Karla Karapetian: Report on the Penny George Institute Conference on Hospital Based Integrative Care

Summary: Imagine this: A hospital system has delivered 61,000 inpatient visits. It is committed to serving as a model for the nation so offers a conference on hospital-based integrative care. Would that be a smart place to be if one wishes to learn the ins-and-outs from experts? Or if not go, have a proxy attend? The Penny George Institute, part of Minnesota's Allina Hospitals & Clinics, and led by Lori Knutson, RN, BS-HN, happens to have offered such an educational opportunity for 4 days in July 2010. For those of us who didn't or couldn't attend, here is a report from our collective proxy, Karla Karapetian. Karapetian, a manager with the American Massage Therapy Association, is a communications professional. Here is her very useful report.

A commitment to integrative health care

Under my hat as executive director for the Academic Consortium for Complementary and Alternative Health Care (ACCAHC), Lori Knutson, RN, BS-HN is a colleague as a member of ACCAHC's Council of Advisers. Knutson, director of the

• George Institute/Allina Hospital publishes outcomes on patients who receive integrative, inpatient care.
• George Institute/Allina inpatient initiative reports $2000 savings per patient in  integrative care program
• Making the Evidence Case for Integration in a Large Hospital System
• Allina Honors Integrative Medicine Visionary:  U.S.'s Top Hospital Program Becomes the Penny George Institute for Health & Healing

Hospital Based Integrative Health Care Conference: 
Transforming Health Care Practice

July 26-29, 2010
Penny George Institute for Health and Healing
Minneapolis, Minnesota

Karla Karapetian
Industry Relations Program Manager
American Massage Therapy Association

 

Contributor Karapetian: Attendee reports on conference

The first annual Hospital Based Integrative Health Care Conference: Transforming Health Care Practice presented by the Penny George Institute for Health and Healing (PGIHH) brought together practitioners and healthcare professionals who were interested in understanding what integrative health is and how it can be applied in a hospital setting.

The conference provided an overview of current best practices from the Penny George perspective in key areas of integrative health. 

PGIHH is a leader in providing integrative medicine in a hospital setting. The Institute is with Abbott Northwestern Hospital (629 beds) and is part of a larger health care network call Allina Health Systems that includes:

• 11 hospitals
• 90 clinics
• 23,000 employees  

PGIHH began in 2003 and consists of inpatient hospital care, an outpatient clinic and a fitness center. They provide acupuncture, biofeedback, healing coach sessions, healing touch, herbal consultation, integrative medicine physician consultation, massage therapy, nutritional consultation, therapeutic yoga, and exercise therapy at the LiveWell Fitness Center to both inpatients and outpatients.

Definition of health promotion ... the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health and supporting them in changing their lifestyle to move toward a state of optimal health ...

It was exciting to see such a diverse group of individuals that included nurses, doctors, massage therapists, acupuncturists, physical therapists, social workers, chiropractors and dieticians.  Out of this group, the largest groups of attendees were nurses and massage therapists.  The majority of people were from the Midwest (Minnesota, Wisconsin, Illinois and Iowa).

Each day began with an overview of why there is a need for integrative health.  Statistics on health spending per country as well as the annual costs of an unhealthy lifestyle illustrated the need for a shift in how health care is defined and delivered in the United States.  A definition of health promotion as the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health and supporting them in changing their lifestyle to move toward a state of optimal health was shared as well as the gaps in current care that include self care knowledge, self care skills and self confidence in health/health care decisions.  It was acknowledged that the health promotion/wellness focus with insurance companies is still up in air as far as who will pay for these things but it is up to us to create that future. 

Integrative Hospital Based Massage Therapy

Knutson: Director of experience-based integration conference

A clinician panel featuring massage therapists (and AMTA members) from PGIHH discussed their experiences and approach to massage in a hospital setting.  They shared how important it is to be cross-trained (i.e. massage, aromatherapy, energy work) because each patients' needs are different and change from moment to moment.  For example, a patient may have indicated pain relief as their main compliant at the time of scheduling but at the time of treatment they may be experiencing nausea or anxiety.  And each patient is unique so what might have worked on one patient for nausea may not work on another.  Therapists also have to assess whether to use hospital lotion or work on skin without lubricant.  Therapists also need to know themselves enough to identify that sometimes another practitioner would be better for a particular patient.

The panel shared the importance of massage therapists being cross- trained (i.e. massage, aromatherapy,  energy work) because each patients' needs are different and change from moment to moment.

The panel also shared their opinion on the traits of a successful massage therapist in a hospital setting including critical thinking skills (which they believe come with experience), trusting in the work (many times results are not immediate), and being comfortable operating in a hierarchical system.  

