSET of the organization

85

Employee Empowerment

15 PTO DaysDonation of PTO days On site Baby SittingSocial Welfare Death of an in-law or grandchild

86

Employees are NOT children, and I was NOT their Father

If you treat people like adults 90% of them will respect you for this effort

If you show them kindness, they will go the extra mile

If you truly demonstrate that you care, so will they

87

Disney Training for ALL employeesEQ2/Emotional Quotient TrainingPlanetree Training TeamDale Carnegie

Employee Training & Development

88

Opening doors to show them that:

There are only four types of responsesNo ResponseNegative ResponseRedirectionPositive Response

89

What were our goals?

Learn Redirection Describe problems clearly and without any

BLAME

Explain the negative impact of a problem

When appropriate, TAKE THE BLAME

Make sure the task is understood

Demonstrate and express trust and confidence

90

Employee Emotional Health

The GreenhousePlanetree RoomHealing GardensGazebosLive MusicCounselorsClergyThe Swat Team

91

Other ways to demonstrate our investment in their futures

Praise ImmediatelyBe specificShare positive feelings (hugs)Encourage them to keep up

the good work

92

Dr. Dean Ornish Program for Reversing Heart Disease

Six Weeks of Ornish LightPersonal Nutrition CounselingHealthy Vending MachinesHealthy Choice Meals

(Fat Free, Vegetarian)

93

Continued Dedication to Employee Personal Growth

Reimbursement for additional college level credits and degrees

WorkshopsConferencesVideo Teleconferencing

94

More Employee FUN!!!

Sundae Parties Subs and Pizza Parties Trips to Pittsburgh Pirates Baseball Tickets to: The Symphony, The

Opera, Theater, Hockey, and lots of DINNERS.

Employee Recognition Dinners Hospital Week Cookout BIG HOLIDAY PARTY

95

We Asked the Bullies to RESIGN

Anesthesiology Critical Care Specialists Internal Medicine Physicians Surgeons

In 11 years we asked 17 highly qualified physicians and 37 employees to LEAVE because they were bullies

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Conventional right brain wisdom said: The secret to seeing--really seeing-- was to quiet the bossy, know-it-all left brain!

52

A Whole New Mind by Daniel H. Pink

97

Right Brain Attributes

Artistry

Empathy

Taking the long view

Pursuing the inspirational

53

98

What will get you in the door?

Creative thinkingCreative ideas

Creative approachesCreative solutions

(But most importantly)

“Relationships”54

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The Patient Experience was Redesigned

THE FUTURE BECAME A DESIGN FUNCTION

100

Multidisciplinary research team with expertise in:

High throughput research, Functional genomics, Proteomics, Molecular biology, Cell biology, Biochemistry, Histopathology, Laser capture microdisection Bioinformatics Database development & data warehousing

Genomics Lab.

Laser dissection Lab.

Proteomics Lab.

PCR Lab.

101

High‐throughput Research

WRI is equipped for high throughput parallel analysis of gene expression.

Parallel examination of global gene expression as a function of disease, habit, therapy or surgery.

DNA Microarray Spotter96 Capillary DNA Analyzer

Ettan Spot Picker

Automated Slide Processor

102

Platforms for parallel analysis characterization of up to 1200 proteins within a 24 hour period

Protein Research

Imaging Protein picking Protein digestionElectrophoresis Identification

MALDI-tof

LC/MS/MS

103

Platform for Large‐scale Biology

Advanced robotics for automated protein spot picking and processing

State of the art instrumentation for:

Global protein profiling Differential expression Peptide identification

Spot handling robot for highthroughput proteomic research

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Clinical Breast Care Project of Walter Reed National Medical Center

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No Boundaries

106

Nick Jacobs, FACHEInternational DirectorSunStone Management Resources

107

1987 – 2014 Memorable Quote from two centuries!

108

“Originality is dangerous. If you want to increase the sum of what is possible for human beings to say, to know, to understand and therefore in the end, to be, you actually have to go to the edge and push outwards. . . At its very best, it’s a revolution”

111

Quality vs. Quantity

112

Medicine in the United States is NOT Integrative

114

Transition from Fee for Service to

Value-based Care

115


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“Obviously, both hospitals and physicians are worried about. . . CHANGE, but it is common knowledge that if something is NOT DONE, our health care system will crash and burn. Think of this, providers would get paid more for keeping their patients healthy and out of the hospital. What a concept.” Dr. Paul Levy

117

THE FUTURE OF HEALTHCARE IN AMERICA

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Successful new care models are emerging, providing new ways to get and give care, to create and maintain relationships, and organize communities. Many of these offerings replace traditional functions, adding new dimensions of accessibility, value, and transparent activity. Consumers and patients are eagerly adopting these new solutions in their lives.

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Concierge, Membership Model,

Par, No Par, Insurance vs. Cash,

Combination Insurance and Cash, Multi-disciplinary Integrative

Practitioners: ND’s, Chiropractors, Massage, Energy Medicine, NP’s, PA’s

Health Coaches, Yoga

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Why can’t hospitals and physicians do the same?

They can – but not without dramatic changesin the way they think, the strategies they adopt

and the innovation processes they use.

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Physicians, Hospitals, and Health Systems that make this commitment will discover

extensive opportunity. They will succeed in engaging large new segments of patients,

both among the public and among businesses, and they will discover ways to

serve them more effectively than ever before.

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Find a way to help you migrate from an old model of care to diverse and growing portfolios of services that engage throngs of new patients and supporters through efficiency, quality, transparency and patient centered care.

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In this fast-changing environment, how canan industry built on a centuries-old model be

transformed?

Opportunities are hard to see and even harder to capitalize on when you are

wearing the blinders imposed by several hundred years of tradition.

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It is NOT our goal to create what people will LIKE.

It is our goal to create what people will LOVE!

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THE FUTURE BECOMES A DESIGN FUNCTION

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Population Health

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$35 billion Annually on diabetes and/or metabolic

syndrome

26 million or 8%Americans diagnosed Type II diabetes

70 million or 22%Americans in development stages

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About 90 percent of our expenditures are because of stress related issues, and when we take such amazing statistics into consideration as the fact that the United States consumes two times more fat than Asia, three times less fiber, and 90 percent more animal protein, it has to make us think a little bit about this course that we are currently pursuing.

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24 Million People in the United States live in Food Deserts!

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Presidents of the United States

Reagan – 20 millionGeo HW Bush – 30 millionClinton – 33 millionGeorge W. Bush – 49 millionObama – 50 million

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Could it be OUR FOOD???

In 1960 our parents spent approximately 18% of their salaries on Food . . .

In 1960 our parents spent 9% of their salaries on Healthcare

In 2013 we spend 9% of our salaries on food

In 2013, we spend 18% of our salaries on healthcare

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7,000 to 10,000 Baby Boomers turning 65 every day

45% of newly insured will be on Medicaid

Creating an imbalance for health care institutions between medical and surgical care

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Why can’t we reach out to our communities in order to save our health systems, practices, and protect our future?

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It has long been recognized that it is easier to put into practice wellness and prevention initiatives than to eliminate a service once it has been offered. So, how do health systems address cost pressures, income shortages and shifting demographics?

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With the creation of Accountable Care Organizations as prescribed through the Affordable Care Act, Integrative Medicine could become a fully endorsed service-line by all Health Systems to be utilized in income creation and expense reduction for numerous aspects of care.

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Integrative Medicine — the practice of medicine that:

Reaffirms the importance of the relationship between the practitioner and the patient,

Focuses on the whole person, Is informed by evidence, and Makes use of all appropriate therapeutic

approaches, healthcare professionals and disciplines to achieve optimal health and healing.

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Holistic Medicine — from the root HEALTH

Medical care that views physical and mental and spiritual aspects of life as closely interconnected and equally important approaches to treatment.

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Diet Exercise Stress Management Group Support

Expanded from 36 to 72 visitsPaying $80 and in 2014 this goes to

$112 a visitOver $7000 per patient

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Because Integrative Medicine deals directly with root cause medical issues, protocols implemented by Integrative Medicine health coaches that follow patients post discharge, ensure follow-up appointments and increase patient satisfaction at all levels through individualized attention and care, several of the cost/price issues will be addressed and marginalized.

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A complete community health related effort that includes the creation of well-being centers, workshops, appropriate screenings, as well as wellness and prevention classes can ignite community wide awareness and participation in health changing attitudes and activities; hence, lowering the need for expensive inpatient care on many levels.

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By assisting the residents of the greater service area to become the CEO of their own health, we are creating an awareness movement not dissimilar to those psycho-social societal efforts that we’ve seen over the past two decades to reduce inappropriate consumption of alcohol, drugs and tobacco.

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Integrative health coaching is a co-creative and dynamic partnership between a

consumer (patient) and professional coach embedded into a healthcare management system designed to identify, monitor, and

motivate behavior in order to maximize the physical, mental, social and spiritual health

of the consumer. Health coaches are medically licensed and coaching certified.

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Having patient advocates co-ordinate the care of the 18 Club, patients with nine physicians with whom they interact annually and nine different drugs that they take daily, would be of tremendous benefit. It would help them avoid unneeded duplications, millions could be saved.

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Help to alter labor cost by redesigning inpatient care models and supplementing nursing care.

This will improve nursing quality and the nursing work environment, prevent demand of less profitable services and create a healing environment that also contributes to lower lengths of stay and fewer hospital acquired infections.

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Show me the money . . .HCHAPS!

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Do the Math!

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Increases in Patient Satisfaction Increases in Employee Satisfaction Increase in Patients Increase in QualityReduction in number of lawsuitsReduction in readmissions prior to 30 days

Transformational Practices

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0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6 Hosp. *

Hosp. A

Hosp. B

Hosp. C

Hosp. D

Hosp. E

Hosp. F

Hosp. G

Medical Center had the lowest mortality rate of 0.8% compared to 8 peer hospitals all above 1%

Risk-adjusted index is statistically significant at a confidence level of 95%

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Come to OUR HospitalYou’ll Die Less Often!

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Judy Rich, CEO Tucson Medical Center/TMC Healthcare

This has been a journey that has required an “all-in” leadership commitment. No dabbling in an ACO… This model fundamentally changes the way we do business. This journey is not for the timid; it is full of risk and potential obstacles, but it is the necessary path for us to fulfill a core mission of providing exemplary healthcare with access for all in our community. It puts us into a full partnership with our medical staff . . .

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Some have embraced it because they believe that it links payment to performance.

Others will embrace it because it focuses on clinical integration and coordination

And finally, some believe that it is a true competitive destination and one to which the organizations are committed before the system takes on more water!

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Their vision was to transform the “MONEY SYSTEM” into a SYSTEM OF CARE!”

And the pitfalls are: complexity, resistance, trade-offs, missteps . . . to name just a few.

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These partnerships of primary-care and specialists doctors with hospitals and clinics might help to produce a model that, although directed toward Medicare, could also have a positive impact on all of U.S. health-care.

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“ACOs were brought into effect with three major aims which are:

Better care for individuals,

Better health for populations, and

Slower growth in costs through improvements in care.”

