Complementary and alternative medicine, also commonly referred to as

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1 Information I n f o r m a t i o n Bulletin B u l l e t i #1 n # 5 SP National Association of Community Health Centers, Inc SPECIAL POPULATION SERIES For more information contact Jacqueline C. Leifer, Esq. Molly S. Evans, Esq. Marcie H. Zakheim, Esq. Feldesman Tucker Leifer Fidell LLP 2001 L Street NW Washington DC Telephone (202) ; Fax (202) MEvans@feldesmantucker.com or Malvise A. Scott Vice President, Programs and Planning National Association of Community Health Centers, Inc Wisconsin Avenue, Suite 210 Bethesda, Maryland Telephone (301) Fax (301) MScott@nachc.com This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the publisher is not engaged in rendering legal, financial or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. Cooperative Agreement Number U30CS00209 from the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) supported this publication. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA/BPHC. Incorporating Complementary and Alternative Medicine Therapies into Your Health Care Delivery Program Complementary and alternative medicine, also commonly referred to as CAM, is a term that, until recent years, was not used in the day-today operations of many health centers. When asked to define what complementary and alternative medicine entails, a provider might name such therapies as acupuncture and traditional Chinese medicine, but would most likely tell you that such therapies were not available at his or her health center. Though numerous CAM therapies have been utilized for thousands of years, the conventional health care community in the United States, including many health centers, has only recently discovered CAM as a viable option for treating patients. This Information Bulletin: Discusses the use of CAM therapies and approaches to treating patients, and Describes specific requirements/conditions of incorporating such treatments into the health center s scope of project and its overall primary and preventive health care plan. Discusses issues such as coverage under the Federal Tort Claims Act (FTCA), credentialing and privileging of health center practitioners providing CAM treatments, and reimbursement for CAM services, and Provides a couple of real life examples of health centers that are currently offering CAM therapies within the areas of traditional Hawaiian and Chinese, and describes the techniques they have utilized to include these traditional modes of health care delivery as part of the services they provide to their patients. 1 August 2004 National Association of Community Health Centers, Inc.

2 Special Populations Information Bulletin #5...CAM systems, although different from one another, generally share common goals of individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual. BACKGROUND ON CAM The term CAM encompasses a broad range of medical, health care, and healing therapies other than those typically included in conventional health care delivery systems in the United States. These CAM systems, although different from one another, generally share common goals of individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual. 1 The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health classifies CAM therapies into the following five categories: Alternative Medical Systems Alternative medical systems are whole systems of medicine, complete with their own theory and practice, that have developed separate and apart from conventional medical approaches. Many alternative medical systems are traditional systems of medicine that have been practiced by individual cultures throughout the world. Examples of alternative medical systems are found in both Eastern cultures (e.g., traditional Chinese medicine, such as acupuncture and Chinese herbal medicine, and Ayurveda, a traditional comprehensive system of Indian medicine that includes the use of diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing), as well as in Western cultures (e.g., homeopathic 2 and naturopathic medicine 3 ). Mind-Body Interventions Mind-body intervention focuses on treating a patient s physical condition through mental therapies. Since the use of CAM therapies is a continuously evolving approach to health care, several mind-body therapies that were previously considered to be CAM (e.g., patient support groups and cognitive behavioral therapy) have been accepted fully as conventional medicine. Examples of mind-body 1 White House Commission on Complementary and Alternative Medicine Policy Final Report, March 2002, page 9. 