IM4U Handbook


Underserved Integrative Medicine - download the PDFof this page
Fasih A. Hameed, MD

Intro: Towards "Good" Medicine

There is a sincere movement underway to bring the best of holistic and integrative medicine to underserved populations. Integrative Medicine is currently practiced in specialized clinics, which see mostly insured or relatively wealthy private pay patients. Patients on public assistance and public insurance plans have therefore been largely excluded from receiving Integrative care, which is patient-centered and open to effective and evidence-based treatment options from Western as well as Non-Western healing traditions.
The nascent field of Underserved Integrative Medicine seeks to find the most cost-effective and sustainable methods of incorporating the best of Integrative Medicine into community health centers and underserved clinics. The goal is to slowly create a paradigm shift which will obviate the need for distinguishing between Integrative vs. Non-Integrative. Ultimately, there will be only "good" medicine.

An Aside: What's wrong with the way it is now

Anyone who has worked in a busy underserved clinic and seen 16 patients in four hours can tell you that the current model of care is good for urgent-care type visits in healthy individuals, but is non-functional for effectively managing chronic disease. Yes, it is possible to check labs, conduct brief physical exams, and adjust medications, but this is only a fraction of optimal patient care. There is essentially no time left to adequately assess the nuances of lifestyle that produce and affect chronic disease, let alone time to hear and understand the patient's personal story or connect at a deeply human level. This relationship-centered model of active listening, connection, and understanding is one of the fundamental principles of Integrative Medicine. It is where the true healing begins. And it is often why patients are drawn to Integrative practices, where doctors take the time necessary to understand the patient's unique situation before reflexively reaching for the prescription pad.
In an ideal world, we would have as much time as we wanted to connect with our patients and help them overcome barriers to optimal health. The reality of our current health care system precludes such luxuries. We therefore offer these creative suggestions which work within the confines of our medical system, and which we hope will benefit all patients until a sufficient tide of change has transformed the practice of medicine at a national level.

Unique barriers in Underserved Integrative Medicine

Underserved patients generally have very limited financial resources. This precludes the use of expensive interventions, foods, supplements and lab tests.
Additionally, many patients have unstable housing and family dynamics which complicate delivery of care. This can make it difficult to find a quiet space for meditation or a healthy environment for restful sleep.
Underserved patients may also live in neighborhoods where violence and safety are a concern, making open-air exercise a daunting endeavor.
Internet access and experience is often limited. Impoverished patients tend to have lower education levels and may also lack experience or familiarity with healing traditions of other cultures. Patient handouts must be of an appropriate reading-level and language to the population.
Patients living in urban areas often have poor access to fresh fruits and vegetables; food is often purchased at fast-food restaurants and convenience stores. Therefore, the diet of many underserved populations tends to rely on heavily-processed, calorie-rich, nutrient-poor �foods?.
Underserved patients may also have limited access to affordable and/or reliable transportation. This makes it harder to access healthy food as well as make frequent visits to the clinic for group visits or classes.

Potential inherent beneficial aspects of Underserved Integrative Medicine

The financial limitations of this population encourage a focus on lifestyle change as well as low-cost, evidence-based supplements and herbs. Lifestyle is the foundation of health. Many chronic diseases are the product of daily lifestyle choices. Unfortunately, in the current medical climate of brief office visits, these lifestyle-produced diseases are managed primarily with pharmaceutical interventions. Underserved Integrative Medicine seeks to identify and treat the origin of disease rather than control the symptoms. Emphasis is thus
placed on making sustainable changes in diet, exercise, stress management, sleep hygiene, and habits as well as in developing healthy and meaningful relationships and interpersonal connections.
Underserved populations, especially those of the older generation, may also have familiarity with use of traditional or folk remedies. These can be utilized in Integrative treatment plans and also to introduce additional herbal or natural therapeutics.
Underserved populations may have less experience with certain techniques of Integrative Medicine. In the case of mind-body interventions and meditations, this �Beginners mind? may facilitate introduction of new techniques, unimpeded by preconceptions or prior experience with similar techniques.