Don Berwick, MD, Administrator of the Centers for Medicare and Medicaid Services

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They would be structured to coordinate care and their reward would be to share financially in savings with the government if they could come in lower than expected, but they could also be PENALIZED if they go over the projected costs.

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The most powerful fix would be to change the relative fees paid to primary care and other cognitive specialists, compared to specialists. Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.

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Medicare can also engage in real clinical transparency, insisting on the publication of real-time information about infections and other important aspects of quality and safety as one of its Conditions for Participation.

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ABIHM – Holistic Integrative Medicine Biotech – SYSTEMS BIOLOGY

Dr. Leroy Hood – Founder and Director of Institute for Systems Biology - Dedicated to identifying strategies for predicting and preventing diseases. His inventions have permanently changed the course of biology, and revolutionized the understanding of genetics, life and human health.

Hood invented four instruments that have unlocked much of the mystery of human biology, including the automated DNA sequencer, a powerful device for sequencing proteins, A machine for synthesizing proteins and An automated tool for synthesizing DNA.

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Within the next ten years, healthcare will fundamentally change from reactive to proactive

This is because medicine will become predictive, personalized, preventative and participatory

WHY? Because biology is evolving into an informational science and it will NOT stop going in that direction

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Proteomics and Genomics will contribute to the continued morphing of our current diagnostic medicine into this new world order

Spectacular computational power will map 2500 blood organ specific proteins from 50 organs to diagnose our patients and provide them with wellness assessments

Vaccinations will be developed as specific therapies for hundreds of different diagnosis

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SNP analysis will be used to monitor toxicity, response dose and combinational therapies.

These types of advancements will result in “Planned strategies for health.”

HenceSystems BIOLOGY

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It cost $3,000,000,000 to map the human genome in 2003. This year? Less than $1000.

It cost $1M for a terabyte of storage for data. Today? 2 TB of Cloud Storage -$16.00.

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Regenerative medicine is the "process of replacing or regenerating human cells, tissues or organs to restore or establish normal function".

Regenerative medicine also empowers scientists to grow tissues and organs in the laboratory and safely implant them when the body cannot heal itself.

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Reagan launched SDI in a March 23, 1983, speech. "Let me share with you a vision of the future which offers hope," he said, and then he described a system that could "intercept and destroy strategic ballistic missiles before they reached our own soil."

Algorithms that could analyze 1500 incoming intercontinental ballistic missiles to determine which were real and which were dummy warheads.

Jess Granone’s sister-in-law

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“Not only would it allow us to cure cancer by repairing or destroying malignant cells one by one but it would revolutionize gene therapy as well.”

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IBM has found a way to meld biology and computing to create a new chip that could become the basis for a fast, inexpensive, personal genetic analyzer. The DNA sequencer involves drilling tiny nanometer-size holes through computer-like silicon chips, then passing DNA strands through them to read the information contained in their genetic code.

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The “DNA transistor” could make it faster and cheaper to sequence individuals’ complete genomes. In so doing, it could help facilitate advances in bio-medical research and personalized medicine. For instance, having access to a person’s genetic code could help doctors create customized medicine and determine an individual’s predisposition to certain diseases or medical conditions.

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Saddle makers- automobiles

Watch makers – the quartz watch

Newspapers

Music

Movies

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Where to put your focus!

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CLEARDo not bury the lead

RELEVANTMake sure to paint a picture and always make sure to demonstrate relevance to the potential investor

ENGAGING

Bring them to their senses: sight, sound, smell, taste, and touch

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ACCURATE

THERE IS NO EXCUSE FOR FACTUAL INACCURACY

TIMELYIt is very important to remember that information is time-sensitive

ENTHUSIASTIC/PASSIONATE

Enthusiasm makes your audience glad to see you

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Spirituality & Wellbeing

Mary Jo Kreitzer PhD, RN, FAANDirector, Center for Spirituality & HealingUniversity of Minnesota

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One could call every illness an illness of the soul. ~ Novalis

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Overview

Discuss the evidence base linking spirituality with health outcomes.

Describe spiritual practices that promote health and wellbeing.

Discuss strategies for advancing wellbeing in the lives of people,organizations, and communities.

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Defining Spirituality

Spirituality is broadly defined as that which gives meaning and purpose to life.

“Spirit” – comes from the Hebrew word “ruah” which means wind, breath or air, that which gives life.

Essence of one’s humanity (Frankl, 1963)

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Power, force, or energy that stimulates creativity, motivation or striving for inspiration. (Chiu, 2004)

Search for the sacred. (Pargament, 1997)

Purpose, meaning and connectedness with self, others and higher power.

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Spirituality is the aspect of being human that refers to the way individuals seek and express meaning and purpose, and the way they experience connectedness to the moment, to self, to others, to nature and to the significant or sacred. (Puchalski and Ferrell, 2010)

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Religion

Organized system of beliefs, practices, and rituals associated with a particular faith tradition.

Religion may or may not be part of a person’s spirituality.

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Relevance for health care providers?

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“Close to the Bone” – Jean Shinoda Bolen

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Diagnosis of a Chronic or Life-Threatening illness

Feelings of anger, grief, loss, despair, and hopelessness.

Why me? Why now? What is the meaning of this?

May provoke a spiritual crisis.

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Greek Temples

Sanctuaries of Healing

Body, mind and spirit were the focus of care.

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Hildegaard of Bingen

12th Century Mystic and Healer

Use of art, music, use of herbs and prayer

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Florence Nightingale

Role of the Nurse …“Put the patient in the best possible condition so that nature can act and healing occur”.

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Nightingale

Tenets of holistic practice – importance of natural light, fresh air, touch, diet, noise control and spirituality

Hygiene, sanitation and infection rates

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Osler

It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.

William Osler

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Historically, the healing professions were grounded in spirituality.

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17th Century Dualism

Wall of separation divided the care of people into mutually exclusive and often antagonistic camps.

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Contemporary Western Science

Often dealt poorly with the spiritual side of human nature by ignoring it.Viewing spirituality as being beyond the scope of professional practice.

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CAM Professions Excelled

Relationship-basedCare of the whole person

Body, mind and spiritListening to the story

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“We have traded mystery for mastery and paid a great price”. Rachel Naomi Remen

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What do patients want?

In two national surveys, over 70% of patients polled believed that spiritual faith and prayer can aid in recovery from illness; 64% of those surveyed believe that health professionals should talk to patients about spiritual issues as part of their care.

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45 Year Gallup PollBeliefs and Attitudes

50% describe themselves as religious.

33% describe themselves as spiritual but not religious.

78% report the need in their life to experience spiritual growth - compared to 20% - 5 years ago. (2002)

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Spirituality in College StudentsFindings from a National Study

Over half of third-year college students place a high value on “integrating spirituality into my life”.

More than 2/3 report that they have had a spiritual experience.

Three-fourths of the students believe that we are all spiritual beings.

– Higher Education Research Institute, UCLA, 2003

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Evidence?

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Spirituality and Health Outcomes

Patients who score higher on spirituality or religious scales have lower mortality due to coronary artery disease or cardiac surgery-related complications. (Haskell, 2003)Degree of spiritual well-being may be an important factor in progression or regression of coronary artery disease. (Morris, 2001)In heart failure patients, spiritual well-being was associated with less depression. (Bekelman et al, 2007)

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Spirituality and Health Outcomes

Spirituality was associated with less distress and better quality of life in cancer patients. (Zakowski and Bair, 2004)Existential well-being was found to have a strong negative correlation with depression. (Nelson et al, 2002)Spiritual struggle was associated with poorer QOL and life satisfaction. (Hills et al, 2005)

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“Love and Survival: The Scientific Basis for the Healing Power of Intimacy”

Opening your heart –when the emotional and spiritual heart begin to open, the physical heart often follows.

Dean Ornish MD

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Assessing Spirituality

What gives you hope and meaning?What spiritual practices are living-giving for you?Are there any specific practices or restrictions that we should know about?Do you have spiritual concerns or issues you need to address? Are you part of a religious or spiritual community?

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FICA Interview Guide

FaithWhat is your faith?

Importance/InfluenceHow important is your faith?

CommunityAre you part of a religious community?

AddressHow would you like spiritual issues addressed? (Puchalski)

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Research Instruments

Spiritual Transformation ScaleBrief Serenity ScaleSpiritual Well-Being ScaleMeaning in Life ScaleSelf-Compassion ScaleIndex of Core Spiritual Experiences (INSPIRIT)

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Addressing Spiritual Issues

The predominant orientation of biomedicine is on curing – diagnosing, treating and repairing the broken or damaged part of the body.

Healing – restoring wholeness and integration. Requires attending to the whole person – body, mind and spirit.

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Shift from a biopsychosocial model of care to a biopsychosocial – spiritual model.

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Integrative Approach to Care

“Being with” - healing“Doing to” – curing

–J Milstein (2005)

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“Being With” – a way to provide spiritual support

Cultivation of skills:Deep listeningCompassionMindfulnessPresence

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Providing Spiritual Care

Is at once both simple and extremely difficult.It requires that the health care professionals bring their humanness to the medical encounter.

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Who provides spiritual care?

Healthcare professionals – spiritual care can effectively and interchangeably be provided by multiple members of the care team.Professionals trained in spiritual care.

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Spiritual Care Providers

ChaplainCommunity-based religious or spiritual leader (priest, rabbi, shaman)Spiritual director or counselor

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Barriers of Spiritual Care

Lack of sufficient time.Lack of skills.Institutional obstacles – lack of privacy and continuity of providers.Social, religious or cultural discordance between caregivers and patients.

(Daaleman et al, 2008)

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Spiritual Care Practices

PrayerMeditationMusic and ArtNatureJournalingWalking a labyrinth

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“Diseases of the soul are more dangerous and more numerous than those of the body”. Cicero

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Spirituality of Health Professionals

Personal growth and well-beingJob satisfaction and burnoutClinical effectiveness

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Spirituality of Health Professionals

Making a spiritual connection with patients will help physicians at least as much as it helps their patients. If physicians reconceptualize themselves as healers, as opposed to solely technicians, who dedicate their lives to reducing human suffering, they will reconnect with the passion and dedication that initially directed them to medicine. (Grubb, 2003)

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Nurturing the Soul and Spirit of Health Care ProvidersFriends, nature, relationships, beauty, food, art, family, contemplation, travel, solitude, education, retreat, community, books, and home.

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Signs of Change

A growing number of medical and nursing schools teach content or even whole courses on spirituality.

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US Hospital Accreditation

Spiritual care is a criteria for accreditation of hospitals by JCAHO. Hospitals must document assessments of spiritual beliefs and practices.Pastoral care must be available to patients who request it.Hospitals must meet the spiritual needs of dying patients and their families.

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Vinland National Center in Loretto Minnesota

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Vinland National Center

Full lives for people with disabilities.Treating the whole person.One of three programs in US that specializes in clients with brain injury and chemical dependency.

