Interprofessional Competencies in Integrative Primary Healthcare

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.

Integrative nursing: application of principles across clinical settings

While the essence of nursing has long been whole person (body, mind, and spirit) and whole system-focused, in reality the contemporary practice of nursing in many settings around the globe has become increasingly fragmented and de-stabilized. Nursing shortages in many parts of the world are significant, and hierarchies and bureaucracies often remove nurses from the point of care, be that the bedside, home, or clinic, replacing them with less skilled workers and filling their time with documentation and other administrative tasks. Integrative nursing is a framework for providing whole person/whole system care that is relationship-based and person-centered and focuses on improving the health and wellbeing of caregivers as well as those they serve. It is aligned with what is being called the "triple aim" in the United States-an effort focused on improving the patient experience (quality and satisfaction), improving the health of populations, and reducing the cost of care. The principles of integrative nursing offer clear and specific guidance that can shape and impact patient care in all clinical settings.

Healthcare utilization and costs in persons with insomnia in a managed care population

OBJECTIVES

To better understand the direct costs of insomnia. Our study aimed to compare healthcare costs and utilization of patients diagnosed with insomnia who received care in a managed care organization with a set of matched controls.

DESIGN

Our observational, retrospective cohort study compared 7647 adults with an insomnia diagnosis with an equally sized matched cohort of health plan members without an insomnia diagnosis between 2003 and 2006. We also compared a subset of patients diagnosed with and treated for insomnia with those diagnosed with insomnia but not treated.

SETTING

A large Midwestern health plan with more than 600,000 members.

RESULTS

Multivariate analysis was used to estimate the association between insomnia diagnosis and costs, controlling for covariates, in the baseline and follow-up periods. Although we cannot conclude a causal relationship between insomnia and healthcare costs, our analysis found that insomnia diagnosis was associated with 26% higher costs in the baseline and 46% in the 12 months after diagnosis. When comorbidities were recognized, the insomnia cohort had 80% higher costs, on average, than the matched control cohort.

CONCLUSIONS

These outcomes suggest the need to look beyond the direct cost of insomnia to how its interaction with comorbid conditions drives healthcare cost and utilization.

How mindfulness changed my sleep: focus groups with chronic insomnia patients

BACKGROUND

Chronic insomnia is a major public health problem affecting approximately 10% of adults. Use of meditation and yoga to develop mindful awareness ('mindfulness training') may be an effective approach to treat chronic insomnia, with sleep outcomes comparable to nightly use of prescription sedatives, but more durable and with minimal or no side effects. The purpose of this study was to understand mindfulness training as experienced by patients with chronic insomnia, and suggest procedures that may be useful in optimizing sleep benefits.

METHODS

Adults (N = 18) who completed an 8-week mindfulness-based stress reduction (MBSR) program as part of a randomized, controlled clinical trial to evaluate MBSR as a treatment for chronic insomnia were invited to participate in post-trial focus groups. Two groups were held. Participants (n = 9) described how their sleep routine, thoughts and emotions were affected by MBSR and about utility (or not) of various mindfulness techniques. Groups were audio-recorded, transcribed and analyzed using content analysis.

RESULTS

Four themes were identified: the impact of mindfulness on sleep and motivation to adopt a healthy sleep lifestyle; benefits of mindfulness on aspects of life beyond sleep; challenges and successes in adopting mindfulness-based practices; and the importance of group sharing and support. Participants said they were not sleeping more, but sleeping better, waking more refreshed, feeling less distressed about insomnia, and better able to cope when it occurred. Some participants experienced the course as a call to action, and for them, practicing meditation and following sleep hygiene guidelines became priorities. Motivation to sustain behavioral changes was reinforced by feeling physically better and more emotionally stable, and seeing others in the MBSR class improve. The body scan was identified as an effective tool to enable falling asleep faster. Participants described needing to continue practicing mindfulness to maintain benefits.

CONCLUSIONS

First-person accounts are consistent with published trial results of positive impacts of MBSR on sleep measured by sleep diary, actigraphy, and self-report sleep scales. Findings indicate that mindfulness training in a group format, combined with sleep hygiene education, is important for effective application of MBSR as a treatment for chronic insomnia.

The impact of Telephonic Health Coaching on Health Outcomes in a High-risk Population

Background:

Health coaching is a client-centric process to increase motivation and self-efficacy that supports sustainable lifestyle behavior changes and active management of health conditions. This study describes an intervention offered as a benefit to health plan members and examines health and behavioral outcomes of participants.

Methods:

High-risk health plan enrollees were invited to participate in a telephonic health coaching intervention addressing the whole person and focusing on motivating health behavior changes. Outcomes of self-reported lifestyle behaviors, perceived health, stress levels, quality of life, readiness to make changes, and patient activation levels were reported at baseline and upon program completion. Retrospectively, these data were extracted from administrative and health coaching records of participants during the first 2 full years of the program.

Results:

Less than 7% of the 114 615 potential candidates self-selected to actively participate in health coaching, those with the highest chronic disease load being the most likely to participate. Of 6940 active participants, 1082 fully completed health inventories, with 570 completing Patient Activation Measure (PAM). The conditions most often represented in the active participants were depression, congestive heart failure, diabetes, hyperlipidemia, hypertension, osteoporosis, asthma, and low back pain. In 6 months or less, 89% of participants met at least one goal. Significant improvements occurred in stress levels, healthy eating, exercise levels, and physical and emotional health, as well as in readiness to make change and PAM scores.

Discussion:

The types of client-selected goals most often met were physical activity, eating habits, stress management, emotional health, sleep, and pain management, resulting in improved overall quality of life regardless of condition. Positive shifts in activation levels and readiness to change suggest that health coaching is an intervention deserving of future prospective research studies to assess the utilization, efficacy, and potential cost-effectiveness of health coaching programs for a range of populations.

The Impact of an Innovative Mindfulness-Based Stress Reduction Program on the Health and Well-Being of Nurses Employed in a Corporate Setting

This study implemented an innovative new model of delivering a Mindfulness-Based Stress Reduction (MBSR) program that replaces six of the eight traditional in-person sessions with group telephonic sessions (tMBSR) and measured the program's impact on the health and well-being of nurses employed within a large health care organization. As part of a nonrandomized pre–post intervention study, 36 nurses completed measures of health, stress, burnout, self-compassion, serenity, and empathy at three points in time. Between baseline (Time 1) and the end of the 8-week tMBSR intervention (Time 2), participants showed improvement in general health, t(37) = 2.8, p < .01, decreased stress, t(37) = 6.8, p < .001, decreased work burnout, t(37) = 4.0, p < .001, and improvement in several other areas. Improvements were sustained 4 months later (Time 3), and individuals who continued their MBSR practice after the program demonstrated better outcomes than those that did not. Findings suggest that the tMBSR program can be a low cost, feasible, and scalable intervention that shows positive impact on health and well-being, and could allow MBSR to be delivered to employees who are otherwise unable to access traditional, on-site programs.