Review Article on Use of Integrative Medicine by Underserved

Introduction

Over one-third of adults in the United States use complementary wellness approaches, most commonly for chronic disease management.^1,2 As defined past the National Institutes of Health, "complementary wellness approaches" include natural products (e.g., herbs, vitamins) and heed–body practices such as acupuncture and meditation.^two–4 Utilise is lower among those who are publicly insured (25%), uninsured (23%), or living in poverty (21%).^two Integrative health intendance, which combines biomedical care with complementary health approaches,^five may better quality of care by supporting patient preferences and increasing access to non-pharmacological treatment for atmospheric condition including chronic pain and diabetes.⁶ All the same, complementary and integrative care is by and large less attainable to uninsured and Medicaid/Medicare patients due to out-of-pocket cost.^7,viii

Group medical visits (GMVs), or shared medical appointments,⁹ are widespread in The states master intendance and growing in use across medical specialties. GMVs bring five–twenty patients to the same space for medical care, health education, and peer back up. Providers bill patients' insurance as for a standard medical appointment and spend 1–3 h with a group of patients. GMVs are normally used for prenatal care¹⁰ and diabetes^xi and increasingly for chronic hurting to support safe use of opioids,¹² admission to medication-assisted treatment,¹³ and availability of non-pharmacological treatment.^14,xv Research indicates that GMVs are associated with comparable or better health outcomes than individual care.^eleven,16 GMVs may also decrease health care costs, in part by reducing emergency room visits.^17–19

In the past decade, some safety-internet clinics accept begun offering integrative GMVs (IGMVs). These combine GMVs' cadre elements of peer back up, health education, and biomedical intendance with access to complementary health approaches such as yoga, acupuncture, or meditation. Small studies propose IGMVs are a promising approach for chronic wellness conditions and health promotion more than broadly, with positive effects on physical and mental health. IGMVs for chronic pain have been associated with lower pain intensity and opioid medication use,¹⁵ improved wellness-related quality of life and slumber,^20–23 and reduced depressive symptoms and loneliness.²⁴ Existing research suggests that stress reduction via increased empowerment in IGMVs potentially contributes to improved health outcomes.²⁵

Although IGMVs are a growing tendency, little is known nigh where and how broadly they are being implemented. Small clinical pilots have provided data on individual-level outcomes in IGMVs. However, scant information is available on safety-internet programs not funded equally research. Given the prevalence of GMVs in safety-net settings and the growth of integrative care nationally, nosotros hypothesized that GMVs would be nowadays in regions throughout the Usa. Our scoping survey sought to describe the structure and scope of care existence provided in safety-internet IGMVs. We sought out a range of safety-cyberspace IGMV programs, examining which health conditions are treated in IGMVs, which complementary health approaches are well-nigh common, and what providers view equally successful and challenging aspects of this emerging approach to care.

Methods

Study design

This survey is office of a larger, mixed-methods report of IGMVs in safety-cyberspace clinics. The study included a national survey, qualitative patient and staff interviews, and ethnographic observations at four community health organizations. Qualitative data (reported separately) aimed to provide in-depth understanding of well-developed safe-net IGMV programs.²⁶ The survey was developed past the authors in consultation with clinicians with IGMV experience. We included questions on the telescopic and structure of IGMVs effectually the United states. To appraise heterogeneity of IGMVs, nosotros asked for data well-nigh a wide range of complementary health approaches, including some that are common in biomedical care (e.thousand., nutrition counseling), others that are increasingly viewed as evidence-based care (e.1000., acupuncture), and still others that remain more controversial (e.grand., homeopathy).

Sample

We distributed the survey at 2016 professional person meetings of the Academic Consortium for Integrative Medicine and Health, and Integrative Medicine for the Underserved. Nosotros sent electronic invitations to complete the survey through: (1) listservs of Indian Health Service and Integrative Medicine for the Underserved; (two) social media sites of professional networks of providers involved with safety-net care; and (3) ∼xc clinics whose websites stated that they provide care in IGMVs. Boosted respondents were recruited through snowball sampling. We chose a purposive, not-probability sampling approach to gather information from a targeted sample of providers with specific expertise in IGMV practice.

Inclusion/exclusion criteria

Eligibility was limited to wellness care providers who were (ane) trained in biomedicine and/or complementary health approaches, and (2) provided intendance in GMVs, which we defined in the survey as "medical intendance provided to multiple patients in the aforementioned room, when insurance is billed for at least some of these patients." Some questions were answered by all respondents. Others were answered simply by those respondents providing care in IGMVs, defined as including all of the following:

Care provided to multiple patients in the same room
Visit billed using ICD-ten codes and documented in patients' medical records
At to the lowest degree one complementary wellness arroyo (e.g., acupuncture, mindfulness, yoga) incorporated in almost grouping sessions and
Patients interact with each other during the group session.