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Unique Residential Approach

1:1 and group counselingPersonalized fitnessIndoor and outdoor physical activitiesComprehensive vocational servicesFamily Program

Courses – include, anger management, self-esteem, grief and loss, wellness, nutrition, aromatherapy, tai chi, leisure education, and conflict resolution

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Spirituality

Native American Healing CeremoniesMeditationJournalingMindfulnessNatureCultureArt Therapy

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Art Therapy – Mask Making

Art is used to raise spiritual, psychological and emotional issues.

What are you hiding behind? What is your street face? What is your love

face? What is your sacred face?

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Recent Outcomes Data – 6 months post discharge (residential program)97% reported 0 times/week use of alcohol.0 % homeless or unsafe living environment.71% good living and 28% great living environment.70% return to work (work, training, volunteer).94% reduction in incarceration.

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Move Beyond “Fixing” Health Care…… Building Capacity in People and Communities

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WELLBEING

• Whole person• Increase capacity and

expand potential• Possible even with chronic

illness and maturing bodies• Individual, family,

organization, community and nation

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Summary

A commitment to caring for the whole person requires that we go beyond caring for the physical body.Human beings are spiritual beings. Whether healthy, injured or ill, human beings naturally ask transcendent questions about meaning value and relationships.

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Summary

Attending to spiritual needs of patients is not just a moral option. It constitutes a moral imperative.

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Reflection“Perhaps our best

work as health professionals is not about something we do but about something we are, something we become and bring into all of our relationships”. Rachel Naomi Remen

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Reflection

At the dawn of the 21st century, the most profound revolution awaiting western biomedicine may not be genomics, nanotechnology, or artificial organs, but rather the re-introduction of spirituality into the practice of health care.

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Global Health & Integrative Medicinethe Future of Health for the Planet & Humanity

Dr. Tabatha ParkerNaturopathic DoctorExecutive DirectorNatural Doctors International (NDI)

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InspirationInspire yourself and others will be inspired. Motivate yourself and others will be motivated. Develop yourself and others will start to develop themselves. Be an example first and then the world changes around you

Author Unknown

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Who are we: USA health providers?Profession Designation in USA SourceAcupuncturist/Oriental Medicine LAc 25000 ACCAHCChiropractors DC 70000 ACCAHCMassage Therapist ‐ Licensed LMP 250000 ACCAHCMedical Doctors (Primary Care) MD 425000 KaiserMedical Doctors (Speciality) MD 428000 KaiserMidwives (Certified Nurse Midwife) CNM 12692 ACNMMidwives (Certified Midwives) CM 73 ACNMMidwives (Direct Entry‐homebirth) CMP 1800 ACCAHCNaturopathic Doctor ND 5000 ACCAHCNurse (Registered Nurse) RN 2,725,000 Kaiser Nurse Practitioner NP 180000 KaiserOsteopaths DO 80000 AOAPhysical Assistant PA 83000 KaiserPhyiscal Therapist PT 183000 APTA

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Natural Doctors International

Where I came from we are• 1st international service NGO created for

licensed natural medicine providers• ND Founders - Dr. Tabatha Parker, Dr.

Laurent Chaix, and Dr. Michael Owen.• 501(c)3 designation in 2003• Started in Moyogalpa Hospital in 2005• Opened NDI clinic in February 2010

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Natural Doctors International

• Expansion of 6 Naturopathic Principles into Global Health, Social Justice, Ecology.

• Integrative and Collaborative • Accept and reach out to all professions:

NDs, DCs, LaCs, Acupuncturists, MDs, DOs, Midwives, PTs, OTs, herbalists, MPHs, activists, students of all kinds, anyone with a genuine desire to contribute.

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NDI a glimpse at our work

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Key principles, practices & opportunities for integrative medicine in global health

The Principles of Holistic Primary Health Care

The principles of Holistic Primary Health Care (HPHC) are a unification of four of the mostimportant international declarations to have emerged in the modern era, presented in a mannerwhich summarises this declaration’s vision of the interdependence of human rights, communityhealth, ecological harmony, and the necessity of multi-sectoral integrative approaches to worldhealth.

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Three pillars

• The Universal Declaration of Human Rights (1948) -upholds the rights of the individual in relation to health.

• The Alma Ata Declaration of Primary Health Care(1978) –upholds the rights of communities in relation to health.

• The Earth Charter (2000) –upholds the rights and importance of the environment in relation to health.

And rests upon the following platform:• The Beijing Declaration on Traditional Medicine

(2008) –upholds the value of holistic medical practices from around the globe and the necessity for them to work in an integrated fashion with existing healthcare services.

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One Health Organisation

Our vision of the interdependence of human rights, community health, ecological harmony, and the necessity of multi-sectoral integrative approaches to world health.

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models of global health: service learning programs vs voluntourism

Which will you choose: Sustainability or convenience? This is our responsibility.

Traditional Model – 1 – 2 week medical mission tours, no permanent links, band-aid medicine, fix-it mentality, convenient for the provider.

Social Justice Model – Service learning, linked to long term projects, community links, listening to needs, partnership, sustainability.

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Stories from abroad

Best intentions• 1 church 7 paintings• 1 patients, 3 enalapril• Morphine lollipops• Unlabeled medicine• Our trash, your present,

your problem

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best practices in service work & social justice medicine

Work legallyRespect local culturesWork with local long-term organizations Do not just join short-term medical tripsTake the time, build the relationships

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global health policies impacting integrative medicine

BenchmarksWHO 2014-2023 Traditional Medicine StrategyFederations

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Benchmarks for Training in Naturopathy –edits 2006, published 2010

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WHO – Strategy on 2014 - 2023

The strategy has two key goals o support Member States (192) in

1. harnessing the potential contribution of T&CM to health, wellness and people centered health care and to promote the safe and

2. effective use of T&CM through the regulation of products, practices and practitioners.

Goals reached by implementing 3 strategic objectives:

1) Build knowledge base and formulate national policies; 2) strengthen safety, quality, effectiveness by regulation; 3) promote universal health coverage by integrating T&CM services and self-health care into national health systems.

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T&CM DefinitionsTraditional medicine (TM):Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, use in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.

Complementary medicine (CM):The terms “complementary medicine” or “alternative medicine” refer to a broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health-care system. They are used interchangeably with traditional medicine in some countries.

Traditional and complementary medicine (T&CM):T&CM merges the terms TM and CM encompassing products, practices and practitioners.

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From the Strategy

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Traditional Medicine

Levels of education, accreditation and regulation of T&CM practices and practitioners vary considerably. In an increasingly globalized world, individuals move freely from country to country in order to live and work. Given this trend, a better understanding of T&CM practitioners is needed to ensure professional consistency and safety.

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What professions have world federations?

Physicians (MDs)HydrotherapistsChiropractorsChinese MedicineAcupunctureOsteopathsNursesPublic Health

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Annex B of the WHO Strategy

World Federation of Hydrotherapy

World Federation of Acupuncture & Moxibustion

World Federation of Chiropractic

World Federation of Chinese Medicine Societies

Osteopathic Alliance

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Purpose of Federations• International Professional Associations • Ensure professional consistency/safety• Create international standards to

reduce variability in education, accreditation & regulation

• Facilitate international collaboration which is beneficial & necessary

• Facilitate relations with health ministries: MINSA (Ministry of Health)

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FORMATION

Paris, FranceJuly 2014

2nd International Congress of

Naturopathic Medicine

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Paris – WNF formedAt the 2nd International Congress on Naturopathic Medicine (ICNM), July 4-6, 2014, Paris, over 30 participants representing national associations from around the world voted unanimously on Sunday July 6th, 2014, to form the World Naturopathic Federation (WNF).

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Interim CommitteeAnne Marie Narboni (France), Babu Joseph (India), Iva Lloyd (Canada), YannickPots (Belgium), Phillip Cottingham (New Zealand), Tabatha Parker (USA), Tina Hausser (Spain/Germany), Jon Wardle (Australia)

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global health priorities impacting integrative medicine

WHOWorld Health AssemblyMDG’sNCD’s

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WHO & Geneva• Every year the WHO has a

WORLD HEALTH ASSEMBLY, convening their 193 nations in MAY. This is the largest most important health assembly in the world.

• In 2014 of this year, 2 NDs attended the 67th WHO WHA -Michael Cronin, ND and Tabatha Parker, ND – becoming the first NDs to attend this assembly in history.

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Having a world federation that is has the stamp of the WHO is important for individual associations & countries to move forward policy in individual countries – ex. Zambia, Democratic Republic of Congo, New Zealand, France – all of these countries have expressed how important this would be for their work!

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1) 40% Reduction in # Children Under 5y/o who are stunted

2) 50% Reduction of Anemia in women of reproductive age

3) 30% reduction in low birth weight4) No increase in kids being

overweight5) Increase the rate of exclusive

breastfeeding in the first 6 months up to at least 50%

6) Reduce and maintain childhood wasting to less than 5%

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"You're only given one little spark of madness. You mustn't lose it.” Robin Williams

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Personalized Integrated Healthcare: A Look Ahead

Jeffrey Bland, Ph.D., FACN

President

Personalized Lifestyle Medicine Institute

www.plminstitue.org

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Learning Objectives

• What do we mean by “personalized integrated healthcare”?

• What is meant by the term “metabolic inflammation”?

• How does this approach apply to the management of the dominant chronic metabolic diseases? • Type 2 diabetes, cardiovascular disease, inflammatory airway

diseases, obesity, autoimmune diseases, osteoporosis, dementia

• How do pattern recognition receptors and specifically toll-like receptors play a role in the etiology of these chronic metabolic diseases?

• What specific therapies derive from the understanding of toll-like receptors and their relationship to chronic diseases?

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The Present Health Challenge

• Present system poor outcome in patients with 2 or more diseases

• More than ¼ of adults have multiple chronic conditions

• 2/3 of Medicare have multiple with 14% having 6 or more conditions

• Goals: Foster Systems Change, Empower people, Equip clinicians, Enhance research

JAMA 2014; 312: 1199. Question: Can we find a common cause of many chronic diseases?

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Do Our Genes Directly Control Our Health Outcomes?

• Why are 370 million people projected to have type 2 diabetes within the next 20 years?

• Is type 2 diabetes monogenetic? • Is type 2 diabetes one disease or

many? • What is difference between

genetic and epigenetic factors ? • What is the role of bioactives

from food in the etiology of type 2 diabetes?

• Does our environment have anything to do with the type 2 diabetes pandemic?

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Monogenetic vs Gene-Environment Etiology of Disease

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YOUR BOOK OF LIFE IN 23 CHAPTERS Expressed Differently in Different Environments

Ridley M. Genome – the Autobiography of a Species in 23 Chapter. 1999. 289

30% of chronic disease is genetically-related:

70% of chronic disease is lifestyle, nutrient and environment-related

What impact will this understanding have on

healthcare?

