Interprofessional Competencies in Integrative Primary Healthcare
Competencias interprofesionales en la atenciуn primaria integral
In October 2014, the National Center for Integrative Primary Healthcare (NCIPH) was launched as a collaboration between the University of Arizona Center for Integrative Medicine and the Academic Consortium for Integrative Health and Medicine and supported by a grant from the Health Resources and Services Administration. A primary goal of the NCIPH is to develop a core set of integrative healthcare (IH) competencies and educational programs that will span the interprofessional primary care training and practice spectra and ultimately become a required part of primary care education. This article reports on the first phase of the NCIPH effort, which focused on the development of a shared set of competencies in IH for primary care disciplines. The process of development, refinement, and adoption of 10 “meta-competencies” through a collaborative process involving a diverse interprofessional team is described. Team members represent nursing, the primary care medicine professions, pharmacy, public health, acupuncture, naturopathy, chiropractic, nutrition, and behavioral medicine. Examples of the discipline-specific sub-competencies being developed within each of the participating professions are provided, along with initial results of an assessment of potential barriers and facilitators of adoption within each discipline. The competencies presented here will form the basis of a 45-hour online curriculum produced by the NCIPH for use in primary care training programs that will be piloted in a wide range of programs in early 2016 and then revised for wider use over the following year.
2014 ? 10 ?,???????? ???? (NCIPH) ??,???? ??????????????? ?????????????? ?,????????????? ??????NCIPH ?????? ??????????????? ????? (IH) ?????? ?,??????,?????? ??????????????? ??? NCIPH ????????, ??????????????? ???????,??????? ??????? 10 ?“??? ?”???????????,? ??????????????? ??????????????? ??????????????? ??????????????? ??????????????? ??????????????? ?????,????????? ??????????????? ???????????? NCIPH 45 ?????????,??? ???????,2016 ??,?? ??????????????, ???????????????
En octubre de 2014, se inaugurу el Centro nacional de atenciуn primaria integral de salud (National Center for Integrative Primary Healthcare, NCIPH) como una colaboraciуn entre el Centro de medicina integral de la Universidad de Arizona y el Consorcio acadйmico de salud y medicina integral, y fue subvencionado con fondos de la Administraciуn de Recursos y Servicios de Salud. El objetivo principal del NCIPH es desarrollar un conjunto bбsico de competencias de asistencia sanitaria integral (SI) y programas educativos que abarquen los espectros de formaciуn y prбctica en atenciуn primaria interprofesional y se integren en ъltima instancia en la educaciуn en atenciуn primaria. Este artнculo detalla la primera fase de la iniciativa del NCIPH, que se centra en el desarrollo de un conjunto de competencias compartidas en asistencia sanitaria integral para las disciplinas de atenciуn primaria. Se describe un proceso de desarrollo, perfeccionamiento y adopciуn de 10 “metacompetencias” a travйs de un proceso de colaboraciуn en el que participa un equipo interprofesional heterogйneo. Los miembros del equipo representan al personal de enfermerнa, las profesiones mйdicas de atenciуn primaria, farmacia, salud pъblica, acupuntura, naturopatнa, quiroprбctica, nutriciуn y medicina de la conducta. Se ofrecen ejemplos de las subcompetencias especнficas de cada disciplina en fase de desarrollo en cada una de las profesiones participantes, junto con los resultados iniciales de la evaluaciуn de los posibles obstбculos y los facilitadores de la adopciуn dentro de cada disciplina. Las competencias que se presentan aquн constituirбn la base de un plan de estudios en lнnea de 45 horas elaborado por el NCIPH para su uso en programas de formaciуn en atenciуn primaria que se pondrбn a prueba a principios de 2016 y serбn posteriormente revisados para la generalizaciуn de su uso el aсo siguiente.
Integrative healthcare (IH) “reaffirms the importance of the relationship between practitioner and 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.”1 By definition, IH addresses the biomedical as well as sociocultural determinants of health and takes a broad view of health creation and disease prevention. In focusing on prevention, patient empowerment and activation, and treating not only the patient but the family and the community, IH has the potential to significantly contribute to the prevention and treatment of many if not all of the chronic health problems causing morbidity and mortality in our society today, including obesity, cancer, cardiovascular disease, diabetes, violence, and depression.
IH includes both conventional and licensed complementary and alternative medicine (CAM) practitioners. According to the US Centers for Disease Control and Prevention (CDC) national surveys conducted between 2002 and 2012, one-third of adults2 and 12% of children and adolescents3 in the United States use CAM. The Institute of Medicine has recommended that all healthcare providers become familiar with CAM approaches, so they can properly counsel their patients regarding their use.4
Published evidence is accumulating regarding both the clinical effectiveness5 and cost effectiveness6 of IH. Yet due to a shortage of trained providers and limited resources, the principles and practice of IH have not been widely incorporated into the conventional healthcare delivery system in the United States. This is particularly true for the medically underserved communities most at risk for health disparities.
To address this gap in access to Integrative health-care, the federal Health Resources and Services Administration (HRSA) during the past 4 years has supported an educational initiative to incorporate evidence-based integrative medicine curricula—initially into preventive medicine residency education and expanding to primary care residency and other health professions training programs through interprofessional learning strategies. The first phase of this initiative was the HRSA-funded Integrative Medicine Program that targeted preventive medicine residency training programs in an effort to develop physician education and tools for the application of integrative medicine to preventive medicine and public health training programs.7
The second phase, begun in the fall of 2014, is a more inclusive effort to build on these tools. The goals include developing a core set of IH competencies and educational programs that will span the interprofessional primary care training and practice spectra to help produce a workforce prepared to close this gap. This second phase of HRSA funding was awarded to the University of Arizona Center for Integrative Medicine which, in collaboration with the Academic Consortium for Integrative Health and Medicine (the Consortium), has now established the National Center for Integrative Primary Healthcare (NCIPH). This article reports on the first phase of the NCIPH effort, which focused on the development of a shared set of competencies in integrative healthcare for primary care disciplines. The competencies presented here will form the basis of a 45-hour online curriculum produced by the NCIPH for use in primary care training programs.
