Integrative Care: Creating A Healthier, More Sustainable System

People are more than patients, and patients should not be reduced to their disease or complaint. They are whole people, with multilayered needs that influence their sense of health and wellbeing. Healthcare providers and professionals cannot support the whole person without deeply listening to the physical, spiritual, environmental, emotional, and psychological needs and goals of the patient. Cultural awareness and appreciation of individual beliefs around health, healing, and illness are essential ingredients of whole person care. Giving credence to this helps patients to better understand and transform their relationship with health. As such, acknowledging and addressing social determinants of health are intrinsic to whole person care.

Patient-centeredness, an intentional focus on specific needs of an individual patient, is central to whole person care. (1) Working in a patient centered model often requires a shift in the traditional power structure within the healthcare system. While clinicians may be experts in their approach to care, patients have the lived experience of their own bodies, multifaceted needs, and an individualized sense of what constitutes wellbeing. Reorienting care around a patient-centered model positions the patient at the center of their healthcare team. Surrounding them with providers and resources relevant to their present needs facilitates whole person care. A genuine partnership between the patient and a full complement of healthcare resources helps achieve optimal outcomes.

Therapeutic relationships must be restored to healthcare. Fee for service payment, misaligned provider compensation models, electronic health records, and metrics-driven systems can result in patients feeling like numbers or transactions. (2) Providers report feeling rushed, disempowered, and burned out, with precious little time for wholistic conversation with the patient they are charged to care for. (3, 4) Patients often report leaving office visits feeling unheard, unvalued, and that their concerns were not taken seriously. (5, 6) All of this speaks to the need for a transformational shift toward a system that facilitates a therapeutic alliance built on mutual trust and deep listening. (7, 8)

Integrative care is predicated upon diversity of thought and life experience. This diversity brings unique insights and perspectives that enhance treatment planning and understanding of patient experiences, needs, and goals, as well as upstream opportunities to improve determinants of health. Patients should be acknowledged and respected for their lived experience. As such, a goal of an integrative healthcare system is to empower patients with agency over their health and to equip healthcare professionals to leverage a wide array of resources and expertise to support patient wellbeing. Integrative care recognizes that most variables that impact health occur outside of the healthcare system, further compelling us to shift our thinking away from transactional care, and toward transformational health creation.

Stepped care, also known as therapeutic order, is a conservative-care first method for providing the right care at the right time. Just as behaviors may contribute to either health creation or disease creation, so can treatments and interventions. Interventions that carry significant risk or that create greater downstream illness than the current condition they are meant to address may ultimately decrease wellbeing, (13, 14, 15) and should be used only when conservative care options are exhausted. Lifestyle interventions and selfcare should be counseled prior to interventions delivered by providers. When clinical care is needed, high-value, least invasive treatments should be applied before those with less evidence of effectiveness, shown to be of lower-value, or carry greater risk of adverse events. (16, 17, 18) Examples may include dietary intervention prior to blood pressure medication; acupuncture or spinal manipulation before spine surgery; or massage and cognitive behavioral therapy before antidepressants.

In an integrative model, patients have access to health coaches and guides for health creation. Team-based providers collaborate to prioritize high-value conservative care first and refer or co-manage patients if escalated care is necessary. In complex care cases, a range of therapies should be available to create health and quality of life while managing disease. Integrative care can be seen as a large toolkit, which allows patients to select the best fit for the circumstance. ’Best fit’ often depends upon the patient and their preferences or ability to access care. Currently, conservative care options are not widely accessible, which often results in greater rates of high-risk, low-value, invasive interventions performed on communities of color, with poor outcomes. (19, 20)

Beliefs influence health-related behaviors and outcomes in a variety of ways. What we believe about health, disease, the abilities of healers and providers, and our sense of agency over our own wellbeing influence both how individuals navigate the healthcare system, and the health outcomes associated with care. (25, 26) Further, while the burden of noncommunicable chronic diseases like obesity, diabetes, cardiovascular disease, and cancer can be mitigated by behavioral change and stronger public health efforts, our healthcare system has been wholly insufficient to address this. (27, 28, 29)