Data collection and informed consent

An English language-language questionnaire with open- and airtight-ended items was adult by the authors and entered into Qualtrics, a secure survey management tool. Questions included respondents' demographic characteristics (e.yard., ethnicity, age); information virtually their workplaces (e.one thousand., location, kinds of insurance accustomed); and details about group visit and integrative health programs at their workplaces (e.g., conditions treated in integrative grouping visits, complementary health approaches offered). Open-ended questions elicited respondents' favorite aspects of integrative grouping visits, greatest challenges, and what they wanted to learn about similar programs at other organizations. Potential respondents accessed the web-based survey through Qualtrics and provided informed consent earlier continuing. For surveys administered at conferences, respondents completed a paper consent class before filling out the survey. The UC San Francisco institutional review board approved all study procedures.

Data analysis

Data from paper surveys were entered into Qualtrics; spider web-based surveys were completed in Qualtrics. Of 61 completed surveys, nosotros identified four cases from multiple staff of a single organization; in these cases, we used the get-go respondent'southward data and removed additional respondents' data from assay, yielding a terminal sample of 57 surveys. We calculated descriptive statistics including mean, median, and standard deviations using SPSS version 24. We analyzed qualitative data using thematic analysis.²⁷ Ii authors (A. T.-L. and P.G.) independently coded the qualitative responses, completed past 31 respondents, then discussed coding and agreed on primary themes.

Results

Demographics

Respondents had a mean age of 50 and were primarily female (90%) and White (83%), with some providers from other indigenous groups (11% Hispanic/Latino, 7% Asian or Pacific Islander, and 9% other race/ethnicity; see Table i). Providers had an average of 6 years of feel with GMVs. Forty-two percent were physicians; 16% were nurse-practitioners, nurse-midwives, or doc administration; and 16% were mental health care providers. Many identified themselves as having multiple professional roles, for example, physician and yoga teacher.

**Table 1. Characteristics of Participants and Workplaces (*Northward*=57)**
Characteristics	N (%)
Age in years±standard deviation	50±10
Gender
Male	6 (10)
Female	51 (ninety)
Race/ethnicity
White	47 (83)
Hispanic/Latino	6 (11)
Asian or Pacific Islander	4 (7)
Other (including African American, Native American)	v (nine)
Professional role^a
Medico (Doc or DO)	24 (42)
Nurse-practitioner, physician banana, or nurse-midwife	9 (16)
Mental health provider (psychologist, licensed social worker)	nine (16)
Acupuncturist	five (9)
Other (including yoga instructor, group plan coordinator, herbalist)	20 (35)
Average years of experience with grouping visits±standard deviation	5.9±6.3
Workplace
Federally qualified health center	23 (forty)
Teaching hospital/clinic	26 (46)
Safety-net hospital	half dozen (11)
Other (including gratis clinic, Indian Health Service, private do)	13 (23)
Country
California	20 (35)
Massachusetts	five (9)
Ohio	5 (nine)
Oregon	4 (nine)
Other^b	23 (forty)
Geographic area
Urban	36 (63)
Suburban or small metropolis	xiii (23)
Rural	iii (five)
Types of insurance accepted
Medicaid	42 (74)
Free or discounted care for uninsured	30 (53)
Medicare	41 (72)
Private insurance	37 (65)
Veteran's benefits	6 (11)
Integrative medicine services offered outside of groups (due east.chiliad., acupuncture, meditation)	51 (89)
Other group programs offered
Therapeutic movement (east.yard., yoga, tai chi)	23 (forty)
Grouping therapy or mental health support	23 (40)
Physical activity classes	17 (30)
Peer support	xv (26)
Cooking classes	16 (28)
Substance abuse treatment	eleven (xix)
Arts or activity groups	9 (16)

Characteristics of respondents' workplaces

Twoscore pct of respondents worked in federally qualified health centers, 57% in safe-net or teaching hospitals, and 23% in other settings such as the VA or costless clinics (Table 1). Many respondents (35%) worked in California (Fig. one), with others in a total of 17 states including Massachusetts, Ohio, and Oregon (each 9%). The bulk of providers (63%) worked in urban areas. Most all worked in settings that accustomed public insurance, including Medicaid (74%), Medicare (72%), and/or veterans' benefits (11%), and many sites provided complimentary or discounted care for uninsured people (53%). A majority of respondents (89%) reported that their workplaces offered integrative wellness intendance services outside of IGMVs.