Overview of Practice Models

Federally Qualified HealthCare Center (FQHC)/community clinic

Integrative Medicine seeks to identify and overcome barriers to optimal health. This takes a great deal of time. Intake visits in traditional Integrative clinics are generally 60-90 minutes in length, with 45 minutes being the absolute minimum. This is extremely difficult in a traditional FQHC or community clinic, where appointments are scheduled every 15 minutes. There are, however, novel solutions to this problem.
An excellent patient education handout system can simplify and edify the explanation of simple Integrative treatment recommendations (further explanation below).
FQHC's are also ideal for developing group visits around chronic diseases such as persistent pain, diabetes, and obesity. These group visits allow the additional time necessary to provide personalized education and are an excellent format for introducing practical applications of mind-body medicine.
With a little creativity, individual IM consultation can be accomplished with minimal impact to patient numbers. For example, a 45 minute session can be arranged by seeing three brief visits (ie. Nurse oversight or BP check) in the first 15 minutes of the hour (as pioneered by Dr. Steven Chen, Oakland, CA). Alternatively, one could hold the last two visits for Integrative Consultation and continue for a small time after clinic is technically "over". This method is also suitable for extensive OMT treatments, biofeedback sessions, guided imagery, hypnosis, and acupuncture.
An hour-long Integrative Medical interview can also be conducted over several weeks by dividing it into four individual fifteen-minute visits. The first visit is dedicated to hearing the patient's life story and deepening the doctor patient relationship. This visit should also include a determination of health priorities (top three) as well as developing a mutual vision of health (when was the last time you felt well?). These visits can be coded as face-to-face counseling time. At the conclusion of this visit, the patient should receive an Integrative Medicine intake questionnaire, including a 3-day food diary. Subsequent visits should focus on review of the questionnaire, with an emphasis on the lifestyle foundations of health: food, movement, stress-management, relationships, habits, and sleep hygiene. The final visit should include a patient-determined roadmap to wellness, with easily obtainable and realistic first steps (ie. "I'll try to eat a healthy breakfast at least once a week" not "I'll eat breakfast every day")

Residency

Residency clinics often serve primarily underserved populations and since residents are often interested in expanding knowledge of integrative services, these are ideal places to initiate Integrative Medicine programs. The Santa Rosa Family Medicine Residency created an Integrative Medicine consult clinic within its Federally Qualified Health Care Center which is also the sole resident continuity clinic within the residency.
The Integrative Medicine consult clinic takes place in a small conference room which has been painted and decorated and furnished to create a more comfortable space than a traditional exam room. Chairs are arranged around a coffee table as one would find in a living room. The patient is seen for one hour with two residents and an Integrative Medicine attending. One of the residents is usually the patient's primary care physician. This is arranged as such to not only deepen the doctor-patient relationship but also so that the primary physician can follow through with the integrative plan and coach the patient through the recommended behavioral changes.
Three patients are seen per clinic. The clinic is held once per week. Each patient completes a comprehensive lifestyle assessment questionnaire prior to the visit. This questionnaire is used to guide the interview and includes questions intended to help the patient formulate his or her own vision of wellness. Behavioral change is promoted through the implementation of "Appreciative Inquiry" motivational techniques. As
is often the case in underserved Integrative Medicine, an emphasis is placed on the foundations of health: diet (food), exercise (movement), stress reduction, relationships (connection), restful sleep, habits, and Spirituality. Basic supplements and herbal therapeutics are incorporated where appropriate.

Specific Modalities

Massage

Massage is a valuable therapeutic but is generally beyond the financial means of the underserved. Many communities have massage schools and these massage students generally must complete a certain number of hours of massage during their training. Some schools even have service requirements. It is therefore possible to direct patients to these schools or coordinate low cost massages for clinic patients. Additionally, with appropriate HIPPA disclosure forms and formalizing a massage student as a volunteer, it may be possible for a clinic to offer complementary massages to patients. Incorporation of brief physician visit with oversight may allow the clinic to bill for these services.