2 Homeopathic treatment is a system of medical practice based on the theory that any substance that can produce symptoms of disease or illness in a healthy person can cure those symptoms in a sick person. For example, someone suffering from insomnia may be given homeopathic doses of coffee. Homeopathic remedies are used widely to treat a large variety of ailments including seasonal allergies, asthma, influenza, headaches and indigestion. 3 Naturopathy is a broad system of medicine based on the theory that the body is a selfregulating mechanism with the natural ability to maintain a state of health and wellness. Naturopathic doctors try to cure illness and disease by harnessing the body s natural healing powers. Naturopathy uses a variety of alternative and traditional techniques, including herbal medicine, homeopathic treatment, massage, dietary supplements, and other physical therapies. National Association of Community Health Centers, Inc. 2 August 2004

3 S pecial Populations Information Bulletin #5 interventions that are currently considered CAM include biofeedback 4, meditation, prayer, and mental healing. Biologically Based Therapies Biologically based therapies utilize substances found in nature, such as herbs, foods, and vitamins as a form of therapy. Examples of biologically based therapies include the use of shark cartilage to treat cancer and bee pollen to treat autoimmune and inflammatory diseases. Biologically based therapies also include the use of diet-based therapies such as the Dean Ornish diet and the Atkins diet. Manipulative and Body-Based Methods Manipulative and body-based methods focus on the movement of one or more parts of the body for treatment. For example, chiropractors focus on the relationship between structure (primarily the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. Massage therapists, on the other hand, manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being. Energy Therapies Energy therapies concentrate on the use of energy fields. There are two types of energy therapies: 1) biofield therapies and 2) bioelectromagneticbased therapies. Biofield therapies, such as qi gong, Reiki, and therapeutic touch, focus on the energy fields that purportedly surround and penetrate the human body. Qi gong is a component of traditional Chinese medicine that combines movement, meditation and regulation of breath to enhance the flow of qi in the body, improve blood circulation, and enhance immune function. Reiki is based on the belief that when spiritual energy is channeled through a reiki practitioner, the patient s spirit is healed, which in turn heals the physical body. On the other hand, bioelectromagneticbased therapies, such as magnet therapy involve the unconventional use of electromagnetic fields for pain management and treatment for migraine headaches. Growing Popularity of CAM In today s healthcare environment, CAM approaches and therapies are becoming more and more popular, both with health care providers and their patients. In fact, a study released by the U.S. Department of Health and Human Services on May 27, 2004 found: 36% of U.S. adults ages 18 years or over use some form of CAM. When prayer specifically for health reasons is included in the definition of CAM, the number of U.S. adults using some form of CAM in the past year rises to 62%. 5 The U.S. public spent between $36 billion and $47 billion on CAM therapies in Of this amount, between $12.2 billion and $19.6 billion was paid outof-pocket for the services of professional CAM providers such as chiropractors, acupuncturists, and massage therapists. By way of comparison, these fees are more than the U.S. public paid out-of-pocket for all hospitalizations in 1997 and about half that was paid for all out-of-pocket physician services. With CAM s confirmed growth and sustainability, medical schools, hospitals, provider groups and managed care organizations are embracing CAM and incorporating CAM therapies into their daily operations. Even the Federal government has shown a demonstrated interest in the development and use of CAM therapies. Importantly, among the places where the Federal government s interest in CAM has shined through the most is in the realm of health centers. 4 Biofeedback teaches clients, through the use of simple electronic devices, how to consciously regulate normally unconscious bodily functions (e.g., breathing, heart rate, blood pressure) to improve overall health August 2004 National Association of Community Health Centers, Inc.

