The Integrative Health Learning Collaborative sought to improve the delivery of whole-person care and make integrative health routine and regular in primary care. During the learning collaborative, Jamaica Hospital Medical Center delivered integrative health to more patients, moved the mindset from sick care to wellness and health and showed that it is possible to deliver integrative health to underserved patients in urban health care settings.

Six in 10 adults in the U.S. have at least one chronic disease, and four in 10 have two or more, according to the CDC.¹ People in underserved communities bear far more of the burden of chronic disease than people in more affluent communities.

The COVID-19 pandemic emphasized these health and health care disparities. More people in underserved communities, especially those from racial and ethnic minority groups, got sick or dyed or were at higher risk of getting sick and dying from COVID-19 compared to the general population.

Even before the pandemic, primary care providers struggled to find the time, tools and resources to help patients with chronic diseases—whether affluent or underserved—improve their health and wellbeing. Yet, most chronic diseases seen in primary care can be prevented, managed or even reversed by addressing their underlying social and behavioral determinants.

Whole-person care and integrative health focus on helping patients achieve health and wellbeing, not just on the treatment of disease, illness and injury. It is a better way to manage chronic disease because it addresses all the factors that impact health and healing:

• Medical treatment
• Mental health
• Personal behaviors and lifestyle
• Social determinants of health
• Personal determinants of healing

Integrative primary care providers use all proven approaches:

• Evidence-based conventional medicine
• Non-drug treatments (including complementary and alternative medicine)
• Self-care

They focus on what matters most to each person and establish trusting, ongoing relationships to help patients heal.

Providers work with patients to create a personalized health plan based on the person’s needs and preferences. To do this, they use free tools such as:

• The PHI (Personal Health Inventory), which assesses the person’s meaning and purpose in life, current health and readiness for change. Patients complete this before or during a primary care visit that integrates health and wellbeing.
• The HOPE (Healing Oriented Practices & Environments) Note, a patient-guided process to identify the person’s values and goals in life and for healing so the provider can assist them in meeting those goals with evidence and other support.

Whole-Person Care Works

Evidence shows that whole-person care is effective in meeting the quadruple aim of:

• Better outcomes
• Improved patient experience
• Lower costs
• Improved clinician experience

Read more about the evidence supporting whole-person care.

The Integrative Health Learning Collaborative sought to better manage chronic disease by addressing social and behavioral determinants of health to:

• Improve the delivery of whole-person care
• Make integrative health routine and regular in primary care

Seventeen clinics participated in the learning collaborative, held from October 2020 to September 2021. The Family Medicine Education Consortium and Samueli Integrative Health Programs sponsored the learning collaborative, which was funded by a grant from The Samueli Foundation.

Read more about the Integrative Health Learning Collaborative.

Jamaica Hospital Medical Center is a 404-bed hospital that is part of MediSys Health Network, a not-for-profit integrated healthcare delivery system that is based in Queens, NY. Most of the 1.2 million patients the hospital serves each year are uninsured or underinsured with little access to quality health care. Patients are culturally diverse, primarily Black and Hispanic, with a significant number of immigrants, many undocumented.

MediSys Health Network supports Jamaica Hospital Medical Center and Flushing Hospital Medical Center. It also includes 16 neighborhood-based family health care centers, a nursing home and a center for traumatic brain injury. The network has 502 physicians in more than 60 specialties, 6,588 staff and an annual budget of approximately $1.7 billion.

Jamaica Hospital Medical Center’s Jamaica Family Medicine Center is a residency clinic that is affiliated with the Albert Einstein College of Medicine. More than 20 providers handle about 1,800 patient visits each month.

Alan R. Roth, DO, FAAF, is one of the providers using integrative health to provide better care to his patients and the leader of the effort to implement integrative health in primary care across the MediSys Health Network. Dr. Roth is the chairman of the Department of Family Medicine, Ambulatory Care and Community Medicine and chief of the Department of Integrative Pain and Palliative Care Medicine at the MediSys Health Network, Flushing Hospital Medical Center and Jamaica Hospital Medical Center.