Acupuncture

Acupuncture is portable, inexpensive and effective, making it one of the most valuable non-pharmacological interventions in the Integrative practitioners tool kit. Several underserved clinics around the country have successfully introduced acupuncture treatments within the traditional clinic setting.
Acupuncture is traditionally practiced in a quiet, comfortable office with dedicated treatment tables, plentiful pillows, soft music, and the ability to perform moxibustion. In this setting, it is also generally beyond the financial means of most underserved patients. A licensed physician, however, can perform acupuncture under the scope of her medical license. Therefore, in a community clinic, acupuncture can be provided during a medical visit as long as there is adequate documentation of appropriate medical management sufficient to warrant an E&M code(ie HPI, PE, A/P). This is how many health centers have been able to provide Acupuncture to their patients while still receiving compensation.
But the delivery of acupuncture in a community health center is complicated by other limitations such as room size, uncomfortable exam tables, and the typical loud and distracting sounds of a busy clinic (crying babies receiving vaccines, etc). Some of these barriers can be overcome by having an adequate supply of pillows, fitting a massage table into a large exam room, and providing small portable music players or encouraging patients to bring earphones. These measures can create a suitable approximation of the quiet, healing environment found in most acupuncture offices.
With two treatment rooms and a well-trained medical assistant, a physician acupuncturist can generally see two patients per hour. With more rooms, it is possible that this number might be expanded. In lieu of a dedicated Acupuncture clinic, it is also possible to see patients during your standard clinic time using either the model of front-loaded short visits (developed by Dr. Steven Chen, Oakland, CA) or by booking your next-to-last appointment of a clinic for acupuncture. This allows you to place the needles and leave them in place for 15 or 20 minutes while you see your last patient. When you are done with your last patient, the needles are ready to be removed.

Mind-body treatments

Mind-body interventions are inexpensive, portable, accessible, adaptable, and effective. The most basic techniques can also can be learned and applied with very limited training. The 4-7-8 breath espoused by Dr. Andrew Weil as well as the 5 second inhalation, 5 second exhalation (or 6 breaths per minute cycle) are ideal introductions to breath work, as is the "soft-belly" mindfulness abdominal breathing technique described by Dr. James Gordon. Simple guided imagery or hypnosis can be performed in a dedicated 15-minute visit. And biofeedback sessions using an inexpensive computer device such the Em-Wave (www.heartmath.com) can help coach patients into deep states of relaxation. All of these mind-body techniques have been used successfully at community health centers.

OMT

Simple OMT can be successfully performed spontaneously as indicated during brief clinic visits. Sub-occipital release, strain-counter strain, 1st rib release, and lumbar-sacral decompression can all be performed with basic training and are quick, safe, and effective. When necessary, a more thorough treatment can be performed in
the underserved setting by reserving the last one or two clinic appointments. It is helpful to have a specialized table for thorough osteopathic evaluation and treatment.

Food as Medicine

Without question, diet has major implications for overall health and longevity. It is the main cause (along with sedentary lifestyle) of our current epidemic of obesity and Type 2 Diabetes. These diseases are rampant in our underserved communities, with some predictive models estimating that 50% of Latino children born in the US will develop diabetes in their lifetime and that these children, for the first time in history, will live shorter lives than their parents.
To combat this epidemic, it is prudent to encourage our underserved and financially-limited patients to spend more money on healthy food rather than costly supplements. Community health centers can play a pivotal role in changing the direction of our nation's eating habits by advocating for plant-based diets rich in healthy fats such as the Mediterranean or Anti-Inflammatory diets. Suburban, rural, and perhaps even urban community health centers can further promote and provide fresh, local fruits and vegetables by cooperating with local farms and CSA's (community supported agriculture). Community health centers can be CSA drop-points (where members pick up weekly boxes of seasonal, local produce) or host a weekly farmers market/farm stand. Efforts such as these can make a great difference in impoverished urban areas where fresh produce is often scarce and fast-food is ubiquitous. Promoting community wellness in this manner will help redefine the role of healthcare in underserved communities, truly making "health" a holistic, comprehensive endeavor.

Integrative Pharmacy

It is possible to purchase supplements wholesale from the manufacturer. Such products can then be stocked and sold to patients at a fraction of what they might pay elsewhere. Cooperation with local supplement manufacturers may also result in donation of supplements and herbs.
Some of the more commonly used supplements and natural medicines in Underserved Integrative Medicine include Vitamin D3, Magnesium, Fish Oil and Essential Fatty Acids, Melatonin, Probiotics, Guar Gum, B12, Folate, and Deglycerinated Licorice. In addition, herbal tinctures can be purchased in bulk for $5 an ounce or bulk herb can be made into tea.
With proper guidance, patients can also be encouraged to wild-craft herbal medicines from commonly available and easily identifiable plants such as rosemary, lavender, fennel, chamomile, nettle, blueberry, etc. Patients with a garden or patch of land can easily grow edible medicinal herbs such as thyme, mint, sage, oregano or plants such as calendula, Echinacea, or garlic, not to mention a host of healthy vegetables. As Hippocrates said, "Let your food be your medicine."