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What a Chromosome Looks Like

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May 27, 2013…Genes and Disease

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Mary Claire King and BRCA 1 and 2

“The lifetime risk of breast cancer among female mutation carriers is presently 82%. Risks appear to be increasing with time. Before 1940 it was 24%. Lack of physical exercise and obesity in adolescence may be important modulating factors for risk in carriers”. Science 2003; 302: 643-50. 293

Incidence of Breast Cancer in Women with BRCA1/2 mutations

Age 294

Health is personal.

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Where it all starts--Parenting

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• Genetics • Nuclear DNA

• Mitochondrial DNA

• Epigenetics • Prenatal environment

• Postnatal exposures

• Sociobiology

• Breast milk • The first “Functional

Food“

• Preconceptional • Parenting before

conception

Science 2014; 345: 743.

297

10/7/2014 15

• Environmental exposures of both parents • Michael Skinner

• Methylation patterns

• Transgenerational effects

• Mitochondrial DNA

• Noncoding RNAs

• Chromatin Integrity

• Nutritional status of both parents

Parenting Before Conception

298

Epigenetics “Father of Nutritional Epigenetics”

• Randy Jirtle

• Visiting Professor, McArdle Laboratory, University of Wisconsin

• Pioneered the use of Agouti mouse to look at the effect of diet, nutrients and environmental agents including BPA on the mammalian epigenome and disease

299

Randy Jirtle and Nutritional Epigenomics— The Agouti Mouse Story

Cooney CA et al. Maternal methyl supplements in mice affect

epigenetic variation and DNA methylation of offspring.

J Nutr. 2002 Aug;132(8 Suppl):2393S-2400S.

Methylation Support

Dams (f0) Offspring (f1)

300

http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3051&itool=AbstractPlus-def&uid=12163699&db=pubmed&url=http://jn.nutrition.org/cgi/pmidlookup?view=long&pmid=12163699

Foods and Phytochemicals that Influence Genome Methylation and Sirutins

301

Ice Storm Babies Show Unique Methylation Signature

PlosOne 2014; 9: e107653 Moshe Szyf and November 2010 FMU interview

302

What we can learn from breast milk about optimal nutrition

• Unique carbohydrates • Oligosaccharides • Bifidobacterium longum

biovar infantis (B. longum bv.infantis)

• Unique fatty acids • Rich in n-3 DHA

• Bioactive proteins • Delivers specific immune

active peptides

• Enzymes • Activated in the gut

Science 2014; 346:747-50. 303

What makes us different?

Personalized

Medicine

Lifestyle

There is a BIG new idea that will change the health of the world.

304

We are not pathways, but networks of genes regulated by our environment

305

What makes us different?

306

Scientific World Journal 2013 307

The Origins of Functional Medicine--

308

Dr. Willoughby Wade and Functional Medicine-1871 • Concepts

• “All disease is disordered function” • Drugs often treat symptoms not cause of disease • Pathology is preceded by alteration in function • Root cause of diverse symptoms may come from primary

alteration in core function • Symptoms of disease may arise from a distant alteration in

function (systems biology) • Disease is a limiting concept and should be replaced by

understanding of origin of the dysfunction

• Biography • 1827-1906, Irish, knighted 1896, Head Kings College &

Hospital 309

28 311

The Functional Medicine Operating Model

Structure

Energy (Production & Utilization)

Cellular Transport

Assimilation/Elimination

Detoxification

Immune Defense

Cellular Communication (Hormones)

Personalized Lifestyle Healthcare/Medicine

Lifestyle Behaviors

Diet

Environment Genes

312

30 313

Proof of Concept

Generating the Data Necessary to Change the Medical Paradigm

314

The Institute for Systems Biology Pioneer 100 Wellness Project

315

10/7/2014 33

The 21st Century Framingham Project

316

Trends in Diagnosed Type 2 Diabetes: 1980-2012

• Rapid increase in T2D from 1990-2008 but leveled off 2009-2012

• Tracks very closely with increase in obesity

• Suggestion that obesity “causes” T2D

• But is that correct? • Association or cause?

JAMA 2014; 312: 1217-25. 318

Trends in waist circumference as a marker of central adiposity

• Trends from 1999 to 2012 indicate continued increase in waist circumference

• Waist size is the most convenient surrogate marker for central adiposity

• Central adiposity is most correlated with metabolic disease • “Angry Fat”

• Metabolic inflammation, sleep apnea, endocrine disruptors, certain medications

JAMA 2014; 312: 1218. 319

Cardiovascular Diabetology 2012; 11: 133-42. 320

Nutritionally Related SNPs of Potential Importance to Disorders Associated with Metabolic Inflammation

• Methylenetetrahydrofolate Reductase (MTHFR)

• Apo E4

• COMT

• IL-1beta receptor

• PON1

• Vitamin D receptor

• Deiodinase

• TLR-4

• HDL

• Adiponectin

• Fatty acid binding protein 3, 4 (FABP4)

• FTO

• PPAR gamma

• IGF 1

• IRS1

• PAI1

321

Where Metabolic Inflammation Starts Toll-like Receptors and Pattern Recognition

N Engl J Medicine 2011; 364: 60-70. 322

Toll-like receptor 4 activation Atherosclerosis, Arthritis, Diabetes, IBD, Dementia,Chronic Pulmonary Disease

N Engl J Medicine 2002; 347: 185-92 323

Toll-like receptor signaling and gene expression (TLRs are expressed in gut, liver, macrophage, adipocyte, brain, lung, kidney, beta-cells and bone)

324

TLR-4 Signaling and NFkB activation

TLR ligands Include: LPS, saturated fatty acids, xenobiotics, hypoxia, oxidized lipids 325

Ingestion of Bacterial LPS Inhibits Taste Response to Sugar • Bacterially-derived lipopolysaccharide (LPS) modulates

neural response to taste stimuli

• Response to sugar was significantly reduced upon exposure to LPS

• This effect is seen through alteration in taste receptor activity (Tastr1/2)

• This is the same receptor that is found in the mucosa of the distal ileum and controls GLP-1 secretion

• The process of altered Tastr1/2 activity is initiated by activation of TLR-4 receptors

Neuroscience 2014; 258: 47-61 326

Bacterial LPS induces insulin resistance due to chronic inflammation

• Chronic elevation of gut-derived LPS(i.e. metabolic endotoxemia) plays role in insulin resistance

• LPS levels found elevated in obese, diabetic humans

• LPS stimulates TLR-4 activity in muscle cells from obese, diabetic humans

• Enhanced metabolic inflammation in the muscle blocks insulin signaling

• Antagonists of TLR-4 may improve insulin action in these individuals

PlosOne 2013; 8: e63983 327

Insulin resistance is activated by TLR-4 action through gut hormones

328

10/7/2014 46

• Toll-like receptors are well characterized immune modulators that enhance inflammation

• TLR-4 activation induces insulin resistance • This is suggested as a primary step in the pathogenesis of

obesity and metabolic syndrome

• TLR-4 is activated by both LPS from gut bacteria and dietary fatty acids

• Increased gut permeability (eg. leaky gut) results in increased systemic TLR-4 activation

• Targeting TLR-4 induced inflammation can prevent the initiation of diabetes, obesity and cardiovascular disease

Toll-like receptor status in obesity and diabetes

J Clin Endocrinol Metab 2014; 99: 39-48 329

Artificial Sweeteners, Diabetes and Gut Microbiota

330

• Pharmacology of metformin is related to gut microbial activity

• Influences GLP-1/PYY production through microbiome/gut immune interaction

• Bacteroides versus Fermicules abundance associated with different clinical effects of metformin

• Stool samples indicated difference among individuals in response to metformin

PlosOne 2014; 9: e100778

331

Thorax 2012; 67: 456-63. 332

Lancet 2014; 384: 691-700 333

Dysbiosis, Systemic Inflammation and Allergic COPD

334

Microbial abnormalities in inflammatory airway diseases- Potential for therapy • Microbiome of the lung has been demonstrated to

be altered in patients with inflammatory airway diseases

• A tempting therapeutic approach is to share the microbiota to restore microbial balance

• The airway microbiome might soon join the intestinal microbiome as a target of intervention

• The concept of “whole body microbiome manipulation” represents an ecological approach to diseases associated with altered bacterial diversity

Pharmacol Ther 2014; 141: 32-39.

335

• Intestinal epithelium responses to bacterial products differently than other organs

• Luminal bacteria are needed for healthy gut • Modest activation of toll-like receptors is important in gut mucosal

remodeling • Optimal function is achieved with control of toll-like receptor activity

through proper diversity of microbiome

N Engl J Medicine 2008; 359: 756-58. 336

Summary Takeaways

• The future for managing chronic disease is personalized medicine that takes into account lifestyle, environment, diet and activity issues

• Insulin resistance and its relationship to metabolic inflammation represents a major unifying principle in chronic disease

• The initiation of metabolic inflammation is related to activation of pattern recognition receptors of which the toll-like receptors are important members

• Toll-like receptor 4 activation is initiated in the gastrointestinal-associated immune system

• Treatment of TLR-4 activation through interventions including pre and probiotics can serve as primary approaches to the treatment of multiple chronic diseases

337

Great Leadership in Integrative Medicine

Mark J. Tager, MDCEO, ChangeWell [email protected]

338

The IM Question for Leaders

As a leader, how do you transfer the whole person attitudes, values and skills of IM into cultures that may or may not be supportive of the same?

339

MotivateTeam

Maintain Stamina & Optimism

Stay on Course

Keep the Ship Afloat

The Turbulent Waters of Healthcare

340

Objectives

n Understand the powers of leadership

n Recognize the strengths & weaknesses of your current style

n Understand culture, context and communication in rapidly changing environments

n Review key attitudes and behaviors for successful leadership in changing environments.

341

Leadership

The process of influencing others to obtain results.

342

Leaders Depend on Power

Positional PowerProfessional PowerPeer PowerPersonal Power

343

You Have an Existing Style

n Direction & Support

n Natural Tendencies

n Work Experience

n Attitudes & Beliefs

n Training Programs

344

WHAT MAKES A LEADER “GREAT?”

345

Worst Boss/Best BossnWhat did s/he do?

nHow did it affect your energy, competence, willingness, enthusiam, performance, motivation, desire to go the extra mile?

nHow did s/he affect your health? Stress-related behaviors? Signs? Sx?

346

Leaders are Paid to Stress People

In a changing environment people don’t always act “rationally”

Productivity

Low Stress High Stress

347

In a World of Multiple Inputs, Some People Are Only There in Body

PerceptionsInterpretation

Compete for attention, hearts and minds

348

Leaders and the New Competition

What can I do?Direction and Support

�To people stay focused and productive?

�To create greater team resilience and improve communication?�To foster trust and inspire confidence?�To keep my own energy, enthusiasm, health and stamina up in the process?

349

Stable vs. Changing Environments

REQUIREMENTS:

�Perspective

�Flexibility

�Empathy

�Trustworthiness

350

The Power of Perspective

�Remain calm and positive under pressure

“Maintain an optimistic outlook. Develop the will to win by capitalizing on your unit's abilities. The more difficult the situation is, the better your chance is to display an attitude of calmness and confidence.”