4 Special Populations Information Bulletin #5 SUPPORT FOR THE PROVISION OF CAM THERAPIES BY HEALTH CENTERS The Bureau of Primary Health Care (BPHC) has long acknowledged the importance of health centers incorporating culturally competent services into their health care delivery systems. Legislation and Policy Section 330 of the Public Health Service Act requires health centers that serve a population that includes a substantial proportion of individuals of limited English-speaking ability to have in place a plan and/or other arrangements responsive to the needs of such population for providing services to the extent practicable in the language and cultural context most appropriate to such individuals. 6...in recent years, BPHC has acknowledged and emphasized the importance of incorporating CAM into the health care delivery plans of health centers. BPHC Program Expectations further state that: Organizational behaviors, practices, attitudes, and policies across all health center functions must respect and respond to the cultural diversity of communities and clients served. Health centers should develop systems to ensure participation of the diverse cultures in their community in programs offered by the health center. 7 Given the aforementioned statutory requirement and policy expectation, the implementation and incorporation of CAM treatments and approaches into a health center s conventional primary and preventive health care delivery system could be considered, at a minimum, essential for health centers that serve populations for whom CAM is a necessary component of cultural competency. That is to say, in order to ensure participation of diverse cultures residing in their communities, health centers should seriously consider including in their scopes of project those CAM therapies that are embraced by such populations as an important part of their culture. To this end, in recent years, BPHC has acknowledged and emphasized the importance of incorporating CAM into the health care delivery plans of health centers. In October of 2000, BPHC published Program Assistance Letter # (PAL # ) entitled Access to 6 Section 330(k)(3)(K) (emphasis added). Complementary and Alternative Therapies. In PAL # , BPHC states that, the BPHC mission to increase access to improve health status of medically underserved populations may include providing access to CAM services to these populations, depending on the needs and priorities of the community. 8 Integrative Medicine and Alternative Health Practice (IMHAP) Initiative In demonstrating its intention to make CAM therapies and approaches more available and accessible to health centers, BPHC also established the Integrative Medicine and Alternative Health Practice (IMHAP) Initiative. The IMHAP Initiative supports BPHC s mission of improving the health status and increasing access to culturally competent, comprehensive and preventive health care for the medically underserved through furthering the integration of complementary medicine and alternative health practices with conventional primary care in Bureau-funded health centers and programs. Under the IMHAP Initiative, health care is delivered through a range of providers, and focuses on diverse populations who might otherwise not have access to these services. 9 7 BPHC Program Information Notice ( PIN ) #98-23: Health Center Program Expectations, at p. 8 (emphasis added). 8 BPHC PAL # : Access to Complementary and Alternative Therapies, at p National Association of Community Health Centers, Inc. 4 August 2004

5 S pecial Populations Information Bulletin #5 White House Commission on Complementary and Alternative Medicine Policy The White House has also shown support for health centers inclusion of CAM in the range of services that they provide to their patients. In its March, 2002 Final Report, the White House Commission on Complementary and Alternative Medicine Policy recommended that the Department of Health and Human Services (HHS) sponsor the development and evaluation of demonstration projects that integrate the use of safe and effective CAM services as part of the health care programs in community health centers. 10 Further, the Commission suggested the creation of demonstration projects of residencies and postgraduate training for appropriately educated and trained CAM practitioners sponsored by Federal agencies and departments such as the NCCAM, BPHC, the Department of Defense, and the Department of Veterans Affairs. According to the Commission, it is particularly interested in the creation of demonstration projects for residencies and postgraduate training at health centers because community health centers represent a unique opportunity for combining education in ethnically, racially, and culturally diverse learning environments with service to medically underserved populations who otherwise might not have access to CAM. As such, the Commission recommended that any current or proposed CAM postgraduate education and training program performed at health centers be given special consideration. 11 ISSUES TO CONSIDER WHEN OFFERING COMPLEMENTARY AND ALTERNATIVE MEDICINE IN HEALTH CENTERS Clearly, health centers that determine that the addition of certain CAM approaches and therapies to their scopes of project would be beneficial to their patients have strong legislative, regulatory and public policy support for proceeding. However, before a health center adds any new CAM approach or therapy to the services it provides, there are a number of important issues that it should consider, some of which are set forth in PAL # , Access to Complementary and Alternative Medicine, others of which are of more general concern. Among the issues that a health center should 10 Final Report of the White House Commission on Complementary and Alternative Medicine Policy, March 2002, at p Final Report of the White House Commission on Complementary and Alternative Medicine Policy, March 2002, at p. 65. consider when deciding whether to add CAM therapies are the following: Choosing Which CAM Therapies and Approaches to Include If a health center decides that it would like to offer CAM therapies and approaches to its patients, it should tailor those therapies and approaches to meet the specific needs of the community in which it operates. Further, similar to other services offered by the health center, the health center should ensure that the CAM services are culturally and linguistically appropriate for the populations served. For example, including traditional Chinese medicine as a CAM therapy may not be appropriate for a community served by a health center in rural Mississippi, if the community is predominantly Caucasian and African- American. According to PAL # , in order to be culturally and linguistically appropriate, it is necessary to integrate complementary and alternative therapies with conventional medicine and indigenous healing practices, as well as the primary language of the patients. In other words, when a health center integrates CAM therapies with conventional primary care and traditional healing approaches, it should ensure that the CAM therapies reflect the culture(s) [including the primary spoken language(s) and housing status] of the communities served. 5 August 2004 National Association of Community Health Centers, Inc.