General Principals for acute care massage were explained as:

• Massage in the hospital is slow and gentle
• Areas massage are the back, posterior neck, scalp, shoulders, heads and feet
• Patients can be positioned side, supine, or sitting
• Light to medium pressure only
• Checking in with patient and asking about pressure often
• Adhere to universal precautions
• Frequent hand washing

 
Body mechanics is also very important when working on patients in a hospital setting.  Massage therapists must work around the patient, equipment, and other staff.  One of the panelists demonstrated proper body mechanics when treating someone in a hospital bed. 

All the therapists on the panel shared the unique emotional environment of working in a hospital.

All the therapists on the panel shared the unique emotional environment of working in a hospital.  You are not working in a quite, soothing setting.  Rather, it is sterile, loud, and busy with an undercurrent of anxiety and pain.  The need to stay centered and set your intentions for compassionate, intentional touch is very important.  You may not have a "positive" experience with everyone you touch.  The staff shared they affirm their position by letting go of expectation and take on the belief that whatever is suppose to happen, will happen. 

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Hospital Based Integrative Care: Mind Body Medicine

Gary Carlson, MD gave an overview of the traditional and non-traditional (CAM) healthcare system.  He discussed how integrative medicine is the best of both systems and this view allows it to become more mainstream and less territorial.  The concept of integrative medicine is looking at the whole terrain of the person - mind, body and spirit.  The integrative healing concepts are:

• Heal (thy) Self (teach patient to fish rather than give them a fish)
• Proper paradigm - meet with the patient where they are in the paradigm, not where they think they are
• Compassion
• Not "or" but "and" - a combination of both traditional and non traditional
• Good communication
• Individuality - treat the person not the disease

The model for how traditional and nontraditional medicine works in a hospital setting puts the patient and symptoms in the center of care.  The health care team looks to treat the imbalances rather than treat the diagnosis.  For example a patient may be experiencing symptoms of depression and back pain.  Under the integrative approach, they may be prescribed medication (traditional medicine), massage, exercise, a social worker and a sleep plan.  All of these treatments work synergistically to treat the present and underlying causes of the symptoms.  It also allows the patient to play a role in their own health and wellness. This approach supports the new government health promotion and prevention initiative.

CAM Research in the Hospital Setting:  Inpatient and Outpatient Exemplars

The Director of Research of Integrative Medicine at the Center for Health Care Innovation at Abbott Northwestern Hospital shared the results from inpatient integrative medicine.  Referrals for integrative medicine are initiated by the medical and nursing staff.  They are ordered in an electronic health record.  The medical record is reviewed at a triage meeting at PGHII and treatments are scheduled.  The treatment always consists of an intake, education of the modality prescribed and the actual therapy.  After the treatment, the practitioner documents the visit in the electronic health record.  Abbott has complied statistics from the data since 2004 and here are some of the results of integrative medicine:

• 61,000 inpatient visits (they do an average of 12,000 per year but this number is not reflective of need/demand but of capacity - need/demand much higher - average of three treatments per patient per hospital visit)
• 17,215 people received services from the Penny George Institute between July 2004 and December 2009.  They did not share what percentage of this was massage therapy.
• The breakdown of specialty areas where patients received integrative medicine - 14% women's care, 15% cardio/vascular, 16% ortho/spine, 19% neuro/rehab and 36% med/surgical
• Anxiety, nausea and pain scores went down by half after integrative medicine visit

The data show an exciting trend among physicians.  The number referring integrative medicine went from 4 in 2003 to 400 in 2010.

The data they have received supports the feasibility in providing integrative care for acutely ill patients.  It also shows an exciting trend among physicians.  The number of physicians referring integrative medicine went from 4 in 2003 to 400 in 2010.  The data also shows there was significant improvement in the reduction of pain and anxiety.  Abbott is about to release some very exciting research through medical journals that shows integrative medicine increases patient satisfaction and is profitable.  The data will be release in August or early September.  

Referrals are so high for the integrative doctors and acupuncturists at the outpatient clinic at PGHII they are booked 8-10 weeks in advance.  They are now running into patient satisfaction issues because people can't access these services when they want to.  It's important to note that these services are reimbursable through insurance.  They also offer massage therapy at the outpatient clinic but on a cash basis only. The PGIHH did not share any data that explains why referrals for the integrative doctors and acupuncturists were so high.  This may indicate people are more apt to try something if it is covered by insurance rather than out of pocket.  What they do know is that people are very receptive to an alternative approach to health care.  