351

Clarify the New Context

Context: a joining together..toweave together…the whole situation or relevant environment�Understanding Context/Content in stable vs. changing environment�Understanding culture�Around here, it’s normal for …

352

� When you first joined the organization, what details struck you?

� With regard to the change process, what typifies to you “the way we do things around here?”

� What rules?

� What procedures?

� What habits?

� Which norms support change positively?

� Which get in the way?

� Homework: Select one positive and one negative. Do a data dump

Bringing Awareness to Culture

353

Communicate with Credibility

The Two-Way StreetHow good is your relationship?OpennessHonestyGive and receive feedbackTrust

How do you develop one?

354

� Listen------Praise-----Catch em’ doing something right---build positivity.

� Now you can give feedback� First, must understand motivation

� Intrinsic� Extrinsic

� Praise and recognition� Task specific� Timely� For them� 4/1 Strokes/Pokes

� Use the rule of 2-1+1

Developing + Relationships

355

� Differences in how people perceive and interpret information

� A consequence of genetics and early childhood upbringing

� Concept of temperament--Jung and others

� Personality determines what stresses people

� To be credible: speak others’ language

Trustworthiness: Validity in Communication

The PowerSource Profile™

356

Grounding Creative

Logic Relationship

Valid Communication by Type

Perception

Interpretation

357

Intuitive Open to new ideas Future oriented Visionary Ask: “Why not?”

Predictable Practical and realistic Information from senses Detail oriented Focused on here and now

Valid CommunicationGrounding Traits Creative Traits

358

Sensitive to others Appreciate feelings Emotional decision making Considerate Time is circular

Objective Quantitative Sequential If A, then B; cause &

effect Historical past

Valid CommunicationLogic Traits Relationship Traits

359

‐1 +1Diminished AnswersIgnored AssurancesInvalidated Solutions

Empathy: Dealing with Resistance�Resistance takes many form�Leaders marginalize people’s resistance and pain

RAnswersAssurancesSolutions+1

R

They feel You respond with

360

Bringing the Best of IM to Leadership

Maintain perspectiveFocus on context/understand cultureBe flexible in leadership/communication styleOrient messages for receiverBuild trust in others

361

Integrative Medicine Certification in Administration

WHY HERE? WHY NOW?

362

Qualitative meets quantitative

Reimbursement Impact:

◦Wrong site surgeries◦Hospital acquired infections◦Readmissions prior to 30 days◦HCHAP scores◦Quality

363

One possible cure?Integrative Medicine:

◦Massage◦ Acupuncture◦ Reiki◦ Stress management◦Music therapy◦ Aroma therapy◦ Pet therapy◦ Guided meditation

364

Atlantic Health Integrative Medicine Treatment Room

365

Hackensack University Medical Center

366

Atlantic Health System’s New Chambers Center for Well‐Being

367

Center Kitchen

368

Exam ROOMS

369

Massage ROOM

370

Dr Mimi Guarneri Senior Medical Advisor

371

EXAMPLE:

The American Board of Integrative Holistic Medicine – 2700 docs

Academy of Integrative Health and Medicine – 420,000 practitioners

IHPC – Integrative Health and Policy Consortium – 200,000 practitioners

372

Contact InformationF. Nicholas Jacobs FACHE

International Director

SunStone Management Resources

112 Washington Place Unit 4D

Pittsburgh, PA 15219

E‐mail: [email protected]

Mobile: 412‐992‐6197

Home: 412‐381‐3136

Fax: 866‐381‐0219

www.sunstonemanagement resources.com

www.nickjacobs.org

373

Integrative Health and Medicine:Navigating Policy Trends

Len Wisneski, MD

374

All the tumult and seeming chaos, when viewed in the light of historical perspective, can be seen to represent not only the death agonies of an old order but also the birth pangs of a new epoch - a new golden age which assuredly will outshine those of the past.

- Historian L. S. Stavrianos

375

Integrative Healthcare and Medicine

THE FUTURE OF HEALTHCARE DELIVERY IN THEUNITED STATES

376

Institute of Medicine ReportCurrent state of affairs – population health

Unsustainable expendituresPrimary care system challengesPublic health infrastructureUninsured populationsHealth behaviorsSocial and economic conditions

377

The Health of the Nation: Poor Value for the Money

Life

exp

ecta

ncy

at b

irth

Total spending on health378

Mortality from Non-Communicable Diseases, 2008

Among the 17 peer countries, the US had 2nd highest Non-Communicable Disease mortality rate in 2008 (418:100,000)

379

The US performs poorly in health and places low on health rankings

Health Promotion: Empowering Change through Policy 7

Source: National Research Council and Institute of Medicine Report: U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013)

Source: Human Capital Report 2013 published by Mercer and the World Economic Forum

Average body mass index in 17 peer countries

US Ranks 43rd in Health

380

Conditions More Prevalent in the U.S. (>Age 50)ObesityInactivitySmokingDiabetesHypertension

Heart DiseaseStrokeChronic Lung DiseaseCancerArthritis

381

The Answer: Prevention and Well-Being

382

A ROSE BY ANY OTHER NAME

Holistic Medicine- ConsumersIntegrative Medicine- Universities Complementary and Alternative Medicine (CAM) – GovernmentEmergent- Integrative Healthcare

383

INTEGRATIVE MEDICINE MILESTONES1978 Founding of AHMA

1990 Study by Dean Ornish MD, shows that lifestyle changes can reverse heart disease.

1992 Congress establishes the NIH’s Office of Alternative Medicine.

1993 Study by David Eisenberg, MD demonstrates that one in three Americans use CAM therapies.

384

1996 Founding of ABHM

1996 Interest in St. John’s wort explodes after British Medical Journal study finds the herb effective in treating depression.

1997 First class of physician–Fellows begins training at the University of Arizona’s Program in Integrative Medicine.

NIH consensus panel supports use of acupuncture for various conditions.

385

1998 The Journal of the American Medical Association devotes an entire issue to alternative medicine.

NIH’s Office of Alternative Medicine is upgraded in status, and renamed the National Center for Complementary and Alternative Medicine.

2000 President Clinton establishes the White House Commission on Complementary and Alternative Medicine Policy.

Nineteen universities form CAHCIM

386

2001 Formation of the Integrated Healthcare Policy Consortium 2003 Institute of Medicine CAM Conference2004 Founding of ACCAHC2009 Institute of Medicine CAM Conference2011 American College of Lifestyle Medicine2012 Integrative Medicine in America Report2013 National Coordinating Center for IM

IMPriME

387

SITE SELECTION AND METHODS

• 60+ sites identified from Bravewell Clinical Network,Consortium of Academic Health Centers forIntegrative Medicine and suggested by IM leaders

• 29 chosen to represent the field•••••

Directed by MD, other doctoral level provider or nurseIn operation at least three yearsSignificant patient volumePrior clinical contributions to the fieldSites only delivering non-conventional care not included

• Directors responded to REDCap-based questionnaire• Site visits made by study team for qualitative data

389

CONCLUSIONS AND NEXT STEPS

• Integrative Medicine is an established part ofhealthcare in the US with increasing acceptanceand demand

• Integrative Medicine is truly integrative• Integrative Medicine is being practiced in diversesites with high concordance for specific conditionssuggesting practice is evidence-informed

• Prospective outcomes data and cost-effectivenessdata should be collected

• Systems to further identify and share best practicesamong centers and practitioners should bedeveloped

393

“Students must have sufficient knowledge of the commonly employed alternative remedies to counsel patients about those that are harmful, those that might interact adversely with prescribed medications, those that are harmless and can be used with impunity, and those that have been shown to be beneficial.”

Jordan J. Cohen, President of AAMCAcademic Medicine, June 2000

394

Current Education/Certification: Integrative MedicineUniversity of Arizona- Primary Care, Peds.National Coordinating Center for IM

American Board of Physician SpecialtiesAmerican Board of Integrative Holistic MedicineGeorgetown University Masters ProgramMetro University Undergraduate ProgramUniversity Courses/Centers

395

The Integrative Healthcare Policy Consortium(IHPC)

396

Health Promotion: Empowering Change through Policy

397

IHPC

Broad coalition of healthcare organizations, clinicians, patients and educatorsIHPC advocates for public policy that ensures all Americans access to safe, high quality, integrative, whole person healthcareIntegrative healthcare includes conventional, complementary and alternative disciplines in a collaborative effort to influence the future of healthcare delivery in the United States

398

Integrative Healthcare Policy Consortium: Mission

The Integrative Healthcare Policy Consortium advocates for an integrative healthcare

system with equal access to the full range of health-oriented, person-centered, regulated

healthcare professionals.

399

IHPC Accomplishments

National Policy Dialogue 2001 (Georgetown University)National Educational Dialogue 2004 (Georgetown University)National Stakeholders Conference 2010 (Georgetown University)Responsible for several inclusions in ACACongressional Briefings 2011-2014

400

Affordable Care Act

Section 2706: Non-discrimination in healthcareSection 3502: Inclusion of CAM practitioners in the Medical HomeSection 4001: National Prevention, Health Promotion, and Public Health CouncilSection 4206: Demonstration projects concerning individualized wellness plansSection 5001: National Healthcare Workforce CommissionSection 6301: Patient-Centered Outcomes ResearchSection 2301: Coverage for freestanding birth center services

401

Integrative Language in (PP)ACASection Title Area Language Used

2706 Non‐Discrimination Payment “ …license or certification …”

3502 Community Health Teams/Patient‐

Centered MedicalHomes

Delivery “may includedoctors of chiropractic, licensed CAM

practitioners …”

4001 National Prevention, Health Promotion and Public Health

Council

Healthpromotion

“integrative health care” “integrative health care strategy” “integrative health” “integrative health

practitioners” “integrative health practices”

5101 National Health Care Work Force Commission

Workforce “doctors of chiropractic”“licensed CAM providers, integrative health

practitioners”

6301 PCORI‐CER Research “experts in integrative health and primary prevention strategies” “State‐licensed integrative

health care practitioner”

402

National Prevention Council –Key Intentions

Shift from sickness care to health & wellness as primary focus of US healthcare

Search for structural rather than biomedical solutions to our nation’s health problems

Create coordination between clinical and community/environmental aspects of health promotion

403

Non-Discrimination in Healthcare (2706)A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.

404

2706: Importance to Patients

Expand access for patients who wish to receive IHC.Encourages the development of an interdisciplinary team approach with all providers delivering care within their scope of practice.Leads to a pluralistic healthcare system based upon prevention and wellness as opposed to disease.

405

Covered Healthcare Providers

MDNaturopathic PhysiciansChiropractorsAcupuncturistsMassage TherapistsOsteopathic Physicians

OptometristsNurse PractitionersLicensed or direct entry midwivesPodiatrists

406

Cost Advantage of IHC

There is significant potential to control costs with integrative healthcare. There is mounting evidence that IHC is cost-effective relative to conventional healthcare delivery.

407

Blue Cross and Blue Shield Service Benefit Plan: 2014Subject to the criteria appearing on page 18, we now cover any licensed healthcare practitioner for covered services performed within the scope of that license, as required by section 2706(a) of the Public Health Service Act.