In 2018, Dr. Roth formed an informal group of family medicine and ambulatory providers at Jamaica Family Medical Center to discuss integrative health. They began implementing integrative approaches to patient care, with an emphasis on nutrition, exercise and prevention.

“I don’t go through a visit with a patient without addressing at least one component of wellness and integrative health. Yoga is my first-line therapy for back pain now,” he says.

“Keeping patients healthy is essential to the health of the hospital.”
— Alan R. Roth, DO, FAAF

Along with providing better care to underserved patients, the integrative health approach helps the hospital achieve financial sustainability. “About 50% of our income is in globally capitated lives where we are paid a flat rate and take the full risk on about 200,000 people,” says Dr. Roth.

Senior hospital administrators began supporting work to expand integrative health after Dr. Roth explained how investing in this would reduce:

• Emergency department visits
• Hospital admissions and re-admissions
• Testing
• Over-utilization of services
• Over-prescribing of drugs

Kamica Lewis, DO, assistant program director of the Family Medicine Residency Program at Jamaica Hospital Medical Center, is working closely with Dr. Roth. They realized their mutual interest in integrative health during one of her training sessions in mindfulness and emotional intelligence for hospital leaders.

By focusing on what matters to the patient, integrative health engages patients. “If you have an understanding of where the patient is coming from and approach this as a partnership, the patient feels like they’re being heard and understood,” says Dr. Lewis. Patients who feel like their primary care provider is listening to them are more receptive to discussing their whole health and the small changes they can make to begin to improve their health and wellbeing.

“You get a lot more buy-in by helping patients find solutions and taking a few extra minutes to explain things instead of just telling them what they need to do.”
— Kamica Lewis, DO

MediSys Health Network’s plan for integrative health started with educating physicians and residents about integrative health. Current steps are:

• Changing the philosophy of care from sick care to focusing on health and wellbeing
• Offering integrative health group visits and other integrative health services

The last part of the plan will be creating urban integrated health centers of excellence that are based in the community and open to everyone. They will focus on primary care and fully integrate mental and physical health. Integrative health services will also be available to patients in traditional primary care practices.

Planned features of the centers include:

• Clinical offices
• A gym where people can exercise and take classes such as yoga and tai chi
• A demonstration kitchen where nutritionists and chefs will teach healthy cooking

Dr. Roth also hopes to rent space in the building to a healthy grocery store and to have a community garden. Plans to open the centers were delayed due to the COVID-9 pandemic. With funding from philanthropy, MediSys Health Network will modify existing buildings or build new centers. Until this can be done, more integrative health services will be added within current family medicine sites.

During the Integrative Health Learning Collaborative, the integrative health team at Jamaica Family Medicine Center delivered integrative care to more patients and developed processes for tracking and documenting integrative health visits. The team also continued work to change the mindset at MediSys Health Network from sick care to wellness and health.

The integrative care team at Jamaica Family Medicine Center is comprised of:

• Seven faculty members
• One other physician
• Six family medicine residents
• Two patient navigators/health coaches
• An integrative health coordinator
• A nutritionist
• A psychologist
• An administrator

The physicians and residents identify and treat patients who would benefit from integrative health services, conduct integrative health visits and track patient progress. Patient navigators/health coaches do the PHI with patients, serve as health coaches and arrange appointments and follow-up contacts.

Edwin Castano, QMI (qualified medical interpreter) is one of the patient navigators. The child of Spanish speaking immigrants who grew up a few blocks from the hospital, Edwin understands the needs of patients. Doing the PHI with patients over the telephone enables him to develop “meaningful connections” with them.

Most visits focus on a part of the HOPE Note that’s most relevant to the patient’s needs. Dr. Lewis, for example, asks some of the general questions to gain an understanding of the patient and then focuses on finding integrative health solutions for his/her current needs.

“Asking every single question is impossible in a 15- to 20-minute session,” says Dr. Lewis. “If we think the patient would benefit from more time, we can schedule a 40-minute visit.” In reality, however, while administrators have approved the longer integrative health visits, providers rarely had time for this during the worst of the pandemic. By fall 2021, they were able to do more longer integrative health visits.

