AN INNOVATIVE PRIVATE. Prof Kerryn Phelps AM PRACTICE MODEL

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1 AN INNOVATIVE PRIVATE Prof Kerryn Phelps AM PRACTICE MODEL

2 CHANGES IN HEALTH CARE MODELS

3 INTEGRATIVE PRIMARY HEALTHCARE MODELS Only GPs, without special CM training, who refer actively to a virtual team of CM practitioners Only GPs who have an understanding of or special training in one or more CM modalities which they incorporate into their therapeutics advice to patients GPs with in-depth knowledge of one or more CM modalities working in a co-located integrated team with CM practitioners with an in-house inter-referral pattern Becoming an integrative practice can be a revolution or an evolution.

4 EVIDENCE-SUPPORTED CHOICE

5 CHANGE Attitudes of medical practitioners, CAM practitioners, the general public and politicians have undergone significant shift. Consumers prepared to invest their own money into CAM treatments despite the lack of financial subsidy from government. Cost is a barrier for many people who expect free healthcare

6 MOTIVES FOR IM and CAM USE Maintain general wellbeing Illness prevention Aid recovery from illness Adjunct to medical treatments in chronic disease management or cancer treatment Dissatisfaction with medical treatment Strengthen immune system Prevent cancer recurrence Withdrawal from medication/substances Treatment of conditions with few/no/inadequate medical answers or where medical treatment is perceived to have too great a risk-benefit ratio eg MS, chronic fatigue, autoimmune disease, menopause, arthritis

7 LEVELS OF TRANSFORMATION INDIVIDUAL GROUP PRACTICE INSTITUTION SYSTEM

8 INDIVIDUAL TRANSFORMATION OPPORTUNITIES: greatly enhanced professional satisfaction Greatly enhanced patient satisfaction. Less fragmentation of care. BARRIERS: resistance to up-skilling of medical practitioners in skills they consider outside the medical mainstream Courses more expensive and less accessible than pharmaceutical-based education Inconsistent registration of complementary health practitioners Colleagues in a group practice may be unsupportive or hostile

9 A HOPEFUL BEGINNING 2006 Integrative Multidisciplinary: doctors, dietician, naturopaths, psychologists, acupuncture, exercise physiology, yoga Computerised, networked, integrated clinical notes integrated (except psychologists) 340 sqm,large investment in fit-out Accredited!0 year lease Adjacent health food store and dispensary

10 MISSION Clearly articulate the mission and philosophy of your clinic Not a one size fits all model Helps attract the right practitioners Lets potential patients and new patients know what you stand for

11 Waiting Room/Seminar room

12 Health food store/parapharmacy

13 DISPENSARY Community-based or hospitalbased herbal medicine and nutritional medicine expertise alongside pharmacy Discussion with practitioners about what herbs, supplements, equipment and devices they prescribe, use or recommend Dispensing methodology, personnel and protocols: weighing, measuring, quality control, expiry dates, stock rotation, record keeping, hygiene, regulations. No commissions paid to practitioners for prescribing

14 Clinical Rooms The physical design of the clinic needed to take into account the types of practitioners and the facilities and equipment they would require. For example, the yoga practitioner requires clear floor space. Doctors require medical equipment to manage the full range of general practice cases including emergencies. The clinic has been accredited by GPA

15 Exercise Lab

16 INFORMATION SYSTEMS Choice of computer hardware Choice of software none currently available are ideal for an integrative model of practice and needed to be modified Shared records Privacy considerations patient permission for shared record system some practitioners may not want to have shared records eg. psychologists

17 PRACTITIONER MIX? Practitioners with skill who share a common philosophy Practitioners prepared to commit to the mission statement GPs, psychologists, acupuncture/tcm; naturopaths; massage; shiatsu; exercise physiology; physiotherapy

18 CM AND INTEGRATIVE RESEARCH

19 INTEGRATION REQUIRES COMUNICATION Interaction between practitioners in private sector within a team Interaction between practitioners in a hospital-based team Virtual teams Interaction between practitioners in hospital practice and community-based practice Mutual understanding and respect based on evidence and experience

20 REALITY CHECK

21 RESEARCH Published our first four years experience Although many integrative medicine clinics fail to survive the first few years, after 4 years, this multidisciplinary primary care clinic had succeeded in establishing a viable health care service offering both integrative medicine and conventional, traditional, complementary and alternative medicine. Finding the right mix of staff members and following up with evaluations to track progress are important. Hunter J et al The Challenges of Establishing an Integrative Medicine Primary Care Clinic in Sydney Australia. JACM Vol 18, No 11, 2012

22 STUDY DESIGN Qualitative data were obtained through personal knowledge of the clinic, reviewing the minutes of staff meetings, and written responses from a staff survey. Quantitative data were obtained from the staff survey, a patient satisfaction survey and the analysis of data routinely collected for administration and clinical records.

23 GROWTH After four years, 6604 patients were registered with the clinic. There were twice as many females (4,435) as males (2,169). Half the patients were aged between 30 and 59 years of age. Patient demographics were in keeping with population trends for TCAM use in Australia. 16 Some patients used the clinic as their primary health care practice; whilst others attended the clinic for specialised IM or TCAM services and saw a regular general practitioner located elsewhere.

24 PRACTITIONER MIX AND PRACTICE VIABILITY Doctors were the main income generator for the clinic because they saw the most patients, billed more per consultation and on average provided shorter consultations. Doctors provided two-thirds (66.1%) of the consultations. Consultation times ranged from 15 to 120 minutes. The median consultation time for doctors was 30 minutes and for other practitioners, 1 hour. Capacity to run at a loss for the first 4 years. By the end of the fourth year, the clinic had finally become financially viable.