Guided Imagery

Guided imagery is used frequently at Abbott in dealing with pain, anxiety, and stress.  Studies have shown a thought process produces a physiological response.  The role of the guide includes:

• Center - attention/intention
• Create a safe environment and hold the space, keeping self out of the process
• Guide the person through their experience
• Trust the process and let go of the outcome
• Be comfortable with affect

These principals are very similar to that of massage therapy and many therapists at PGHII are cross trained in this modality. 

Creating the Organizational Culture for Integrative Health Care

PGHII shared their advice on how integrative medicine practitioners can begin building a presence in hospitals and clinics.  Pain management is the biggest challenge for all hospitals and it is also the area where integrative medicine can be most effective.  Below are some of the starting points:

• Assessing attitudes, beliefs, and knowledge
• Determining the gap in care (physicians, nurses, patients, system) in attaining optimal patient outcomes
• Creating the opportunity (pilot the partnership/look for your physician champions)
• Keep it simple but effective, and in a short timeframe
• View every encounter as a teaching opportunity.

 
These points could be useful for those wanting to do research in a hospital setting as well.  They also stress to keep it simple - one indication (symptom): one intervention and to provide simple tools for physician to begin to learn the language of integrative medicine.  The biggest hurdle for massage therapists and acupuncturists is to have the confidence and professionalism to speak and interact peer-to-peer.  If you don't have those traits, physicians won't respect or listen to you.  This is something that the Institute had to work on with their staff.  Another tip is to have integrative medicine staff encourage their patients to write/email letters to the hospital administrators about their experience. 

Demonstrating Clinical and Operational Outcomes for Success and Sustainability

	These data help evolve the practice of these therapies and they hope to become a national warehouse for all data for hospitals all over the U.S. for integrative medicine.

PGHII had to build onto the existing electronic medical record database to ensure that they would be able integrate fully into the system while having the ability to pull reports and collect data on integrative medicine.  One of the items they included was narrative notes so they could document the unique stories (qualitative data).  They now have an ongoing research database that is updated quarterly that collects clinical, financial and indirect (teaching research, program development, etc) data used for research, operations and for continuous improvement.  They have captured 18,000 recorded services (70% women and 30% men) and attempted 22,000 services.  This means they were able to service 75% of patients.  They are pioneers when it comes to tracking data on all aspects of providing integrative therapies to patients in a hospital setting.  This data helps evolve the practice of these therapies and they hope to become a national warehouse for all data for hospitals all over the U.S. for integrative medicine.
 

The most common aromatherapy types are lavender, mandarin, ginger, spearmint, sweet marjoram, Roman chamomile and frankincense. There were 2,074 patient visits (using) aromatherapy from July 2009 through March 2010.

Aromatherapy in the Clinical Setting 

Aromatherapy is another therapy the Institute uses within the hospital.  Many of the massage therapists also are certified in this therapy.  They use oils both topically and for inhalation.  The most common types are lavender, mandarin, ginger, spearmint, sweet marjoram, Roman chamomile and frankincense.  There were 2,074 patient visits from July 2009 through March 2010.  The top three symptoms treated by aromatherapy were pain, anxiety and nausea.  All three symptoms were reduced statistically significantly by the treatment.  They are now cross training nurses who want to become certified.  Aromatherapy is a component of holistic nursing.     

Conclusion

This four day conference was a glimpse into the future of health care.  PGHII is forging the path for integrative medicine in many ways.  They have built an environment that allows the therapists to thrive while putting in place a database to prove the efficacy of their work.  They have created the balance of providing integrative care within a traditional medical model.  The rapid increase in physician referrals is a testament to their ability to connect and educate the hospital staff.  Their compassionate approach to treating the whole person is resonating with patients and staff.  This approach of seeing the patient as a unique whole person is very familiar to massage therapists and other integrative health providers.  However, this is a paradigm shift for the western medical model and it is exciting to see this change in motion. 

Lori Knutson, executive director of PGHII charged each of the attendees to decide how they were going to be the agents of change and what role they will play in bringing integrative health to their organization.

"This four day conference was a glimpse into the future of health care.  PGHII is forging the path for integrative medicine in many ways. 

• They have built an environment that allows the therapists to thrive while putting in place a database to prove the efficacy of their work. 
  
• They have created the balance of providing integrative care within a traditional medical model. 
  
• The rapid increase in physician referrals is a testament to their ability to connect and educate the hospital staff. 
  
• Their compassionate approach to treating the whole person is resonating with patients and staff. 
  

"This approach of seeing the patient as a unique whole person is very familiar to massage therapists and other integrative health providers.  However, this is a paradigm shift for the western medical model and it is exciting to see this change in motion."