An Integrative Algorithm: Identity, Roles & Responsibilities

Writing a short article on integrative health care recently gave me a chance to reflect on what’s taken place in the field over the last two decades. The system is evolving, slowly in some places and quickly in others. In 1997 a team at Northwestern College of Chiropractic developed a set of seed algorithms for integrative care teams. Based on the experience of opening the Natural Care Center at Woodwinds Hospital (now closed), I wrote a somewhat tongue-in-cheek take on working with hospitals and ‘health’ care systems. At that time, medical staff were commonly entrenched in opposition to integrative services. That dynamic has changed a lot, but it still may serve as a guide to the relationship dependencies required today.

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While other providers now have quite a few more opportunities than exist for chiropractors in hospitals and clinic settings, that’s likely to change in the next decade. Outside of those systems, much has changed. In the late 1990s, it was a rare doctor of chiropractic who was practicing with any other type of practitioner; today it is commonplace. One thing that was true then is still true now, however: the word ‘integrative’ is remarkably imprecise. The image I often used twenty years ago is still valid now: integrative health care is much like a handful of blind men touching different parts of an elephant; depending on what part you’re touching, you’ll describe it very differently. ‘Integrative’ can mean simply the juxtaposition of two professions with no formalized interaction; it can mean a structured team approach to care; it can mean a virtual referral network of resources; and it can mean any nuanced combination of those as well.

Arguably what has not advanced as thoroughly is an understanding shared across the industry about what the basis for integration should even be. Is it driven by medical interest in broadening clinically effective options for patients? Is it driven by a business mindset that’s intent on responding to consumer interests? Or is it something in between?

One way to look at integration is to design care delivery by posing a fundamental question: do we know if one profession does something more effectively than another? It’s an important question in the context of ‘value-based care,’ which is, increasingly, how purchasers are looking at options for different services. Personally, I use a simple litmus test for integrative care. Whether something is ‘integrative’ or not to me rests on the answer to a basic question: is there anything one provider does not do because someone else does it better? If the answer is ‘no,’ then I would argue it’s multidisciplinary, but not formally integrative. Others will challenge me on that, and they’re also right; it’s an imprecise term. But until more comparative research takes place, it’s a hard question to answer. With more ‘retailized’ health care consumers paying out of pocket for services, their satisfaction with their perception of outcomes—and thus, their purchasing decisions—may make the question moot.

One way to look at the current set of options for any type of practitioner has to do with roles and responsibilities. Fitting into any system (whether a small office or highly matrixed vertical organization) usually requires a clear definition of how anyone applies their clinical training. One way to look at the opportunities for integrative providers is to describe them in tiers. The top tier would involve unfettered ability to practice within the limits of their legal scope of practice across a full range of applicable complaints; a second tier would involve a focused contribution to a type or range of conditions; and a third tier would be essentially to operate simply as a therapy.

Why does this matter? Because providers’ values (in the context of their clinical paradigms) about their ability to offer services and care cover a wide range; because it’s important to understand explicitly what those roles and responsibilities include. It’s also important to be very clear about what happens when a provider is constrained (reduced) to a purely therapeutic role (eg, spinal adjustments in the absence of whole-person/whole body care, nutritional/functional medicine counseling in the absence of a whole systems approach, applying acupuncture in the absence of whole-system diagnosis, problem-based massage in the absence of an assessment of broader fascial involvement). And it is a reductionistic model like these examples that can really skew any analysis of outcomes when all other variables of a provider’s clinical practice are excluded, permitting misleading conclusions to be drawn.

At least within chiropractic, arguments about roles and responsibilities in the context of integrative or systemic participation should not be framed up in ‘philosophic’ terms, for two reasons. First, DCs who are subluxation-based and those who embrace a broader clinical role both do so in the context of a clinical paradigm that is, for each, intact and coherent. Secondly, neither type of clinical approach suffers in the top tier of role descriptions, but both suffer in a purely therapeutic role.

A simple map of the options attempts to explicitly define aspects of a clinician’s role that are affected by whether or not patients have direct, condition-based or referral-dependentDC Integration Roles & Responsibilities v1 042816 access. With each come certain dependencies that affect not just whether or not a clinician can be effective or how broadly their role is defined, but also whether they can exercise their legally-enabled (and required) clinical judgement. For some professionals, a range of roles may be acceptable; for others, formal restrictions on aspects of their role or applying clinical judgement may be intolerable.

But health care is getting more and more complex with most professions seeking to broaden their roles. So these types of questions–and the roles’ dependencies–will likely come to matter more and more.

 

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