**FIG. 1.** Geographic distribution of integrative group medical visits.

Group teaching and back up programs

Most clinical sites also offered not-medical group education or support programs (Table ane). Most common were therapeutic move classes such as yoga or tai chi, and group therapy or mental health support groups (each 40%). Exercise classes such every bit Zumba were besides common (30%), as were cooking classes (28%).

Complementary health approaches in group visits

Clinicians at 37 of the 57 sites offered care in IGMVs. The following results are based on this subsample. At the 37 IGMV sites, providers reported a wide multifariousness of complementary health approaches (Table two). Nutrition (seventy%) and mindfulness, meditation, and breathing exercises (59%) were almost commonly included in IGMVs. Tai chi, yoga, or other move practices (51%); acupuncture (46%); herbs and supplements (43%); and chiropractic, massage, or osteopathic manipulation treatment (30%) were also offered.

**Table 2. Characteristics of Integrative Group Medical Visits (n=37)**
Complementary health approaches offered in IGMV^a	North (%)
Nutrition	26 (70)
Mindfulness, meditation, or breathing	22 (59)
Tai chi, yoga, or other movement	19 (51)
Acupuncture	17 (46)
Herbs or supplements	xvi (43)
Chiropractic, massage, or osteopathic manipulation treatment	eleven (xxx)
Conditions treated in IGMV
Chronic hurting	28 (76)
Diabetes	23 (62)
Cardiovascular affliction or metabolic syndrome	14 (38)
Cancer	8 (22)
Mental wellness and/or substance use	7 (19)
Prenatal care	8 (22)
Pediatrics	6 (sixteen)
IGMV languages offered
Spanish	15 (40)
Korean	one (2)
Chinese	1 (2)
Estimated number of patients attention IGMV, mean (range)	7.5 (4–15)
Frequency of IGMV sessions
Weekly	57%
Every other week or twice a month	viii%
Monthly	26%
Other	eight%
Number of IGMV sessions patients are eligible to nourish
ii–5	26%
6–10	29%
>10	7%
Ongoing/indefinite	38%

Conditions treated in IGMVs

Most sites offered IGMVs to care for chronic conditions, including chronic hurting (76%), diabetes (62%), and cardiovascular disease or metabolic syndrome (38%). A small number of sites treated substance utilise and/or mental wellness (19%) in IGMVs.

IGMV program characteristics

Typical attendance in IGMVs ranged from four to 15 patients, with an average of vii.v patients per session (Table two). IGMV programs were structured in a variety of ways; 57% met weekly, 26% met monthly. In over one-third of IGMV programs (38%), patients were eligible to attend ongoing groups indefinitely; the remainder limited attendance to a set number of sessions. Some sites offered IGMVs in languages other than English, including xl% in Spanish, one program in Chinese, and another in Korean.

Successes and challenges of IGMV programs

Providers shared qualitative responses on their favorite aspects of IGMVs, the about challenging aspects, and what they wanted to learn about programs at other organizations (Tabular array three). They more often than not reported positive experiences with IGMVs and saw benefits to both patients and clinicians participating in this model of intendance. Cantankerous-cutting themes included (1) patient-related factors such every bit recruitment and retentiveness; (two) staff-related factors such equally how to staff and bill for the integrative attribute of IGMVs; (iii) IMGV program implementation and sustainability.

**Table 3. Qualitative Themes and Participant Quotes**
Most challenging aspects	Patients missing appointments: "When patients are ill or they take transportation or health challenges and they miss a visit, it affects the whole group and the group dynamics."	Finding and paying for staff trained in complementary health approaches: "What has been nigh challenging is to railroad train our staff in the integrative modalities. We have rarely had the fiscal resource to hire others into the system with the expertise. Nor had the system been willing to pay for preparation in integrative modalities."	Program sustainability: "maintaining appropriate administration/human resources support" "recruitment and programs sustainability, i.e., nursing and front end office support."
Favorite aspects	Patients supporting each other and sharing expertise: "The connection it generates for patients that would usually be isolated." "Witnessing peer to peer learning."	Positive changes to patient–provider relationships: "How the (power) dynamic betwixt patient and provider is dissolved. Happier patients and happier providers." "I relish working as a provider with a group—unlike dynamics than 1:one with patients."	Seeing patients' health better, integrating complementary health approaches: "Patients really get better and are able to significantly increase the quality of their lives also equally often diminish the pain they are experiencing. I could never get these results in a i:i traditional western medicine format of a dr.-patient visit."
Want to larn from other programs	How to recruit and retain patients: "How to manage enrollment and retention in [a rubber-net] population with many barriers to care."	Staffing and billing for group visits: "How to serve patients with high co-pays." "How to bill, who can bill." "Is at that place a limit to how often [patients] tin can come and exist billed for [group visits]?"	How to mensurate outcomes: "I would dearest to encounter a collective of people gathering information on these groups together, from all their unlike sites." "…Interested to know what modalities were the nigh well received among the dissimilar populations."