The integrative health coordinator coordinates appropriate health care and social services for patients and provides support with health care-related needs. The nutritionist provides nutritional advice and support and the psychologist provides behavioral health and mental health support services. The administrative assistant focuses on data, reporting and team meetings and communications.

The Resource Library

The Jamaica Family Medicine Center developed an integrative health resource library for patients with content on mindfulness-based stress reduction, healthy eating and more. Most resources are electronic, however, print handouts are available for patients who don’t have a smart phone (about five percent of the center’s patients).

Most of the resources, as well as information about integrative health services such as nutrition and group visits, are available on Epic (the hospital’s electronic health record system). A monthly newsletter keeps providers updated on new and existing resources.

Jamaica Hospital Medical Center evaluated its use of integrative health for practice and clinical improvement. They used the Plan-Do-Study-Act (PDSA) cycle and the McKinsey 7S model of change management to plan and manage implementation and to evaluate their changes and plan next steps to expand the delivery of integrative health.

Read more about PDSA cycles and the McKinsey 7S model of change management.

Here is what Jamaica Hospital Medical Center did.

Jamaica Hospital Medical Center reported the following accomplishments related to integrative health before and during the Integrative Health Learning Collaborative.

Primary care providers treated more underserved patients with whole-person care and integrative health, aiding in closing the disparities gap.

The integrative health team is using the HOPE Note process and tools for discussions about the patient’s values and goals and ways to help each patient meet those goals. “Integrative health gives patients voice and choice in their care. The patients set priorities for their health instead of being told by a provider what to do,” says Castano.

During the Integrative Health Learning Collaborative, the team introduced integrative health group visits for patients with chronic diseases and expanded the role of patient navigators like Castano to include health coaching. They plan to add acupuncture and massage to their services through contracts with local schools training those providers.

“Patients love the extra engagement in integrative health. They feel that we care what’s going on and that they’re not just a number.”— Kamica Lewis, DO

Thirteen staff members completed training in group visits, which currently focus on pain management or health and wellness empowerment. “Patients tend to learn and be more inspired from each other than from just speaking to a physician,” says Dr. Lewis who led the introduction of group visits and facilitated one group.

Also, group visits help combat the epidemic of loneliness that was exacerbated by COVID-19.

“Group visits show patients that they’re not alone,” says Dr. Roth. Decreasing loneliness improves health outcomes, adds Dr. Lewis.

Providers facilitated the group visits, with the help of patient navigators and the administrative assistant. Each group met for 60 to 90 minutes weekly for six weeks and focused on a different topic each week. The facilitator introduced the topic then led an activity and the discussion. At the end of each session, patients had homework, something they choose or agreed to do before the next session to be healthier.

“Often, we say a few words and then the patients start teaching each other and supporting each other,” says Dr. Lewis. “It gives people hope and builds buy-in when patients feel they have peers to be accountable to. They want to step up and do what they said they would do.”

As a co-facilitator in the group visits, Castano serves as a host, “making everyone feel at home” and participates in the discussions. “Group visits create community bonds in a safe space. Watching patients create those bonds and become friends with each other was amazing,” he says.

A health system is changing the mindset from sick care to wellness and health.

Along with changing clinical practice, Dr. Roth and hospital leaders are transforming the MediSys Health Network to focus on integrative health and use fewer drugs to treat patients.

“We’re changing the philosophy of care and cutting down on the use of pharmaceuticals.”— Alan R. Roth, DO, FAAF

Residents and attending physicians are seeing the benefits of using the HOPE Note in providing better care to patients. Engaging residents in integrative health is especially important in changing mindsets at MediSys Health Network and more broadly.

“Residents are like sponges. What you teach them during these years is very impactful,” says Dr. Lewis. “We’re teaching them to give the best care to underserved populations. When they graduate, they’ll be able to become leaders in integrative health and create change wherever they go.”

Resident training at Jamaica Hospital Medical Center includes monthly integrative medicine grand rounds and a monthly noon conference for residents and faculty. Each year, three residents are enrolled in the University of Arizona Integrative Medicine in Residency certificate program.