Group Visits (General)

Social isolation is rampant in many underserved populations, especially amongst the elderly. The limitations imposed by chronic diseases can further isolate these individuals. Group visits are an ideal way to overcome several barriers to health. They promote socialization and connection as well as allow adequate time to educate patients about the nuances of their particular condition. Group visits can be conducted with as few as 2 or as many as 30+ patients. There are many ways to conduct groups, but generally only two ways to bill for these visits.
Dr. Jeff Geller, director of the Lawrence Massachusetts Underserved Integrative Medicine Fellowship, runs over thirty groups a week! His model is based on promoting patient self-empowerment. The members of the group play an active role in designing the activities of the group. These can range from artistic pursuits to exercise classes to dance to tai chi. Group participants are not billed at each visit, but are seen for a brief face-to-face encounter with Dr. Geller when appropriate. Thus, in group of roughly 20 persons, Dr. Geller might see 4 patients per hour for brief visits while the group is being conducted. This encourages the patients to keep the visit brief, as they are usually eager to return to the activities of the group. Dr. Geller has had tremendous success with this model.
The other main model of billing for group visits necessitates a smaller group size, ideally 8-12 patients per two-hour group. This model relies on billing each patient at each group. It requires that patients sign a HIPPA disclosure stating that their health information may be shared with other members of the group. Whenever possible, we try to limit the sharing of personal heath history, but in the course of "checking-in", which is the subjective part of the progress note, some personal details are unavoidably revealed. This disclosure is a natural part of the group process, and thus it is rarely a barrier to patient participation. At the conclusion of group, a standard progress note is completed based on the plan developed following assessment of subjective and objective data, which is all documented in the medical record.

Group Visits (specifics)

There are many ways to run group visits. Many models use a standard format of check-in, didactic discussion, movement, mind-body technique. These can be arranged in order as appropriate for the group. For example in "wellness group", which was a monthly ongoing open support group, we began with a meditation and then a long check-in followed by a writing or art exercise, which concluded with a sharing of our respective work. In chronic pain group, on the other hand, we began with a very limited check-in followed by a lengthy topic-discussion based on a standard curriculum (this group consisted of 7 weekly meetings) followed by gentle physical exercise and concluding with a breathing exercise. Some groups, such as anxiety or depression groups, are process-oriented and consist only of lengthy check-in.
A brief sampling of the group model:

Chronic Pain

In chronic pain group, participants learn holistic behavioral methods to minimize pain while maximizing function.

Nutrition

Cooking demos, didactics, and in-depth nutritional Q&A sessions.

Wellness/Lifestyle

Structured more as a class series. Explores various wellness topics including nutrition, stress reduction, sleep hygiene and exercise. Santa Rosa Family Medicine Residency has started a new, and very successful, lifestyle group.

MBSR

Mindfulness-based stress reduction. Eight-week series pioneered by Jon Kabat-Zinn, PhD. Thirty years of supporting research with demonstrated efficacy for numerous health conditions. Has been adapted to prison populations and inner-city underserved clinics. Instructor training is available through the Omega Institute (www.eomega.org) Jon's book, Full Catastrophe Living, is an excellent introduction to the techniques and principles of the MBSR program.

Diabetes/Obesity/HTN/Pre-Diabetes/Hyperlipidemia

Diabetic groups can be structured in various ways and tend to be ongoing rather than a fixed series. Enrollment is generally open and topics range from diet to stress reduction to diabetic specific teaching. However, with minimal loss of content, it is possible to structure the diabetes groups so that the information is applicable to pre-diabetes, hypertension, hyperlipidemia, obesity, or even pre-pre Diabetes (FBG high 90's). Such preventive measures may prevent patients from the inevitable progression to diabetes, which is all to common.

Acupuncture

The group acupuncture model (working class acupuncture) was pioneered by Lisa Rohleder and is described in her book, Acupuncture is like Noodles. These clinics are now sprouting up all over the country, bringing acupuncture to patients who could otherwise not afford it (www.communityacupuncturenetwork.org). This exciting new method of delivering acupuncture uses powerful distal points without electric stimulation. Patients relax in recliners while the practitioner places the needles, which are left in place for as long as an hour. This method allows practitioners to see many more patients and charge significantly less per visit (~$25). This method is now being modified for implementation in underserved clinics.