Providers noted how IGMVs allowed patients to share expertise and support one another, which several described every bit patient-empowering. Providers' favorite aspects of IGMVs included positive changes in patient–provider relationships. They also noted improvements in patients' physical and mental health, which they attributed to both complementary health approaches and peer support.

Normally reported barriers included patient recruitment and memory. Specifically, respondents emphasized the need for adequate staffing and institutional back up for patient recruitment, such as staff to brand reminder phone calls to patients and to open facilities during evening hours when more patients are bachelor. In addition, providers highlighted structural challenges, such every bit access to reliable transportation, which make it challenging for patients to participate in IGMVs. These challenges are as well common in safety-net settings outside of IGMV programs. Specific challenges of IGMVs included finding and paying staff trained in integrative intendance given the lack of reimbursement for complementary health approaches, as well as finding means to successfully integrate complementary wellness approaches in group settings.

When asked what they wanted to know about how other organizations implemented IGMVs, approaches to recruitment and retention of patients was a dominant theme. Providers also had specific questions about staffing IGMVs with appropriately trained clinicians and support staff, and implementing and billing for complementary health approaches. Several providers expressed interest in working with others in similar programs to collect data, develop best practices, and measure wellness outcomes of IGMVs.

We found that IGMV implementation is complicated in means that are consequent with existing literature on GMV plan implementation and rubber-net care more broadly.^16,28,29

Clinicians reported that challenges to starting and sustaining grouping visit programs include obtaining adequate back up from their organizations and wellness intendance systems. For case, IGMVs crave clinicians who are capable of facilitating a grouping-based care model as well equally using or teaching complementary health approaches. In addition, clinic staff need time to recruit patients, develop curricula, and consummate other administrative tasks to support IGMV programs.

Give-and-take

In the United States, people with lower income and education levels are less likely to apply complementary health approaches, despite the growing testify base on their usefulness for chronic weather condition.² Our enquiry describes an emerging model that can increase admission to complementary wellness approaches, specially in safety-net settings. We constitute that IGMVs are geographically dispersed throughout the United states of america. Although the number of clinics offering IGMVs remains unclear given our not-representative sample, this tendency is parallel with national growth of complementary and integrative health services in settings ranging from large academic medical centers³⁰ to a national network of customs acupuncture clinics.³¹

Nosotros found that clinicians from a range of professional backgrounds are providing GMVs and IMGVs in rubber-net settings that serve uninsured and publicly insured patients. These models offering integrative health care that low-income people struggle to afford when information technology requires out-of-pocket payment. Our findings signal considerable involvement in and enthusiasm for this model of intendance amongst clinicians effectually the country and demonstrate that IGMVs include a wide range of complementary wellness approaches to treat patients with a variety of chronic weather, including diabetes and chronic pain. Consistent with the growing trunk of enquiry on integrative health services in safety-net settings,^22,32–34 clinicians in our written report reported that IMGVs are providing access to integrative intendance and peer support, benefiting patients in multiple means.

Though GMVs and specifically IGMVs are increasingly common, guidelines for billing both public and private insurance for intendance provided in groups remain unclear.^35,36 Despite the Affordable Care Act's requirement that wellness insurance should non discriminate confronting any licensed provider,³⁷ reimbursement is often unavailable for licensed not-biomedical providers such every bit acupuncturists and naturopathic doctors.^38,39 Given the lack of insurance reimbursement for nearly complementary health approaches, it is unsurprising that the approaches most commonly used in IGMVs were those that tin can be offered by biomedical providers with some specialized grooming or practice (e.g., meditation). Some respondents to our study reported on IGMVs that include other licensed providers such every bit acupuncturists or chiropractors. However, in our qualitative results, clinicians reported difficulty paying these providers. Broad implementation of IGMV models would be more feasible if both public and private insurers provided reimbursement for a range of licensed wellness care providers such every bit naturopathic doctors and acupuncturists. Such reimbursement would not merely allow safe-cyberspace clinics to hire integrative intendance providers but likewise support the infrastructure needed at the clinic and organizational levels to make these programs feasible and sustainable.