Healthcare is all too often reduced to an algorithm, relying on systems to create efficiencies while neglecting the critical thinking and adaptation needed to help patients change unhealthy beliefs and behaviors. Understanding a person’s beliefs around their symptoms or state of health and using this information to guide patients through behavior management is a more patient-centered approach to lasting behavior change. All providers should recognize the role of health beliefs and behaviors on disease and outcomes. However, providers often lack the requisite expertise to do this well, and compensation models don’t support this activity. One solution may be to integrate community health workers and health coaches into healthcare and community health. This brings behavior change and lifestyle diseases into greater focus. (30, 31) Health coaches may be a crucial member of the integrative healthcare team, partnering with patients and providers to clarify goals, identify implementation strategies, and sustain progress toward greater wellbeing.

Our vision for the future is that what is now called “integrative healthcare” will someday simply be referred to as “healthcare”. Integrative healthcare advocates for the inclusion of evidence-based approaches to health creation and disease management. This includes not only medical approaches considered to be “mainstream” in the US, but also eastern medicine, herbal medicine, massage therapy, chiropractic, indigenous healing, functional medicine, and many others. Current nomenclature uses the term “complementary and integrative healthcare” when referring to the inclusion of a range of healthcare disciplines in care delivery. While the term “complementary” typically applies to non-allopathic therapies and is an improvement over “alternative”, it still implies they play a supportive role only, or operate peripherally to mainstream care. This does not align with how patients actually receive care. (32) Utilization data suggest a range of factors influence how the public chooses members of their healthcare team based on skills, scope, philosophical alignment, and access. (33)

The delivery of care should prioritize the right treatment from the right provider at the right time, as opposed to the traditional hierarchy of the healthcare system. When needed, treatment should be based on the beliefs, needs, and wishes of the person in question. First line treatment may be delivered by any type of provider who is operating within their scope of practice, and ideally, at the top of their license. (32) Other treatments, delivered by any type of provider, may be considered complementary to the first line intervention. Ideally, the provision of services, whether first line or complementary, should be provider agnostic. Instead, skilled providers should be empowered by the system to deliver care aligned with their education and licensure, and compensation should align with outcomes instead of credentials. It is time to erase the line between mainstream and complementary, and transcend the false dichotomy created by these terms.

No one healthcare provider, discipline or field can meet all the health needs of a person or community. The traditional hierarchical structure of mainstream healthcare inherently limits input from some professions and stakeholders, and importantly, often relegates the patient to a passive or deferential role. (34) Historically, gate keepers have reinforced a hierarchical structure and may limit access to care based on cost and other considerations.

Multidisciplinary care places disciplines adjacent to one another. Interdisciplinary care engages disciplines with one another, reaching across siloes of thinking. Transdisciplinary care is the most holistic of these three concepts, transcending differences in the interest of bringing multiple ideas and points of view to bear on complex problem solving. (35) The lead in the care team may be any practitioner, depending on the needs of the patient at a given moment. All team members, including the patient, are empowered to lead and share insights from where they are, regardless of level of education. Transdisciplinary healthcare removes barriers between disciplines, departments and organizations that are typically siloed within the healthcare system. (36)

The system must be designed for fluid leadership of all stakeholder groups: patients, families, community members, and staff to improve care delivery and outcomes. Collaborative leadership and transdisciplinary care are interdependent. Both leverage cross-functional teams to inform problem solving larger systems. This may include individuals, families, communities, social services, community resources, healthcare professionals, administrators, government, and third-party payers. Transdisciplinary healthcare is predicated on enhanced communication tools, including improved electronic health record interoperability, as well as increased opportunity for interprofessional education for healthcare professionals.

Collaborative leadership flattens the traditional hierarchical structure within healthcare. This shared decision-making model enables input from all stakeholders. In a clinical encounter, patient input is valued, and individuals feel well-informed and empowered by all members of their healthcare team to reach their therapeutic goals. Different members of the care delivery team may need to lead at different times, and the person leading at any point in time is determined by best practices and expertise required for the circumstances in question. Further, a collaborative leadership model enables diverse paradigms of healing, life experiences, and points of view to bring important perspective to the clinical reasoning process. Collaborative leadership within healthcare systems values a wide range of stakeholder input and uses it to inform care delivery. This model has been shown to increase team performance, staff engagement, and satisfaction. (37)