6 Special Populations Information Bulletin #5 Adding CAM Services and Providers to the Health Center s Scope of Project Once the health center has determined which CAM treatments would be appropriate based on the needs and cultures of its community (and special populations within the community), the health center should begin the process of adding such therapies and approaches to its approved scope of project. In general, to include the provision of non-primary care services within a health center s scope of project, the service must be based on the needs of the community and the capacity of the health center to provide those services. 12 Once a health center has determined that particular CAM therapies are needed within the community, the health center should then: Determine whether it has the capacity to provide such services, in terms of both financial and personnel resources; Assess whether the benefits of providing CAM outweigh the costs; and Decide whether risks associated with providing the services can be minimized and managed by the health center. With respect to CAM providers, such individuals may be included in the health center s scope of project if the provider is practicing in compliance with State law and regulations. 13 Accordingly, the health center should: Evaluate its State law licensure and scope of practice requirements: To determine what kind of treatment CAM providers are authorized to provide, and To ensure that its CAM providers conform to such practice requirements. Typically, CAM providers should either be licensed by the State to provide the specific CAM therapy that they offer or meet other State requirements related to the specific CAM therapy. By way of example,...to include the provision of non-primary care services within a health center s scope of project, the service must be based on the needs of the community and the capacity of the health center to provide those services. 12 BPHC PIN # : Scope of Project Policy, at p BPHC PIN # , at p. 6. according to the NCCAM, as of 2002, acupuncture was licensed in 42 states. A health center in one of those 42 states, therefore, could include acupuncture in its scope of project and, if the need were there, offer it as a CAM therapy to its patients. As a general rule, the only unlicensed CAM providers that are permitted to practice CAM therapies are those who do not violate State scope of practice requirements in offering their therapies. That is to say, if a health center wants to engage an unlicensed CAM provider to provide a specific CAM therapy, the State scope of practice requirements may require that the unlicensed provider practice in accordance with specific requirements, such as practicing under the supervision of a licensed physician. If a health center determines that it wants and is able to add a particular CAM therapy to the scope of services that it provides, then it will need to submit a post-award change in scope request pursuant to BPHC PIN # , Scope of Project Policy. According to BPHC PIN # , approval of a health center s change in scope is contingent on, among other things, a demonstration of projected revenue and expenses showing break-even (as a worst case scenario) or the potential for generating a surplus. Without approval of a change in scope from HRSA, Section 330 FQHC-related benefits (i.e., use of grant funds, PPS Medicaid reimbursement, cost-related Medicare reimbursement, FTCA and 340B, as applicable) would not be available to the health center for these services. National Association of Community Health Centers, Inc. 6 August 2004

7 S pecial Populations Information Bulletin #5 Accessing Federal Tort Claims Act ( FTCA ) Coverage For CAM Providers In order to extend medical malpractice liability protection under FTCA to CAM providers furnishing services at the health center: The health center must be deemed under the Federally- Supported Health Centers Assistance Act of Once a health center has been deemed, in order for FTCA coverage to extend to the health center s CAM providers, the providers must be either employees of the health center or fulltime 15 independent contractors whose contracts are directly with the health center (i.e., the contracts cannot be between the health center and another organization that employs the CAM provider, such as a massage therapy group). Further, the CAM therapies that the providers intend to furnish must be included in both the health center s scope of project, as discussed above, and the CAM provider s scope of employment/ contract. If FTCA coverage does not extend to a CAM provider because either the provider or the arrangement does not satisfy the requirements discussed above, the health center should obtain private malpractice insurance or require the CAM provider to secure and maintain private malpractice insurance and supply evidence of this coverage in the selection and credentialing process. Including CAM Therapies, Approaches and Providers in the Health Center s Clinical Practice Once the health center determines