Integrated Care: Because That's Where the Patients Are

William "Willie" Sutton was one of the most successful bank robbers in history. Sutton ultimately stole more than $2 million dollars, most of it in the 1940s and 1950s. But he is perhaps most known for his response to a reporter's question of why he robbed banks. His response, "because that's where the money is."

After almost 120 years, only an estimated 12% of the U.S. population sees a doctor of chiropractic in a given year.¹ In contrast, approximately 81% of U.S. adults make at least one visit to a medical doctor or other provider.² For the chiropractic profession to begin to see a majority of the U.S. patient population, an application of the "Sutton" principle may be required. This would essentially require doctors of chiropractic to work with or even for medical doctors in a manner that opens the door to unrestrained appropriate referral.

A modern example of how this model might work can be found in the chiropractic clinics in military bases across the country. According to a report in Military Medicine:³ "In today's VA and DoD (Department of Defense) facilities, it is common to see chiropractors working alongside physical therapists, sports medicine physicians, primary care managers, and other specialists, depending upon the needs of the beneficiaries in the area. Chiropractors are functioning currently in departments of primary care, physical therapy, orthopedics, and sports medicine in many VA and DoD facilities and, in some locations, exist as stand-alone departments. Neurosurgeons and orthopedic surgeons sometimes request a course of physical therapy and/or chiropractic care to see if a case will respond to conservative management before planning on surgery.

"Various subpopulations of active duty service members are a good match for chiropractic care, as chiropractors provide conservative care, do not prescribe medications, and are most often able to treat a patient without the need for light duty or med-down status. For example, chiropractic care can be a valuable asset in the aviation community where pilots, who often have neck and back problems, can obtain relief from their pain without jeopardizing their flight status. Many posts have discovered that in addition to assisting in the management of common musculoskeletal problems, chiropractors are also well versed in providing education pertaining to injury prevention, ergonomics, and other health and wellness topics to provider groups and beneficiaries."

In fact, the inclusion of chiropractic at military bases is working so well that some bases are bringing in additional doctors of chiropractic to keep pace with demand. These DCs are very busy and most MDs are happy to refer because they have so much else to deal with. DCs at these bases generally see about 50 new patients per month per DC. And while part of their duties includes combat patients, which may take longer to treat, a typical DC will see about 20 patients per day at the ambulatory clinics.

Perhaps most exciting is that approximately 90% of these patients had never seen a doctor of chiropractic before. The vast majority will likely seek chiropractic care again.

An Integrated Practice Model

Approximately 13% of U.S. chiropractors report that they practice in an integrated setting.⁴ This can include a wide variety of practice models and professional relationships. A recent study in England actually tested the success of including alternative health providers in a medical clinic as an integrated part of the clinic.⁵ The medical clinic was located in the heart of London with approximately 11,500 patients. For the research study, patients were limited to no more than six treatments. "Appointment making was integrated into the practice's computer-based reception system, so that patients could book their sessions in the normal way via the practice reception (in person or by telephone). Decisions about patients' treatments were not constrained by any research protocol, but were delegated to the practitioners who were free to treat as they would in everyday practice."

The "CAM" (Complimentary and Alternative Medicine) services provided in this study were acupuncture and "manual therapy", which included manipulation. Sadly, the researchers chose to provide manipulation by osteopaths rather than doctors of chiropractic.

What the researchers found was very similar to the experience of the U.S. DCs practicing at military bases:

• Comparisons between pre- and post-treatment for the primary outcome measure revealed a highly statistically significant improvement in musculoskeletal problems.
• "Comparisons between other study variables pre- and post-treatment revealed a statistically significant improvement in health-related QoL (Quality of Life)" and "a statistically significant reduction in medication use."[pb]

• "Some patients reported improvements in other physical health conditions, for example decreased headaches, menstruation pain and improved energy levels."
• "Other patients felt they had experienced improvements in their psychological well-being."
• "Patients appreciated having the (manual therapy) service at their GP practice, it was a convenient location and a familiar environment. They trusted a service provided through their GP practice, and felt reassured that their GP would know details about their... treatment."
• Ninety-one percent of participants said that they would use this care again at their GP's clinic.
• "This figure fell to only 30.8% who would use it privately, this was principally because of the cost of treatment."
• Almost 25% had problems getting their manual therapy because the providers were so popular.
• "GPs particularly valued having the service on site, this meant they were aware that their patients were having CAM treatment and were able to access details of patient appointments on the practice's computerised system and communicate with CAM practitioners easily. GPs also welcomed the relatively short waiting time for appointments and having an extra referral option."
• "Our results reveal patients are enthusiastic about the benefits of CAM treatments for pain when expertly delivered. ...the current study shows how high patient approval and demand for effective CAM services can have unexpected results. One drawback of the service was that patients wanted more CAM provision than originally estimated. Ideally there should be a degree of flexibility of CAM therapists to provide more or less appointments depending on patient demand."
• "Our findings suggest that it is possible for a GP... to quickly adapt to incorporate a CAM pain service."
• "It demonstrates that it is possible to introduce treatment modalities into a GP surgery for patient benefit, even when the underlying philosophy differs to that of biomedicine.

At the time of this writing, a report was published by Health Forum, a subsidiary of the national hospital association, and the Samueli Institute. The report found that the percentage of U.S. hospitals that "offer one or more alternative therapies, including meditation, relaxation training, homeopathy and chiropractic care" has risen from 37% to 42% in the last four years.⁶

Action Plan

Given the move for greater access to chiropractic and other forms of alternative health, it only makes sense to at least consider practicing where the patients are. Patients in both the military clinics and the English medical clinic received effective care from providers and in both cases, the alternative providers are very busy with lots of new patients.

With the English study in hand, a doctor of chiropractic could make a very good case for the inclusion of chiropractic care in their local medical clinic. With a copy of the English study and the Samueli report, a DC could approach their local hospital about establishing a relationship. In both scenarios, the doctors of chiropractic will be providing care that will exceed the usual care, receive an enthusiastic response from their new patients and the medical staff will have more time to focus on ailments they are better suited to address.

These two studies are powerful. They open the door for DCs to practice in an integrated health care environment, seeing patients they would probably never get to see. They also expand access to chiropractic care to the environments where most of the patients already frequent.

References:

1. Lawrence DJ, Meeker WC. Chiropractic and CAM Utilization: A Descriptive Review. Chiropractic & Osteopathy 2007, 15:2 doi:10.1186/1746-1340-15-2. http://chiromt.com/content/15/1/2
2. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics. December 2010. www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf
3. Green BN, Johnson CD, Lisi AJ. Chiropractic in U.S. Military and Veterans' Health Care. Military Medicine 2009, vol. 174, no. 6
4. National Survey of Doctors of Chiropractic. MPA Media. Aug 18, 2011.
5. Cheshire A, Polley M, Peters D, Ridge D. Is it Feasible and Effective to Provide Osteopathy and Acupuncture For Patients With Musculoskeletal Problems in a GP Setting? BMC Family Practice. 2011;12(60) www.medscape.com/viewarticle/747199
6. 2010 COMPLEMENTARY AND ALTERNATIVE MEDICINE SURVEY OF HOSPITALS. © 2011 Samueli Institute. www.siib.org/news/2468-SIIB/version/default/part/AttachmentData/data/CAM%20Survey%20FINAL.pdf