409

Allina: Shifting Payment Incentives

“We’ve been in the business of treating diseases and we do it well.

Now, for the first time ever, the payment will change to keeping

people healthy.

"For the first time in 100 years it will be our job at Allina to keep the

village healthy."Health System & Military Leaders Say Cost and Pain are Motivating Inclusion of Integrative

Medicine http://theintegratorblog.com/index.php?option=com_content&task=view&id=795&Itemid=18

9

Ken Paulus, CEO,Allina Hospitals & Clinics

12 hospitals, care for 1/3Of Minnesotans;

Home of Penny George Institute;Commitment to integrative model

410

Perlin/AHA: “We Don’t Fully Understand the Recipe”

"From Sick Care to Health Care"

“We have been honed to focus on sick care… It is a tough transition, but we have to

learn how to move from sick care to healthcare.

"I'm not sure that any of us … fullyunderstands or knows the recipe."

Jonathan Perlin, MD, PhDChair‐Elect, AHA

CMO, HCA

411

Mayo: From “Producing Health Care” to “Creating Health”

"We are realizing fairly quickly thatwe need to change the focus of the

health care industry tocreating health, not just producing

health care."

American Hospital Association's Hospitals and Health Networks, April 2013http://www.hhnmag.com/display/HHN‐news‐

article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2013/Apr/0413HHN_FEA_PatientexperienceGate

Douglas Wood, MDDirector, Strategy and Policy

Mayo Clinic Center forInnovation

412

Berwick: “Radical Shift” Toward “Creating Health”

“It is fortunately commonplace now to saythat we would be better off to re‐directsome of our health care enterprise fromfighting illness … to health creation."

"The pursuit of health, the creation ofhealth, may require … a redesign that may

be even more radical than we haveimagined."

Plenary Panel, Institute for Health Improvement, December2013http://www.youtube.com/watch?v=r5Tbikk44jY

Also: “Hooking Up: Don Berwick, Integrative Medicine and His Call for a Radical Shift to 'Health Creation‘”http://www.huffingtonpost.com/john‐weeks/don‐berwick‐integrative‐m_b_4781105.html

Don Berwick, MDFormer CMS AdministratorPast CEO, Institutefor Health

Improvement

413

Opportunities & Challenge“Integrative medicine supports self-efficacy.”

________ “We have good evidence that some integrative

therapies help a patient’s ability to cope.”________

“Many of today’s cost are associated with a lack of a holistic, integrated approach”

_________“The movement is toward more holistic measurements of health and well-being”

__________

“The challenge to integrative providers is to demonstrate value.”

Dave Moen, MD, Executive Medical DirectorFairview Health Services

414

National Coordinating Center for Integrative Medicine

HRSA Funded Project through the American College of Preventive MedicineIntegrative Medicine in Preventive Medicine Education ( IMPriME)Development of Integrative Medicine Core and Curriculum CompetenciesTwelve Grantee Programs

415

Core Competency Considerations

The Integration of Integrative Medicine and Preventive Medicine is concordant with a major theme in modern healthcare to shift emphasis from disease treatment and management to health promotion and wellness whenever possible.

416


Interprofessionalism and the importance of integrating not just therapies and modalities but also healthcare professionals and disciplines is an important and ongoing part of the Integrative Medicine dialogue.

417


The competencies are designed to facilitate a broad-based exposure to Integrative Medicine rather than an in-depth expertise.

418

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESHealth Resources and Services Administration

Bureau of Health ProfessionsDivision of Public Health and Interdisciplinary Education

Center for Integrative Medicine in Primary Care ProgramAnnouncement Type: New

Announcement Number: HRSA-14-123

Catalog of Federal Domestic Assistance (CFDA) No. 93.117

FUNDING OPPORTUNITY ANNOUNCEMENTFiscal Year 2014

Application Due Date: June 13, 2014Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

Deadline extensions are not granted for lack of registration.Registration in all systems, including SAM.gov and Grants.govmay take up to one month to complete.

Release Date: May 12, 2014Issuance Date: May 12, 2014

Irene Sandvold, DrPH, MSN, FAANProject Officer, Public Health BranchEmail: [email protected]: (301) 443-2295Fax: (301) 443-0157

420

ARMY MEDICINEServing To Heal...Honored To Serve

United States Army Development ofInterdisciplinary Pain ManagementCenters

Marcie Fowler, PhDUS Army Institute ofSurgical Research

14 August 2012

Unclassified

421

ARMY MEDtCINETw�ifti IM Mill iirt Tb fcl iB

Multidisciplinary Pain Management CenterAn Integrative and Wholistic Approach

Integrative ModalitiesAcupuncture

Movement-Yoga Warrior Tai ChiBody Based Manipulation

Medical Massage ResearchSpiritual

Core valuesPerspective

Identity, Meaning and PurposeEnvironmental

Optimal Healing PhilosophyGreen SpacesShen Gardens

Labyrinth

Biofeedback DoD Survey ofIMMind-Body/Mindfulness Mindfulness and PTSD

Spousal Needs AssessmentMost Research in IM (VA/DoD)

Social Soldier and FamilyCaregiver Support Groups

Educational CurriculumSocial, Family and Task Cohesion

Medical ManagementPrimary Care Champions

Clinical PharmacistInterventional Spine

Procedures

FunctionalRestoration

strengthEnduranceFlexibilityCulinary

EducationHealthy Choice

Kitchen

BehavioralSubstance Abuse Counseling

Coping SkillsMind Wellness

■ 1Wellness Fusion Campus

t •—i vam AiLu Im

422

Integrative Medicine in the Military Health System Report to Congress2013-2014

2013-2014

423

EXECUTIVE SUMMARY

INTRODUCTION: The report responds to Senate Report 112-196, page 231, accompanyingH.R. 5856, the Department ofDefense Appropriations Bill, 2013, page 231, which requests theSecretary ofDefense to submit a report explaining the criteria used to evaluate the effectivenessofintegrative medicine programs, the result ofthose evaluations, and the number of Servicemembers receiving integrative medical treatment by Service and location ofmedical care withinthe Military Health System (MHS). The report also includes plans for future expansion oftheseprograms.

FINDINGS: The review found that 120 Military Treatment Facilities (MTFs), 99 in thecontinental United States (CONUS) and 21outside the continental United States (OCONUS),offer a total of275 complementary and alternative medicine (CAM) programs. Active duty(AD) military members used 213,515 CAM patient visits in calendar year (CY) 2012 with themost visits for chiropractic care (73%) and acupuncture therapy (11%). In addition, the UnitedStates Army (USA) Medical Research and Materiel Command (MRMC) funds CAM relatedresearch to identify safe and effective therapies to treat MHS patients.

EVALUATION: Various assessment tools are being utilized by many ofthe sites offeringCAM therapies. Patient assessment/feedback, qualitative assessment by the provider, pre- andpost-appointment questionnaires, patient satisfaction questionnaires, and measurement ofphysical improvement are being used to evaluate the CAM therapies offered to AD militarymembers. Patients reported improvement in symptoms, reduction in anxiety, improved sleep anddecline in psychological symptoms across the CAM modalities in use.

CONCLUSION: There is wide-spread use of CAM therapies across the MHS. Providers andpatients were interested in using CAM therapies even though many are not evidence-based.Some providers have added CAM therapies as an adjunct to conventional therapies for a holisticapproach to patient management.

RECOMMENDATIONS: Part 199 ofTitle 32, the Code ofFederal Regulations (CFR)provides criteria to use to determine whether a therapy is safe and effective. The MHS willevaluate CAM programs for safety and effectiveness, as well as cost-effectiveness. As resourcesallow, the Department will consider widespread implementation in the MHS ofcost-effectiveCAM programs meeting TRICARE guidelines for safety and effectiveness.

2

424

July 23, 2013 1

DEPARTMENT OF VETERANS AFFAIRSVeterans Health AdministrationOffice of Academic Affiliations

Washington, DC

PROGRAM ANNOUNCEMENT

Chiropractic Care Residency Pilot InitiativeNew Chiropractic Care Residency Programs

for Academic Year 2014-2015

425

Healing Touch With Guided Imagery for PTSD in ReturningActive Duty Military: A Randomized Controlled Trial

Shamini Jain, PhD*t; CDR George F. McMahon, NC USNf; LCDR Patricia IHasen, NC USNf;CDR IVIadelyn P. Kozub, NC USNf; Valencia Porter, MD, MPHjl; Rauni King, RN, Mlf-i, CfHTP§;

Erminia M. Guarneri, MD§

ABSTRACT Post-traumatic stress disorder (PTSD) remains a significant problem in returning military and warrantsswift and effective treatment. We conducted a randomized controlled trial to determine whether a complementarymedicine intervention (Healing Touch with Guided Imagery [HT+GI]) reduced PTSD symptoms as compared

totreatment-as usual-(TA-U)Tetuming combat-exposed active duty military-with significant PTSD symptoms. Activeilutymilitary {n = 123) were randomized to 6 sessions (within 3 weeks) ofHT+GIvs. TAU. The primary outcome was PTSDsymptoms; secondary outcomes were depression, quality oflife, and hostility. Repeated measures analysis of covariancewith intent-to-treat analyses revealed statistically and clinically significant reduction in PTSD symptoms (p < 0.0005,Cohen's d = _Q_.�5I.as well as depression (p < 0.0005, Cohen's 0.7Q)_for HT-t-GI vs. TAU. HT+GI also

showedsignificant improvements in mental quality of life {p = 0.002, Cohen's d = 0.58) and cjTiicism {p = 0.001, Cohen's d =0.49) vs. TAIirPafficipation in a complementary medicine intervention resulted in a clinically significant reductionin PTSD and related symptoms in a remming, combat-exposed active duty military population. Further investigation ofGT and biofield therapy approaches for mitigating PTSD in military populations is warranted.

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Design Principles of HealthcareforAccelerating PersonalandHealth System Renewal

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1. Honor wholeness and interconnectedness in all actions.

2. Enhance the capacity for self-repair and healing.

3. Prioritize care in accordance with a hierarchy of treatment.

4. Improve care through continuously expanding the evidence base.

5. Embrace the fullness of diverse health care systems.

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6. Partner with patients, their families and other practitioners.

7. Use illness and symptoms as opportunities for learning and growth.

8. Explore integration in one’s own care.9. Align resource investment with these

healthcare principles.10. Respect the time required for personal

and health system change.

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Sit down before fact like a child and be prepared to give up every preconceived notion. Follow humbly wherever and to whatever abyss nature leads or you shall learn nothing.