that the CAM therapies and approaches it would like to provide are appropriate for its community and that the services are approved by HRSA as included within the health center s scope of project, the health center s Board of Directors should amend the health center s clinical policies to include standards for the provision of CAM therapies. First, appropriate members of the health center s management team should develop written policies and procedures for the clinical use of CAM therapies. Next, the health center should establish written policies on the selection process for CAM providers, as well as amend its privileging and credentialing policies in order to include CAM providers. Once the CAM providers have been appropriately credentialed and privileged, the health center should conduct an annual written review of each CAM provider, whether licensed or legitimately unlicensed for quality assurance purposes. 7 Securing Reimbursement for CAM Therapies Regardless of the appropriateness and need for CAM services, whether and to what extent a health center can secure appropriate reimbursement for CAM therapies and approaches may ultimately limit (or even prevent) a health center s ability to offer CAM. Currently, Medicare and Medicaid reimbursement for CAM therapies is limited. Medicare On the Federal level, Medicare includes some limited coverage of chiropractic services and Christian Science nursing. While some CAM insurance coverage is under consideration, other CAM therapies have been determined not to be covered. For example on April 14, 2004, the Centers for Medicare and Medicaid Services (CMS), concluded that acupuncture is not reasonable and necessary for the treatment of fibromyalgia or osteoarthritis within the meaning of section 1862(a)(1) of the Social Security Act. 16 As such, CMS has continued to hold that acupuncture is not reimbursable. CMS, however, continues to evaluate Medicare coverage for other 14 A health center will be deemed if the Secretary of Health and Human Services determines, among other things, that the health center providers are appropriately credentialed, certified, etc., and that the health center has implemented policies and procedures designed to reduce the risk of malpractice. 15 This assumes that the CAM provider cannot be appropriately classified as a family medicine, OB/GYN, or internal medicine provider. 16 Transmittal 11, Pub , Medicare National Coverage Determinations Manual (April 14, 2004). August 2004 National Association of Community Health Centers, Inc.

8 Special Populations Information Bulletin #5 According to a survey performed in 2000 by the American Association of Retired Persons, three-quarters of State Medicaid programs surveyed cover chiropractic services, and another fifth cover biofeedback. CAM therapies. Among the CAM therapies that CMS is evaluating is the Medicare Lifestyle Modification Program, a demonstration project implemented by CMS Center for Beneficiary Choices. The demonstration project tests the effectiveness of providing payment for cardiovascular lifestyle modification program services. The demonstration, which began in 1999 and extends until February 2006, includes two separate projects: the Dr. Dean Ornish Program for Reversing Heart Disease developed by Dr. Dean Ornish and offered through the efforts of the Preventive Medicine Research Institute in Sausalito, California and Lifestyle Advantage, Pittsburgh, Pennsylvania; and The Cardiac Wellness Extended Program developed by Dr. Herbert Benson and offered through the Mind/Body Medical Institute in Boston, Massachusetts. As the nation continues to battle the current obesity epidemic, it is likely that CMS will continue to look for more CAM U.S.C. 1396d(a)(6). approaches to lifestyle modification such as the biologically-based CAM therapy demonstration projects discussed above. State Medicaid programs can receive Federal funding to provide optional Medicaid health care services in addition to the required Medicaid services that they provide. Medical care provided by statelicensed practitioners within their scope of practice (as defined by State law) is an optional Medicaid service. 17 According to a survey performed in 2000 by the American Association of Retired Persons, three-quarters of State Medicaid programs surveyed cover chiropractic services, and another fifth cover biofeedback. 18 As Medicaid coverage of CAM therapies will vary widely from State to State, health centers should be sure to evaluate their State-specific coverage in determining whether to offer certain CAM therapies. 