Much of the learning is hands-on through discussions of using the PHI and the HOPE Note with patients and how this is different than usual care. Also, residents learn how to collaborate with other professionals, such as nutritionists and the social worker.

Jamaica Hospital Medical Center embedded integrative health tools such as the PHI and the HOPE Note into Epic.

Conducting and tracking integrative health visits is easier now that integrative health tools are part of Epic. Physicians, residents and health navigators have access to tools, and integrative health visits can be documented like a traditional medical visit.

Tools that are now embedded in Epic are:

• HOPE Note
• PHI
• PROMIS-10
• CDC Healthy Days Measures

The integrative health team worked with the hospital’s IT department to develop a tracking system and data reports for use in monitoring the effects of integrative health interventions. Leaders troubleshoot problems with providers.

Integrative health became a routine part of care for COVID-19 patients with ongoing symptoms.

To help patients recover from ongoing COVID symptoms, Jamaica Hospital Medical Center established a long-COVID integrative health clinic comprised of a primary care physician, a pulmonologist, a mental health provider and other specialists. The primary care physician uses the PHI and the HOPE Note to assess each patient and to develop an individualized integrative health care plan.

The integrative health care plan is based on the patient’s symptoms, life goals, medical needs and lifestyle. The team uses a combination of symptom management and self-care to help patients recover from COVID. Treatments include an anti-inflammatory diet, breathing exercises, exercise and a mindfulness plan, such as yoga, journaling, meditation or guided imagery. Medications are used when needed and appropriate. Recently, the clinic published a peer-reviewed article on the use of integrative health for treatment of long-COVID. ²

Jamaica Hospital Medical Center demonstrated the importance of delivering, and the ability to deliver, integrative health in urban health care settings.

“Being able to implement an integrative health approach is more challenging here than anywhere. If we can make this happen in one of the poorest hospitals in New York, anyone can,” says Dr. Roth.

Adds Castano, “We’re really making a different in our patients’ lives. We are creating stronger bonds, one patient at a time.”

The integrative health team at Jamaica Hospital Medical Center reported the following benefits of participating in the Integrative Health Learning Collaborative.

The integrative health effort regained momentum lost due to COVID-19.

Being part of the Integrative Health Learning Collaborative helped the integrative health team focus on their goals: educating physicians and residents about integrative health, implementing integrative health services and ultimately, creating integrative health centers. The team also developed a more organized approach to implementing integrative health.

“We were so motivated before COVID but we were exhausted in the past year and a half. The learning collaborative helped us reset and refocus on our goals.”— Kamica Lewis, DO

Learning from other clinics participating in the Integrative Health Learning Collaborative was valuable.

Meeting other people who are also engaged in implementing integrative health encouraged and challenged the integrative health team at Jamaica Hospital Medical Center. Also, the integrative health team learned from clinics that had more advanced integrative health programs. One key insight was the need to gather resources early before implementing integrative health programs.

“We’re happy that we did it,” says Dr. Roth. “We have gotten a lot of our folks excited about this approach to wellness and health.”

Members of the integrative health team benefitted personally from participating in the Integrative Health Learning Collaborative.

Dr. Roth, Dr. Lewis and Castano all benefitted personally from participating in the Integrative Health Learning Collaborative. Dr. Roth says that participating has “speeded up the knowledge” of members of his team, giving him more help in implementing integrative health at Jamaica Hospital Medical Center. “That has taken some of the burden of implementation off of me,” he says.

For Dr. Lewis, practicing integrative health is helping her take care of her patients the way she wanted to when she was an idealistic resident. Now she can focus on helping her patients achieve health and wellbeing.

Castano built his skillset. “I’ve been helping patients navigate the health system. Now I also help them navigate their health choices,” he says. His expanded role is “very satisfying and rewarding.”

Create and share goals and define roles and responsibilities. Implementing integrative health takes time and effort. Create goals that providers and administrators agree upon to facilitate the work. Define roles and roles and responsibilities of the team members who will be implementing integrative health.

For example, initially, providers were doing the PHI with patients and entering data into Epic, but the providers didn’t have time to complete the PHI in a visit. The team trained patient navigators to do the PHI and enter the data before the visit. Providers were very happy with this and were able to focus on the HOPE Note discussion and development of a personalized health plan during the visit.