T.H. Huxley

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Integrative Healthcare and Medicine

THE FUTURE OF HEALTHCARE DELIVERY IN THEUNITED STATES

431

AIHM

WE TOO HAVE A DREAM

Where healthcare is about health and available to allWhere prevention is our foundation and mechanical fixes are there when we need themWhere all healthcare providers work collaboratively to heal body, mind and spiritWhere sustainability is integrated into our culture, practice and training

We are the Solution

Working together to establish a new paradigm of health care for humanity and the planet

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Overview

•Integrative Medicine•Integrative Psychiatry

•Medical Psychiatric Units a. The needb. Barriersc. Finances

•Integration of Outpatient Medical Psychiatric Services

Mind Body Spirit

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Integrative Medicine

• Patient & Practioner are partners in the healing process•All factors that influence Health, Wellness and disease are taken into consideration•Mind, Body, Spirit and Community•“Conventional” + “Alternative” medicine

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Integrative Psychiatry

Bio-Psycho-Social-Spiritual Model

George L. Engel, M.D. 1977

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The Need for Medical Psychiatric Units

•Patients with co-morbid medical and psychiatric illness often receive fragmented/sequential treatment resulting in:

• Length of Stay• Cost• Complications• Satisfaction

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The Need for Integrated Medical Psychiatric Units

Facts•2% to 4% of admissions to general hospitals have serious psychiatric and medical co-morbidities•5 % of patients consume 50% of resources

American Hospital Association

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The Need for Integrated Medical Psychiatric Units

•Mental health and medical conditions are risk factors for each other, and the presence of one can complicate the treatment of the other•Depressed patients are 3 times more likely to be non compliant with treatment recommendations•Individuals with co-morbid conditions are at heightened risk for readmission after discharge

American Hospital Association

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Benefits of Integration

• Stigma• Cost• length of stay• Polypharmacy• Complications

•Falls•Hospital acquired infections•Injuries

• Patient Satisfaction• Employee Satisfaction• Access to healthcare

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Challenges

•Hospital Administration•Nurses•Physicians•Insurance Companies•Stigma

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Health Care Reform aims for:

• Better Quality Care• Better Outcomes• Lower costs

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Hospital Savings

• Length of stay• Constant observation• 30 day readmissions

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Savings

Length of stay• Length of stay by 4 days• $6,000 per treated patient• 400 admissions to the MPU• 400 x $6,000= $2,400,000

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Savings

Constant Observation• $20.00/hr x 24hrs = $480/day• $480/day x 4 days = $1920• $1920 x 400 patients = $768,000

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Savings

• Length of stay = $2,400,000• Constant observation = $768,000

Total Savings = $3,168,000

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Results

Polypharmacy

• Number of psychiatric medications on admission 4.5

• Number of psychiatric medications on discharge 1.8

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Staff Competencies

Medical Director Psychosomatic medicine trained

Associate Medical Director Internist with knowledge of psychiatric disorders

Nurse Manager Nurse practitioner in psychiatry or medicine

Staff Psychiatrists Familiarity with medical and neurological disorders

Staff Nurses Training in basic medical procedures (I.V., NG tubes)

Social Workers Familiarity with medical and psychiatric community resources

Nutritionist Knowledge of Behavioral and Medical Disorders

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Medical Psychiatry Units Modalities

•Standard Psychiatric Care•Telemetry•Intravenous medications/fluids•Foley catheters•Nasogastric tubes•Central lines•Hemodialysis•Peritoneal Dialysis

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Case ExamplesAge / Gender Psychiatric Diagnosis Medical Diagnosis Medical Interventions

35‐year‐old man Schizophrenia ‐Malnutrition‐Starvation

‐Central line for nutrition

40‐year‐old woman Major Depression ‐Clostridium DifficileInfection

‐Contact isolation‐I.V. antibiotics

23‐year‐old woman Borderline Personality Disorder

‐Tri‐cyclic antidepressant overdose‐Cardiac arrhythmia

‐Telemetry monitoring

55‐year‐old man Schizophrenia ‐Diabetes‐Cellulitis

‐I.V. antibiotics

60‐year‐old man Major Depression ‐End‐stage renal disease ‐Intra‐peritoneal dialysis

30‐year‐old woman Major Depression ‐Diabetes‐MRSA infection

‐Glucose control‐Contact isolation

28‐year‐old woman Bipolar Manic ‐Preeclampsia‐High‐risk pregnancy

‐Fetal monitoring

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Results – 8 Years Experience

• Admissions• Contribution margin• Patient & employee satisfaction• Safety• Access to care

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Number of Admissions to MPU by year

0

200

400

600

800

1000

1200

1400

1600

2007 2008 2009 2010 2011 2012 2013 2014 projected

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Contribution Margin

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

2010 2011 2012 2013 2014projected

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Results

Stigma Integrated care helps reduce the stigma of mental illness.

Savings With an average cost of $1,500/day, reducing the length-of-stay by four days will save $6,000 per patient. The need for one-to-one sitters is reduced.

Plan of Care Patients are discharged with better coordinated outpatient care with medical and psychiatric appointments.

Patient Satisfaction Patients appreciate being able to walk around the unit and attend psychotherapy groups as opposed to being on a one-to-one observation on a medical unit.

Staff Satisfaction Initial anxiety was quickly replaced with increased satisfaction after seeing the results accomplished by integrated treatment in a MPU.Increased satisfaction among medical and surgical teams to be able to follow their patients with co-morbid mental illness in a MPU.

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Outpatient Medicine / Psychiatry Integration

•One location• increased access

•Reduce stigma•Emphasize wellness•Reduce cost

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Debra Simon Center For Integrative Medicine

•HackensackUMC Fitness and Wellness powered by the Giants•Debra Simon Foundation Fund•Debra Simon Center for Integrative Behavioral Health and Wellness

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Education

Integrated units provide a perfect setting to teach residents and students in the delivery of healthcare in a humane, empathic and efficient manner.

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Research

More research is needed to develop Evidence Based Practices.

Current Research Initiatives•Exercise in the treatment of depression•Music therapy vs. Medication for acute anxiety in hospitalized patients•Aromatherapy as a treatment for insomnia in hospitalized patients

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Conclusion•Integrated Medical/Psychiatric Units

a. Are cost effectiveb. Improve quality of carec. Increase patient and employee satisfaction

•Integrative Medicine requires collaboration between Behavioral Health providers and other clinicians

Now is the right time

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Healthy Food from the Clinic to the Community

Lessons of Success through Integrated Operations

Jamie Harvie, P.E. Executive Director ISF

AIHM, San Diego, October 31st

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Ecological Model of Health

• Progressive nesting of individuals within families within communities and finally within ecosystems.

• Variables at any level can directly or indirectly influence measures of health at any level.

• Influences may be identifiable as individual markers or as community level markers

GBPSR – Healthy Aging Report

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Bioregionalism and Value Chains

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www.cultivatemichigan.org

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Adapted from Institute for Healthcare Improvement477

Adapted from U Wisconsin Population Health Institutes County Health Rankings 2010478

Inside Outside Hospital Walls

Community Food

Patient and Employee Food

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CHNA InputAt a minimum, take into account input from:

• Persons with special knowledge of or expertise in public health;

• Federal, tribal, regional, State, or local health or other departments or agencies, with current data or other information relevant to the health needs of the community served by the hospital facility; and

• Leaders, representatives, or members of medically underserved, low‐income, and minority populations, and populations with chronic disease needs, in the community served by the hospital facility.

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CHNA and Community Benefit

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Hunger and Healthcare • For low‐income patients with diabetes, the

risk of hospital admission for hypoglycemia increased 27 percent in the last week of the month versus the first week. (This was not the case for higher income populations.)

• Food insecurity affected nearly one in six U.S. households in 2011.

• Hospital admission for hypoglycemia cost $1,200 per visit in 2003

• ACA Section 3025 Medicare reimbursement penalties with higher than expected rate of acute care readmissions within 30 days of discharge.

Barker LA, Gout BS, Crowe TC. Hospital malnutrition: Prevalence, identification and impact on patients and the health‐ care system. Int J Environ Res Public Health. 2011;8(2):514‐527 Lim SL, Ong KC, Chan YH, et al. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3‐year mortality. Clin Nutr. 2012;31(3): 345‐350Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J ParenterEnteral Nutr. 2011;35(2):209‐216http://health.usnews.com/health‐news/hospital‐of‐tomorrow/articles/2014/02/13/treating‐hunger‐as‐a‐health‐issueSeligman et al Exhaustion Of Food Budgets At Month’s End And Hospital Admissions For Hypoglycemia Health Aff January 2014 vol. 33 no. 1 116‐123

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Community Health Workers• CHW intervention improves access to

primary care and quality of discharge while controlling readmissions

• CHW workforce improves post hospital outcomes by addressing behavioral and socioeconomic drivers of disease

• CHWs help patients navigate the health care system and address key health barriers, such as housing instability or food insecurity.

• Intervention improved both patient experiences and health outcomes, while reducing repeat hospital readmissions.

Kangovi, et al, Patient‐Centered Community Health Worker Intervention to Improve Posthospital OutcomesA Randomized Clinical Trial JAMA Intern Med. 2014;174(4):535‐543. doi:10.1001/jamainternmed.2013.14327.

“Some patients might be too embarrassed to tell hospital staff they don't have a working stove or refrigerator, so vital to eating healthy food and keeping medicine safe. "

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Local Foods InitiativeSacred Heart Hospital, WI

“ Local food bolsters family farms, keeps money in the community, creates jobs, and fulfills the sisters’ vision of holistic health. Local food is good medicine for everyone.”

Steve Ronstrom, CEOSacred Heart Hospital

http://www.progressive.org/eisen1110.html#sthash.fcDSUhFd.dpuf

Earned media value: $1.5 million

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Fletcher Allen Health Care

• Nationally recognized food program

• 40% local, sustainable food• Self operated hospital serves

5,000 to 6,000 meals per day. • Works with more than thirty

Vermont food vendors, as well as several from Quebec.

The health system is currently below the 50th percentile nationally for food costs.

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Oregon Health and Sciences University (OHSU)

• Preference for FairTrade, Organic and locally grown products.

• Gluten‐Free offerings• GMO‐Free• High Fructose Corn ‐Syrup Free• Vegan offerings• rBGH‐ Free• Trans‐Fat Free• Coloring & Dye‐Free• Low Sodium

Profitable “It’s All Good” Natural Food Store

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• Mashed potatoes and gravy, only available by request.

• Carbs were replaced with more healthy choices like wheat pasta, quinoa and brown rice

• Pomerado now buys 47 percent of its produce from local suppliers or from those that use sustainable‐growth methods.

• Double‐digit percentage increases in sales since introducing healthier offerings last year.

“If the food tastes good, they’re going to buy it”

Javier Guerrero Pomerado HospitalFood and Nutrition Services Manager

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Budget Strategy: Better Meat• Improving health and reducing ecological

footprint

• Serve smaller quantities of sustainable meat to promote healthy eating habits

• Serve less meat overall AND choose sustainably‐produced meat to reduce greenhouse gas emissions

• The medical costs attributed to ARIs ranged from $18,588 to $29,069 per patient, while the duration of hospital stay was extended 6.4 ‐12.7 days for affected patients.