18 Complementary and Alternative Medicine: The Road Less Traveled?, AARP Public Policy Institute Issue Brief #46. REAL LIFE EXAMPLES OF HEALTH CENTERS USING CAM While the incorporation of CAM therapies and treatments into the conventional health care delivery system is a relatively new phenomenon, currently there are several good examples of CAM implementation at health centers nationwide. The following examples provide a glimpse into the types of CAM offered by health centers and the manner in which the CAM services have been incorporated into their respective health care systems. Traditional Hawaiian Therapies The Waianae Coast Comprehensive Health Center, Inc. (WCCHC), located on the island of Oahu, Hawaii, operates an overall comprehensive health care delivery system that includes (in addition to the integrative healthcare) primary, preventive and emergency medical care; specialty care; dental care; behavioral health services; substance abuse treatment; case management; and social services. In December 2002, WCCHC opened the doors to providing integrative health services, a nonwestern approach to healing. Integrative health is organized to mesh traditional practices and western medicine and typically is provided through a team approach that includes physicians trained in National Association of Community Health Centers, Inc. 8 August 2004

9 S pecial Populations Information Bulletin #5 alternative medicine, registered dietitians, health educators, a psychologist, a certified exercise fitness trainer and community health workers. Waianae s Integrative Health Institute provides Native Hawaiian Traditional Healing, the Waianae Diet (a traditional Hawaiian diet approach), and other integrative practices such as acupuncture, as well as conducts research on integrative medicine, practices and approaches. A Kupuna Council (Council of Elders) sets policy and oversees cultural practices. In particular, Native Hawaiian Traditional Healing includes the arts of Lomilomi (traditional, spiritual and physical muscle stress, relaxation therapy); La au Lapa au (healing with the use of compounding herbs and other traditional remedies); Ho oponopono (traditional Hawaiian family problem solving process); and La au Kahea (healing through prayers and chants). Native Hawaiian Traditional Healers are considered providers of enabling services as well as healers. (See the NACHC/MGMA report indicating that traditional healers can provide enabling services.) A pilot project, funded by AlohaCare (a managed care organization established by Hawaii community health centers), is currently providing a capitation for integrative health services. This will set the stage for other health plans to support a capitation for integrative health. For additional information regarding WCCHC s Integrative Health Institute please contact Dr. Terry Shintani at (808) Traditional Asian Therapies Northeast Medical Services (NEMS) located in San Francisco, California, serves a predominantly Asian population. NEMS offers comprehensive outpatient health care services, including: primary care in internal medicine, pediatrics, obstetrics and gynecology, and family practice; and specialty care in radiology, cardiology, surgery, allergy and immunology, ophthalmology, and ENT. NEMS also offers adult and pediatric dentistry, optometry, acupuncture, podiatry, health education, nutrition, social services, mental health counseling, and ancillary services (e.g., x-ray, laboratory, and pharmacy services). All direct service staff are fluent in at least one Asian language (e.g., Chinese, including Cantonese, Mandarin, and other dialects; Vietnamese, Korean and Burmese). Offering acupuncture is one way NEMS attempts to blend Eastern traditions with the conventional Western treatments offered as part of its primary care program. Further, NEMS offers a variety of prevention and wellness programs based on traditional Chinese medicine, including Tai Chi and Qui Gong. Although an important component of the traditional Chinese medicine system, NEMS does not offer Chinese herbal therapies. The main concern in not offering these therapies is quality control (i.e., whether NEMS is able to guarantee the quality of the ingredients dispensed in an herbal prescription). United States authorities circulate lists to herbal stores that catalog certain banned toxic ingredients. While herbalists are supposed to check that banned herbal drugs are not prescribed, herbs with illegal ingredients such as mercury, arsenic, and others still make their way into this country, and, hence, into prescriptions. Complicating the issue of quality control are persons who travel abroad and bring back herbs for personal use to treat their particular medical conditions, such as heart disease or diabetes. Often, such individuals will present at the health center with the natural form of the herbs or in pill form. While there are instances when a particular pill will include an ingredient sheet, other times ingredient sheets are not included, presenting a huge quality control issue. Additionally, NEMS has found that even when the herbs include ingredient sheets, the drug itself may be laced with certain toxic While herbalists are supposed to check that banned herbal drugs are not prescribed, herbs with illegal ingredients such as mercury, arsenic, and others still make their way into this country, and, hence, into prescriptions. 9 August 2004 National Association of Community Health Centers, Inc.