25 CHALLENGES The challenges encountered were: managing high staff and practitioner turnover, finding the right balance between medical and non-medical practitioners and services offered creating an integrative medicine team, and building research capacity Finding a financially viable model

26 THE RIGHT MANAGEMENT Four practice managers in four years. Typical issues arose that can occur with any employment, particularly in a new business, such as problems with personality, management styles, competency and role overload. Although the first three managers were experienced medical practice managers, none of them had experience working in an IM clinic with a variety of practitioner types. Called for a new set of organisational and interpersonal skills able to respond to a wider range of patient and practitioner needs. Eventually promoted a receptionist with previous managerial experience outside of healthcare, who learnt the role with no preconceived ideas about how to manage an IM clinic, but with the experience of working in one.

27 PRACTITIONER TURNOVER The clinic opened with 13 practitioners: five doctors, a dietitian, an exercise physiologist, a psychologist, three naturopaths, a traditional Chinese medicine practitioner and a shiatsu practitioner. Over the first four years, 20 practitioners came and went 6 doctors, 3 naturopaths, 3 nutritionists, 3 dietitians, 2 exercise physiologists, 1 physiotherapist, 1 masseuse, and 1 chiropractor. The most common reason for practitioners leaving the clinic was insufficient patient numbers and therefore lack of personal income. Aside from two doctors, the TCM practitioner and shiatsu practitioner, all practitioners had to build a patient base from scratch. Referral from outside was a restriction. Low demand for musculoskeletal therapies and exercise physiology.

28 RESEARCH In 2009, Sydney Integrative Medicine commenced clinical research into areas of complementary and integrative therapies with a NICM grant Supervision by Emeritus Prof Stephen Leeder at Sydney University Six peer reviewed publications One PhD Ongoing research program with ethics approval of RACGP and external support of UTS

29 WHAT DID WE GET WRONG? Before our time Retail component Find the right manager Practitioner mix (made compromises to get a team together) Over-capitalised on the initial fit-out

30 WHAT DID WE GET RIGHT? Figured out what combination worked (eventually) Succesfully integrated a number of healthcare disciplines Provide a unique personalised clinic environment with high quality patient care Great word of mouth recommendations Referrals from specialists and other GPs eg iron infusions Commenced an IM research program Closed the retail store Survived to make a profit Purchased the premises

31 Research publications 2013 Hunter J, Marshall J, Corcoran K, Leeder S, Phelps K. A positive concept of health - interviews with patients and practitioners in an integrative medicine clinic. Complementary Therapies in Clinical Practice (4): Hunter, J., & Leeder, S. Patient questionnaires for use in the integrative medicine primary care setting A systematic literature review. Eur J Integr Med, (3), Hunter J, Corcoran K, Leeder S, Phelps K. Integrative medicine outcomes: What should we measure? Complementary therapies in clinical practice : p Hunter J, Corcoran K, Leeder S, Phelps K. The integrative medicine team--is biomedical dominance

32 MEDICARE SUBSIDY MEDICARE has made funding available for GP-referred limited allied health services, including psychologists, speech pathology, physiotherapy, dieticians, exercise physiologists, audiologists, osteopaths, chiropractors and podiatrists. This has facilitated more comprehensive primary health care, but is not indicative of an integrative system. There is a distinction between allied health professionals and CM practitioners, a definition at least partly based on professional registration. CM products do not attract a subsidy through the Pharmaceutical Benefits Scheme, regardless of evidence. Only pharmaceutical medications attract the subsidy.

33 BEST PRACTICE GUIDELINES Best practice should be measured by best outcomes in a socially and culturally appropriate context Current Australian practice does not reflect current culture and may not be best practice. What is current international best practice may vary widely from culture to culture CAM may be most appropriate first line treatment. Recent examples include management of arthritis, mental illness and menopause. Need to involve practitioners from different paradigms as well as medical practitioners with knowledge of evidence for CM modalities to update treatment guidelines. Because of the rapid growth of CM usage and evidence, guidelines will need to be frequently reviewed.

34 HOSPITAL-BASED PRACTICE The concept of integrative medicine in a secondary or tertiary setting is not new, but in Australia it is vastly underdeveloped. In 1999, New York s Memorial Sloan-Kettering Cancer Center established an Integrative Medicine Service with the aim of complement(ing) mainstream medical care and address(ing) the emotional, social, and spiritual needs of patients and families. Complementary therapies are used in concert with medical treatment to help alleviate stress, reduce pain and anxiety, manage symptoms, and promote a feeling of wellbeing.[i] The University of Maryland Medical School Center for Integrative Medicine founded in An international center for research, patient care, education and training in integrative medicine, the CIM is a National Institutes of Health (NIH) Center of Excellence for research in complementary medicine and a NIH International Center for traditional Chinese medicine research.(ii)

35 PRIMARY-TERTIARY MATRIX Untapped potential for a primary-tertiary integrative health care matrix Currently a disconnect between community-based practice and hospital and outpatient practice Physicians often not aware of all treatments undertaken by patients, even when it has the potential to affect their hospital treatment Physicians with little or no knowledge of CAM tell patents to stop taking everything or it is all a waste of time and money. Future development of an integrative model requires education and change management

36 A CHANGE OF BRANDING Our current team: 7 doctors Dietician Naturopath TCM / acupuncture Yoga

37 IV Suite Wellbeing Viral illness Conditions not responding to conventional therapy (eg atypical facial pain) Cancer recovery Research project underway

38 BOOKS PUBLISHED