• 2013 ‐ 81% of ground turkey and well over half of ground beef and pork chops tested contained some form of these “superbugs

Roberts, et al, Hospital and societal costs of antimicrobial‐resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. j ClinInfect Dis. 2009 Oct 15;49(8):1175‐84. doi: 10.1086/605630.2011 Retail Meat Annual Report of the National Antimicrobial Resistance Monitoring System (NARMS) www.ewg.org

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Better Meat Case StudySanta Rosa Memorial Hospital, CA

• Reduced meat offerings and increased vegetarian entrees in both settings• Strategic pricing of healthy choices in cafeteria• Cost savings reinvested into sustainably‐produced beef and poultry• After one year 5,000 pounds less meat prepared • Savings < $5000

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Procurement BenchmarksCarroll Hospital, MD

• Less Red Meat, More Poultry, More Fruit and Vegetables– 13% decrease in meat

purchases– 6% increase in poultry

purchases– 11% increase in fresh

fruits/vegetables• Increase in Organic /

Sustainable– 5% meat purchases were

sustainable– 9% produce purchases were

organic• Budget savings

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Food & Nutrition Services Vision Statement

Catholic Healthcare West

CHW recognizes that food production and distribution systems have wide ranging impacts on the health of people, their communities and the ecosystems in which they live; and so

CHW recognizes that “healthy food” describes not only nutritional quality, but equally by a food system which is ecologically sound, economically viable, and supportive of human dignity and justice, and so;

CHW aspires to develop a healthy food system

We will work within our system to develop policies, procedures, contracts and education for staff, patients, suppliers, and local and global community that reflect this vision.

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Sustainable Food Policy & PlanOregon Health and Science University (OHSU) Hospital

o Utilized Green Guide for Health Care Food Service Credits as Framework for comprehensive sustainable food policy and action plan

o Created a Vision: The goal of this Policy & Plan is to provide a framework in which OHSU Food and Nutrition Services will:

o Purchase and provide foods which prevent disease and promote health and healing, based on scientific research.

o Make purchasing choices which demonstrate an understanding of the inextricable links between human, public and ecosystem health.

o Establish ecologically sound, economically viable and socially responsible purchasing principles and practices.

o Provide patients, staff, students and visitors with information regarding the sustainable and healthy purchasing practices Food and Nutrition supports.

o Integrate health, research and service through ethically sound practices, doing no harm.

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www.gghc.org

Green Guide for Healthcare (GGHC)Food Service Metrics

• FS Credit 1: Sustainable Food Policy and Plan

• FS Credit 2: Sustainable Food Education and Promotion

• FS Credit 3: Local, Sustainably Produced Food Purchasing

• FS Credit 4: Reusable & Non‐Reusable Products

• FS Credit 5: Hospital Supported Agriculture: Food and Farm Linkages

• FS Credit 6.1: Food Donation and Composting

• FS Credit 6.2: Food Services Recycling• FS Credit 7: Food Vendors • FS Credit 8: Chemical Management

for Food Services

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Creative Budgeting and Health System Procurement Spend

Food $52

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Sugary Beverage Sales Phaseout• Cleveland Clinic, OH initial one

year drop in sales, then rebound• Fairview Medical Center, MA

revenue neutral• Grand Itasca, MN revenue neutral• Bottled water to filtration stations

revenue positive.

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“it is important to talk about WHY we do all this and the reasons behind these efforts…

As a health care organization and academic medical center, we have a responsibility to be leaders and models in this area – and teach others to do the same.

With a sustainable food system, we can achieve multiple benefits, including improved nutrition, decreased resistance to antibiotics, climate change mitigation and the creation of vibrant, local communities.

Sustainable food also has an impact on health care costs – as improving nutrition helps reduce the burden of chronic disease, one of the main drivers of health care costs.

It’s important to note that whether we pay to improve healthy eating today – or care for a patient with chronic disease later on – either way, health care bears those costs. “

CEO Melinda Estes, M.D, Fletcher Allen Healthcare

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Adopt Policy: Build a Program

• Leadership Policy Adoption• Support Policy• Develop And Connect

Team(s)– Outside/ Inside

• Adopt Metrics and Benchmarks

• Contracts– Ask for what you want

• Start Small• Tell your story• Aggregate

Our biggest accomplishment to date was to build a team and develop tracking mechanisms in order to grow the program.

Barbara Hamilton, Palomar Health System Sustainability Manager

“We had a mandate to make wellness part of the clinic’s brand.

Scott McFarland, Former President of WellnessCleveland Clinic

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www.wellthcare.com

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Anchor Institution Collaboratives

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Health and Wealth Building: Evergreen Collaborative Case Study

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Resources

• www.commonshealth.org• www.isfusa.org • www.chna.org• www.gghc.org • www.democracycollaborative.org• www.healthierhospitals.org• www.ahealthieramerica.org/our‐partners/hospitals/

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“A transformational approach recognizes that conflict is a normal and continuous dynamic

within human relationships”‐ John Paul Lederach

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What could possibly challenge

a holistic approach in the

acute care environment?

505

Ironies of treating in the acute care environment.

506

Inpatient ‐ 22 providers across disciplines

Providing holistic care across the hospital’s6 major centers of excellence.

Outpatient, fitness, research

507

Endeavoring to bring a holistic mindset to the acute care

environment

508

Integrative Health Sessionin Progress

512

• Progress note scan here

513

Organic Integration: Bringing Chinese medicine into a biomedical,

acute care setting.

515

The opportunity for growth lies in the tension between

safety and innovation

516

Adapting Chinese medicine to our hospital environment.

Obstacles

Cultural understanding

Infection concerns

Bleeding concerns

Neutropenia

IV poles, picc‐linesTED socks and otherimpediments to needlingthe hospitalized patient

Adaptations

Needling styles

P6, ginger tea

Qigong

KHT

Ear beads

Group acupuncture

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How do we cultivate authentic collaboration?

518

Responding to physician concerns

519

Measures & Analysis

INR values were dichotomized at the 90th percentile value of 2.3 and categorized as “higher” (≥ 2.3) or “lower” (< 2.3). A chi‐square test was used for statistical analysis.

Acupuncture Treatment for Hospitalized Patients on Anticoagulant Therapy ‐ A Safety Study

Cynthia P. Miller1, LAc; Barbara Hopperstad1, MA; Anne M. Jurek2, PhD; Jeffery A. Dusek1, PhD 1Penny George Institute for Health & Healing, Abbott Northwestern Hospital; 2Center for Healthcare Research & Innovation, Allina

BACKGROUND

As acupuncture becomes increasingly available in allopathic medical settings, some healthcare providers raise concerns about patient safety. One such concern is excessive bleeding at acupuncture points after withdrawal of needles, particularly in patients who are receiving anticoagulant therapy and have elevated International Normalized Ratio (INR) values.

Although “bleeding” and “bloodletting” are recognized by practitioners of Chinese Medicine as therapeutic techniques, bleeding has been described in the modern acupuncture research literature as an adverse event (Chung et al 2003, White, et al 2001, Yamashita et al, 2000).

The purpose of this study was to examine the incidence and amount of bleeding at acupuncture points in hospitalized patients on anticoagulants with elevated INR values.

BACKGROUND

DATA Population

In this IRB‐approved retrospective medical record review, data were obtained from electronic health records (EHRs) for inpatient acupuncture treatments provided by six licensed acupuncturists on staff at Abbott Northwestern (ANW) Hospital between January 1, 2010, and December 31, 2011. The Penny George Institute for Health and Healing at ANW hospital provides the acupuncturists to enhance health care through an integrative health approach.

RESULTS

DISCUSSION AND CONCLUSION

Minimal bleeding was noted at acupuncture points in patients on anticoagulant therapy. Moreover, incidence of bleeding did not differ by INR status for the sample overall.

Our findings suggest that acupuncture can be used safely for patients on anticoagulant therapy with INR values in the therapeutic range.

Patient Characteristics

The 886 unique patients consisted of 525 females (59%) and 361 males (31%). The average age was 65 years (range: 24‐96 years).

INR Results

Of the 1,519 acupuncture treatments with INR values drawn on the same day, the mean INR value was 1.5 (standard deviation: 0.5; range: 0.9‐4.4). At the 90th percentile for INR values, 10% (N=153) of inpatients were classified as having a “higher” INR value.

RESULTS Continued

Bleeding Noted with Acupuncture

Bleeding was noted in 14% (N= 208) of the 1,519 acupuncture treatments. All but 2 involved cleanup with Q‐tip. The highest number of points with bleeding noted occurred at Stomach 36 and at auricular points. The percent of inpatients with bleeding noted was no different between those with “higher” INR and those with “lower” INR values (16.3% vs. 13.4%; P > 0.05).

Chung A, Bui L, Mills E. Adverse effects of acupuncture, Which are clinically significant? Canadian Family Physician, 2003;49:985‐989.

White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32,000 consultations with doctors and physiotherapists. British Medical Journal, 2001;323(7311):485‐486.

Yamashita H, Tsukayama H, Hori N, Kimura T, Tanno Y. Incidence of Adverse Reactions Associated with Acupuncture. Journal of Alternative and Complementary Medicine, 2000;6(4);345‐350.

REFERENCES

METHODS

Sample

Patients were receiving anticoagulants and had an INR drawn the same day as acupuncture therapy. Patients also had data entered in a “bleeding noted” field in the EHR, noting whether or not bleeding occurred after withdrawal of needles as well as the point location of any bleeding. Our sample included 886 unique patients who received a total of 1,519 acupuncture treatments.

520

Group Acupuncture in the Joint Replacement Center

Using the tools of the system to become part of the system

Working in partnership with the group physical therapy program

for total joint replacement to enhance the patient’s experience

521

Documentation as integration

Equal status in EMR

Documenting according to paradigm and licensure

Communication with other providers through documentation

What is unique in our experience?

525

Data as an ally

Demonstrating our significance relative to outcomes

Quantifying patient satisfaction deepens relationships with other providers

Describing a unique benefit beyond “Usual and customary care”

528

If, in times of change, we focus

on what we might be losing or letting go of, we miss the

opportunity to see what we

might be gaining

529

Does evidence change people or do beliefs shift our perspective on evidence?

What changes beliefs?

What is the evolution of a new idea?

530

The seeds for healing lie in the places we are already whole

532

Nurturing transformation

Start small – pilot

Share information

Keep the needs of the next generation in mind

533

Sustainability is an essential ingredient to success

Recognize and accept your role

Time is part of the environment

A collaborative approach

Build bridges

534

The role of activist is a lonely one.

What is the larger vision?

Where do we resist?

You may never see the fruits of your labor, because sometimes change is slow in coming.

adapt

Under what circumstances are people more likely to adapt?

How do you deal with having vision that the world is not ready for?

Overheard...

backlash.

Sometimes, In the moment it feels like the only thing happening is backlash.

How do you create a way that you can be comfortable in your role as disrupter, innovator, late adopter, or laggard?

535

Is money squeezing the life out of us?

536

“All great truths begin as heresy and wind up as orthodoxy.”

adapted from Thomas Huxley

537

ciha syllabus

Education

integrative health certificate

integrative health model

integrative health framework

health care transformation

population health

health of populations

person approachesto

models of integrative