10 Special Populations Information Bulletin #5 elements. As such, all NEMS physicians must research the herbs and herbal pills for their content before they can truly know what the patient is taking (and, therefore, avoid contraindications). Quality control issues such as these may result in serious consequences NEMS has had a few patients hospitalized as a result of bad herbal prescriptions that were either filled in the United States or personally brought back by the patient from abroad. While quality issues prevail, other traditional cultural customs may also present serious concerns. For example, there is a traditional belief that after giving birth a post-partum woman should drink a mixture of wine and vinegar to cleanse her body of the birth blood. However, this mixture may result in patients bleeding much more heavily than usual, which, in turn, may have more serious consequences. As such, the NEMS medical staff must educate the families (and the women themselves) to avoid such practices, which may cause unnecessary problems. For additional information regarding NEMS use (or non-use) of traditional Asian therapies, please contact Daniel Chan, MD, Co-Medical Director for Quality Improvement at International Community Health Services, Inc. (ICHS), located in Seattle, Washington, specifically targets its services to the Asian/Pacific Islander communities, yet strives to serve the health needs of all individuals, in a manner sensitive to the patient s language and cultural needs. ICHS provides high quality health care with a focus on education, prevention and early intervention. ICHS s programs represent a wide array of primary and preventive health care services, including women s health care and family planning, obstetrical care, pediatric care, adult medicine, chronic disease management, wellness and prevention services, immunology, podiatric services, mental health services, newborn care, nutritional counseling, and health education. In addition to interpretation services, ICHS employs a culturally and linguistically competent medical staff. In addition to its medical, dental and family planning clinics, ICHS operates a Chinese Traditional Medicine Clinic, which is co-located with one of its primary care clinics. Services offered at the Chinese Traditional Medicine Clinic include Traditional Chinese diagnosis and treatment with acupuncture, acupressure, and moxibustion, or herbal prescription. Patients can either refer themselves for these services or they may be referred by ICHS allopathic medical providers and followed concurrently. For additional information regarding the Chinese Traditional Medicine Clinic, please contact Ping Wong, LAC at ext CONCLUSION In recent years, CAM treatments, therapies, and approaches have experienced not only a growth in popularity, but also an increase in acceptance by the Federal government and the conventional health care community overall. As such, exploration of the provision of CAM may be a worthwhile endeavor for health centers that do not currently offer these therapies. This issue brief provides a brief overview of the types of CAM therapies and treatments available, as well as the legal and policy-related underpinnings for offering CAM approaches at health centers. Further, in exploring whether to provide specific CAM therapies, health centers should consider many factors, including (but not limited to) whether: The contemplated therapies meet the specific needs (cultural and otherwise) of the community in which they operate; The health center has or is able to obtain sufficient resources (including appropriate reimbursement) and capacity to provide such services; The therapies can be incorporated into their scopes of project with BPHC approval; and National Association of Community Health Centers, Inc. 10 August 2004

11 S pecial Populations Information Bulletin #5 The risks associated with providing the CAM services can be minimized and managed by the health center (i.e., through appropriate licensure, certification, insurance, etc.). Health centers interested in pursuing the development of CAM that require assistance or further guidance may want to contact BPHC s IMHAP Initiative at (301) The IMHAP Initiative offers technical assistance, training and consultation to BPHC funded programs interested in pursuing CAM. In recent years, CAM treatments, therapies, and approaches have experienced not only a growth in popularity, but also an increase in acceptance by the Federal government and the conventional health care community overall. 11 August 2004 National Association of Community Health Centers, Inc.

12 Special Populations Information Bulletin #5 National Association of Community Health Centers, Inc Wisconsin Avenue, Suite 210 Bethesda, MD Telephone: Fax: 301/ Website: 12 National Association of Community Health Centers, Inc. August 2004