Group Exercise Classes:

Yoga
Yoga can be taught with minimal training or specialized equipment. All that?s really needed is a room, an hour, and a willing instructor. Yoga mats are helpful, but not essential, and condition-specific modifications can be made as appropriate, such as in prenatal-yoga. These features make yoga one of the most "flexible" exercise classes to introduce in an underserved setting.
Walking
Patients often site lack of a workout partner as a major barrier to sustaining an exercise routine. Walking groups and pedometer programs can serve as great motivational tools.
Zumba/Dance
Exercise that doesn't feel like exercise is often easier to initiate and sustain. Fun movement classes like Zumba (high energy dance with a Latin flair) are an excellent way to keep people motivated and moving. An underserved clinic in New York City uses it's waiting room (after hours) to host Zumba classes and the patients love it! http://www.zumba.com/us/

Community Outreach/Partnership

Community partnership is one of the most powerful weapons in the fight against the diseases of poverty which are rampant in our underserved communities. Creating allies with farming co-ops, massage schools, acupuncture schools, and herbal/integrative pharmacies can lead to rapid uploading of new resources with little financial investment. These organizations are often willing to donate significant time, energy, and services to developing programs which will directly impact the health of the community at large, and they understand that community health centers are an excellent place to access this larger population.

CME lectures/educational sessions

In order to develop a successful Integrative Medicine program in a community health center, it is ideal to offer ongoing educational sessions to the staff, including MA's, Providers, and support personnel. This will facilitate understanding of the evidence-based foundation and holistic approach of Integrative Medicine and help dispel any possible misconceptions or assumptions.

Patient Handouts

Think of something you find yourself telling patients multiple times per week. It may be as simple as how to supplement with vitamin D3 or how to mix up saline nasal rinse. This is the perfect thing to turn into a patient handout. Over time, borrowing from the following sources and building your own, you will develop a useful library which you will find invaluable for patient education.

Check out:
http://www.srfmr.org/fellowship_links.php
Santa Rosa Fellowship Site with a humble assortment of homemade handouts in English and Spanish

http://www.uwhealth.org/alternative-medicine/health-professionals/11434
Amazing and quite professionally produced high-level patient handouts from the masters of Integrative Medicine, David Rakel, et al.
Other links:
The STFM group on Integrative Medicine for the Underserved (IM4U)
National monthly conference calls, 1st Monday of each month, 1230PM (PST).

Fellowship
There are currently two fellowships in Integrative Medicine for the Underserved.
Lawrence, MA
http://glfhc.org/index.php?option=com_content&task=view&id=29&Itemid=45
Santa Rosa, CA
http://www.srfmr.org/fellowship_mission.php
Thanks to the IM4U cooperative (Integrative Medicine for the Underserved):
Dr?s Jeff Geller, Steven Chen, Connie Basch, Rick McKinney, Anna O?Malley, Onna Lo, Ben Brown, Wendy Kohatsu, Ben Kligler, Andrea Gordon�

A note about Underserved Populations:

There are complex legal definitions of medically underserved areas and populations as well as health professional shortage areas (HPSA). Most of these complex definitions are meant to specifically delineate the primary care needs of certain areas and fringe populations within those areas so that appropriate measures can be taken to reconcile and ameliorate health disparities.
The U.S. Department of Health and Human Services (DHHS), Health Resources and Services Administration (HRSA), which oversees the National Health Service Corps, uses the following specific criteria for HPSA designation (according to the HRSA website http://bhpr.hrsa.gov/shortage/primarycare.htm)
Geographic areas must:
  • Be a rational area for the delivery of primary medical care services
  • Meet one of the following conditions:
  • Have a population to full-time-equivalent primary care physician ratio of at least 3,500:1
  • Have a population to full-time equivalent primary care physician ratio of less than 3,500:1 but greater than 3,000:1 and have unusually high needs for primary care services or insufficient capacity of existing primary care providers
  • Demonstrate that primary medical professionals in contiguous areas are overutilized, excessively distant, or inaccessible to the population under consideration.
Population Groups must:
  • Reside in an area in that is rational for the delivery of primary medical care services as defined in the Federal code of regulations.
  • Have access barriers that prevent the population group from use of the area's primary medical care providers.
  • Have a ratio of persons in the population group to number of primary care physicians practicing in the area and serving the population group ratio of at least 3,000:1
Members of Federally recognized Native American tribes are automatically designated. Other groups may be designated if the meet the basic criteria described above.

A note about the Author's Clinic:
The Petaluma Health Center is a Federally Qualified Health Center with a HPSA score of 5, which makes it a loan-repayment eligible site through the National Health Service Corps. It is designated as residing in an urban Medically Underserved Area (MUA). The clinic serves primarily low-income Latino and non-Latino Caucasian populations.