Develop resources for patients early and make it easy for providers to access them.

Providers need health and wellness resources to share with their patients. Develop resources early in the implementation of integrative health so that when providers identify a need, they can help their patients.

Current resources at Jamaica Hospital Medical Center include educational tools on diet and education, a YouTube series on integrative health with classes in yoga and tai chi, and group visits. The YouTube integrative health series (scroll down to integrative health) includes videos on yoga, mindful meditation, exercise, nutrition, supplements and more. Dr. Roth recommends including massage therapy and acupuncture, which he plans to add soon. Jamaica Hospital Medical Center made the resources available to providers through Epic and also highlights them in a monthly newsletter.

Work with integrative health schools. Contracting with professional complementary and integrative health schools such as for acupuncture and massage is a cost-effective way to provide these services, especially for low-income or medically underserved patients. These schools provide lower cost care and often have a sliding fee scale. Faculty instructors closely supervise the care.

Find Integrative Health School Clinics by city or state and practice type.

Train family medicine residents in integrative health. Residents can help provide integrative health and when they complete residency, they’ll take integrative health skills with them to wherever they practice medicine. Training methods include grand rounds, conferences, and hands-on learning through doing and discussing integrative health visits.

Minimize primary care provider burden and maximize time for developing the personalized health plan by using other staff to complete the PHI. Jamaica Hospital Medical Center used patient navigators/health coaches to work with patients to complete the PHI before the visit and to enter data into Epic. This freed up the primary care providers to do a HOPE Note discussion and work with each patient on a personalized health plan.

Providers need integrative health resources. Providers at Jamaica Hospital Medical Center started doing integrative health visits without having tools and services to help patients. “There was a lot of frustration. Providers found problems but didn’t know where to send patients or what to do,” says Dr. Roth. He recommends putting together a list of resources early when implementing integrative health. The list should start with at least a dozen or so resources for patients, such as educational tools and services.

Providers have limited time for integrative health. Initially, the integrative health team had the providers do the PHI with patients and enter data into Epic, but the providers didn’t have time to complete the PHI in a visit. The team trained patient navigators to do the PHI with patients and enter the date into Epic before the visit. Providers were very happy with this and were able to focus on the HOPE Note discussion and development of a personalized health plan during the visit.

COVID-19 significantly disrupted the integrative health work. From late fall 2020 to March 2021, Jamaica Hospital Medical Center had another COVID surge. Residents and attending physicians who were working in integrative health were deployed back to the hospital again. For a few weeks, patient navigators were assigned to COVID vaccination efforts and were unable to assist with the PHI and other parts of the integrative health program.

Jamaica Hospital Medical Center continues to provide integrative health visits and will be expanding the group visits for patients with chronic disease and begin billing for group visits. The integrative health team will engage more providers and some residents in group visits. The team would like to offer both open and closed groups. In the open groups, patients can drop in when they want to.

Group visits, in person and virtual, are billable if the provider does a brief targeted physical exam with each patient (five minutes or less) and documentation criteria are met. In the initial group visits, Dr. Lewis focused on learning the process and teaching it to other members of the integrative health team. In future group visits, they will be implementing processes to do billable group visits.

The integrative health team plans to engage more patients in integrative health services by providing more integrative health services virtually. Virtual services will include:

• Guided imagery by Health Journeys
• An integrative health resources page on the family medical center’s website
• Continuing the YouTube integrative health series (scroll down to integrative health).

Dr. Roth hopes to be able to open the first MediSys Health Network integrative health centers by the spring of 2023. He is working on obtaining funding to modify existing buildings or build new centers. The integrated health centers will integrate mental and physical health for primary care patients and also offer integrative health services to patients in traditional primary care practices within the MediSys Health Network.

Evidence from existing whole-person care supports the effectiveness of this model in meeting the quadruple aim:

• Better Outcomes
• Improved Patient Experience
• Lower Costs
• Improved Clinician Experience.