Our study found that over 75% of sites with IGMVs used this model to deliver integrative intendance for chronic pain, and over half provided diabetes care in IGMVs. This is notable given that these and other chronic conditions disproportionately affect low-income individuals, and wellness care disparities exacerbate this higher prevalence. In that location is a strong research base for diabetes GMVs,^11,40 and integrative care may provide boosted benefits to patients with diabetes. All authors of this article have ongoing qualitative and mixed-methods projects examining group-based integrative intendance for chronic hurting.^14,26,41 Our projects advise that such approaches are a promising innovation that may help reduce or eliminate opioid medication utilise while allowing organizations to comply with Joint Commission requirements to offer not-pharmacological chronic pain handling options.⁴² In addition to offering GMVs in which they bill patients' wellness insurance, most sites offered additional free or low-cost, group-based complementary health approaches such as yoga and tai chi.³⁴ Many safety-net clinics have also integrated primary care and mental health intendance services, and these efforts are visible in the many sites offering group therapy or mental health support groups.^43,44

Limitations

This study had a small, targeted sample, limiting the generalizability of the findings. Our sample was ninety% female and 83% white, which may not exist cogitating of the national safety-net workforce providing care in IGMVs. More broadly, there was a potential for bias in favor of GMVs, because we specifically sought out providers currently providing care in GMVs. Information technology is difficult to decide how many organizations are offering IGMVs every bit clinics rarely advertise these programs on their websites or publish information about them elsewhere. This scoping survey points to the demand for additional quantitative and qualitative enquiry on IGMVs also every bit broader policy issues of depression-income people'due south access to integrative health care. One example would be a national survey of all federally qualified health centers to assess whether and how they are implementing integrative health care, GMVs, and IGMVs specifically.

Nosotros requested that respondents written report on IGMVs offered for item health conditions and using particular treatment approaches, and several commented that our questions nearly treating specific health conditions (e.g., assuming IGMVs were organized specifically for people with diabetes or chronic pain) did not reverberate their programmatic models. Many IGMVs are designed to treat multiple health conditions at one time, as is true for integrative health care more broadly. Such an approach is difficult to measure and points to the demand for rigorous, mixed-methods approaches to studying integrative health intendance interventions. A final limitation is that the survey blueprint did not explicitly ask clinicians to name their workplaces, to protect anonymity. We identified cases of multiple survey respondents reporting on the same organizations and removed four respondents from the analysis, but it is possible that other overlaps were missed.

Conclusion: Implications for Health Equity

Despite these limitations, this study uniquely contributes to our knowledge of IGMVs in safe-internet settings past describing the structure and scope of intendance provided in IGMVs. Though other studies have reported on the outcomes of specific IGMV programs,^{15,twenty,22,23} to our knowledge, this is the beginning study of existing IGMV programs across multiple organizations. IGMVs typically provide multidisciplinary care that aims to treat multiple health conditions at once, an arroyo that is well suited to the needs of safety-net patients and clinicians. Our findings show that despite limited insurance reimbursement for complementary health approaches, rubber-net clinicians are creatively increasing access to such treatment by offering it alongside biomedical care in IGMVs. Survey responses indicate that such programs can exist used to manage some of the atmospheric condition in which major health disparities are nowadays, providing innovative approaches to weather such equally diabetes and chronic pain past increasing access to complementary health approaches. Such intendance can advance health equity for low-income people receiving intendance in safety-net settings, including many people of color and immigrants.

Acknowledgments

The authors thank the health intendance providers who participated in this study for their fourth dimension and interest. In addition, we thank Howard Pinderhughes and Janet Shim for guidance with this projection and Michelle Myles for assistance with survey preparation and recruitment. The study was supported by the National Institutes of Health, the National Center for Complementary and Integrative Health (F31AT008747 [AT-50] and K01AT006545 [MTC]), as well equally the UC San Francisco Department of Social and Behavioral Sciences and UC San Francisco Graduate Division. Contents are solely the authors' responsibleness and do non necessarily represent the official views of the funders.

Writer Disclosure Argument

No competing financial interests exist.

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Cite this article as: Thompson-Lastad A, Gardiner P, Chao MT (2019) Integrative grouping medical visits: a national scoping survey of rubber-internet clinics, Health Disinterestedness iii:one, one–viii, DOI: 10.1089/heq.2018.0081.

Abbreviations Used

GMV	group medical visit
IGMV	integrative grouping medical visit

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Source: https://www.liebertpub.com/doi/10.1089/heq.2018.0081