Integrative Healthcare Training Needs of Health Professionals in the Affordable Care Act Era
The ultimate goal of the NCIPH is education of interprofessional teams that will be highly effective in embedding the principles of IH8 (Table 1) with a focus on prevention and elimination of health disparities in primary care. This goal is especially critical given the shifts in the healthcare landscape being brought about by the implementation of the Affordable Care Act (ACA). As our healthcare system struggles to provide quality care for more than 30 million potential new patients and moves toward team-based, collaborative, interprofessional care with a stronger emphasis on prevention, it becomes more critical that our primary care workforce be versed in the principles of whole-person, patient-centered, IH. The development of the new evolving infrastructure for healthcare in the United States—based on the medical/health home model and the role of Accountable Care Organizations that will focus on prevention and patient engagement as strategies to control cost and deliver quality care—provides a tremendous opportunity to incorporate these principles more deeply into our system. Some of the new skills needed for IH-trained practitioners include how to work with an interprofessional team; how to engage patients and care partners in preventive self-care strategies to stay healthy rather than wait for disease to develop; and how to actively incorporate the patients’ perspectives, experiences, strengths, and resources into the plan of care.8 These are just a few of the core skills of IH that have generally been absent or underemphasized in conventional primary care training, yet they are critical for successful functioning in the new healthcare delivery model.9
|1.||Patient and practitioner are partners in the healing process.|
|2.||All factors that influence health, wellness, and disease are taken into consideration, including mind, spirit, and community, as well as the body.|
|3.||Appropriate use of both conventional and alternative methods facilitates the body’s innate healing response.|
|4.||Effective interventions that are natural and less invasive should be used whenever possible.|
|5.||Integrative medicine neither rejects conventional medicine nor accepts alternative therapies uncritically.|
|6.||Good medicine is based in good science. It is inquiry-driven and open to new paradigms.|
|7.||Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount.|
|8.||Practitioners of integrative medicine should exemplify its principles and commit themselves to self-exploration and self-development.|
The NCIPH will advance the incorporation of competency and evidence-based IH curricula and best practices into primary care education and practice. Targeted primary care disciplines include family medicine, internal medicine, pediatrics, preventive medicine, nursing, public health, behavioral medicine, pharmacy, chiropractic, acupuncture, naturopathy, physician assistants, nutrition, and others. In order to accomplish our goal of building effective and knowledgeable interprofessional integrative team care and to begin to break down the “silos” that divide the professions in terms of training and practice standards,10 the NCIPH leadership made a strategic decision to engage as wide a spectrum as possible of professions involved in primary care to create a common set of competencies in IH.
Addressing Disparities in Access to Integrative Healthcare Among Diverse Populations
Although complementary and integrative therapies are used by approximately one third of US adults, use among most minorities and individuals with lower income or education is less common.2,11–14 For example, in 2012, 38% of non-Hispanic whites reported CAM use in contrast to only 19% of blacks and 22% of Hispanics.2 Using yoga as an exemplar, national usage increased substantially from 3.8% in 1998 to 8.4% in 2012.15 However, in 2007 yoga was used by 6.5% of whites vs 3.3% of blacks; 6.6% of non-Hispanics vs 2.9% of Hispanics; 9.5% in college-educated individuals vs 1.9% in non–college educated individuals; and 8.6% of individuals in the highest income quartile vs 4.9% of individuals in the lowest quartile.16 Barriers to accessing complementary and integrative therapies among diverse populations include affordability, availability, and awareness. Limited disposable income, lack of integrative services in low-income, racially diverse neighborhoods, and lack of knowledge about IH often prevent low–socioeconomic status minority populations from benefitting from complementary and integrative therapies. This disparity is concerning given increased evidence of the safety and effectiveness of different complementary and integrative therapies. For example, yoga is now considered moderately effective and safe for chronic low back pain, which disproportionately impacts racial and economically diverse populations.17 Yoga is just one example; the same is true for numerous other integrative approaches. Moreover, racially diverse populations are amenable to trying new integrative approaches if they are made affordable and available and if patients are made aware of and understand them.18,19 As federal, private, and academic stakeholders invest millions of dollars into IH research, education, and clinical services, it is imperative that diverse socioeconomic and multicultural communities and vulnerable populations have equal access to evidence-based complementary and integrative therapies.
The NCIPH will provide adequate training in integrative primary healthcare to the interprofessional workforce and offer services to these patient populations, particularly in federally qualified community health centers. This will address multiple challenges. Vulnerable patient populations experience risk from potential interactions and adverse effects of some integrative approaches when their primary care providers are not routinely trained in complementary and integrative therapies. In addition, ethnically diverse and medically underserved populations are deprived of potentially beneficial approaches when their health-care team lacks training. For example, the NCIPH curriculum will train primary care professionals to offer sound advice on such topics as herb-medication interactions; dietary supplement contamination and adulteration; the role of mind-body therapies in treatment of chronic pain and stress-related conditions; and the applications of acupuncture, manual, and movement therapies. Our specific conclusions and recommendations regarding the competencies that will guide this curriculum are described below.
During the past 15 years, several primary care professions have developed and published competencies for IH practice. Family medicine, preventive medicine, and nursing in particular have done substantive work in this area.7,20–23 Competencies have also been published for medical student education24 as well as for fellowship training in integrative medicine.25 A small group from our NCIPH Interprofessional Leadership Team (InPLT; see Table 2 for InPLT team memb