This evidence includes a narrative review of several models of whole-person care and studies illustrate the business case for whole-person models in primary care² and the models and studies cited in this section.

Whole-person care:

• Increases the ability to manage chronic pain and decreases opioid doses.³
• Improves patient-reported health and wellbeing.⁴
• Lowers A1c in people with diabetes.⁵
• Improves medication adherence.⁶
• Facilitates a healthier lifestyle.⁷
• Reduces the severity of heart disease.⁸, ⁹
• Reduces loneliness among seniors.¹⁰
• Lessens symptoms, including pain, depression, low back pain and headaches.¹¹, ¹², ¹³

Whole-person care:

• Improves retention among patients most at risk of switching providers.¹⁴
• Improves patient satisfaction with providers and overall care.¹⁵, ¹⁶, ¹⁷
• Improves trust in, and relationships with, providers.¹⁶, ¹⁷
• Improves quality of care ratings.⁴, ¹⁷
• Improves patient input on care decisions.⁴

Whole-person care:

• Lowers the cost of drugs.¹⁸, ¹⁹
• Lowers total medical costs.²⁰, ²¹
• Leads to fewer ED visits.¹⁷
• Reduces hospital admissions.²⁰
• Reduces length of hospital stay.¹⁷, ²⁰
• Decreases outpatient costs.¹⁹, ²²

Whole-person care:

• Reduces provider burnout.⁴, ²³, ²⁴
• Reduces turnover by providers and employees.⁴, ²⁵
• Improves quality of life for providers.²⁶

Read more about the evidence supporting whole-person care.

The PDSA cycle is a tool for documenting change. Clinics participating in the Integrative Health Learning Collaborative planned and tested small changes, learned from the results, and modified the changes as necessary.

PDSA Cycle

Source: Slide 9, PDSA and 7S Report Outs v1

The McKinsey 7S model of change management is a good way to plan and manage implementation of integrative health. The model considers three structural elements: strategy, systems and structure. It also recognizes three “people” elements needed to win the hearts of everyone from front office staff
to the most senior physicians. These include addressing the types of people who are going to lead the change, the skills of the people who will be involved, and the overarching leadership style within the organization. These elements are fuzzier, more intangible, are influenced by corporate culture and are sometimes more difficult to address.

The McKinsey 7S Model of Change Management

Graphic CC-BY 2.5 Wikimedia

Managing change by addressing all these barriers leads to the 7th “S,” creation of shared values underpinning the culture of the group.

Structural and People Elements in the McKinsey 7S Model of Change Management

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Addressing all these issues through careful planning will lead to development of the shared values, the commonly accepted standards and norms within the practice that will make the switch to whole-person care a success.

Substantial planning is necessary to make the change to whole-person care.

Strategy: The obvious changes, as part of this initiative, are to start using the PHI, start conducting integrative visits around the HOPE note, and start setting up a way to monitor both your implementation and the outcomes you’ve settled on. Who is going to do what?

Systems: Careful attention is needed to identify new systems to support whole-person care. Most aspects of the practice will need to be changed in some way, including front-office, billing, and clinical care workflows. Having a Plan B on the shelf will be useful.

Structure: Determine how the roll-out will occur. It may be best to start a pilot project with a single team, carefully chosen for their ability to embrace change. Their success must be carefully monitored so that processes can change when barriers are discovered.

Style: Decide on whether the change to whole-person care will be incremental or dramatic. Decide on who will lead the implementation and how they will approach it. Develop a means of getting staff members excited. Decide how much input the staff will have in the implementation. Set up a rapid cycle quality improvement plan.

Staff: You will need to enlist key people to make your implementations happen and to make it stick. These may be people in key roles, but you will need to identify an opinion leader and a first follower (the first person in the organization to support the opinion leader) for the implementation to be widely adopted.

Skills: Whole-person care requires a new set of skills and new practices. Identify who will need to receive new training and determine how to provide the training.

The McKinsey model is probably well known to most hospital administrators but less known to clinicians and managers. Soon a five-part continuing medical education series for clinicians, staff and managers will be available that explains the HOPE note and introduces integrative health to the team and managing and monitoring the implementation process.

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