Abstract
The theme of appropriate access of care is a major consideration in all efforts toward health care reform. When one considers the appropriate use of integrative health practices and practitioners, the theme of access has particular resonance. Even in areas such as pain management 1 and cancer treatment 2 where a quality evidence base for their use has accrued, insurers rarely cover. Those who cannot pay cash are typically denied what may be their optimal treatment.
This context stimulated many in the integrative health community to seek to develop group models of delivery through which to spread access to integrative practices. We assumed the efficiencies and the lower costs. We did not know, as we now increasingly do, that such methods on their own or together with one-on-one care may even be more effective than the typically individual-focused treatment model. We engaged in this Special Focus Issue on Innovation in Group-Delivered Service to foster and explore what evidence suggests for the integration of group-based delivery in the context of clinical settings.
While we cast a broader net with our call for articles, the articles chosen for this special focus issue reflect the quality and breadth of research about complementary and integrative medicine (CIM) and group-based visits. For simplicity, we refer to the paradigm as an integrated group visit (IGV). IGVs are patient centered, lifestyle or health focused, and typically complex interventions with one or more CIM delivered in a group setting by a health care team. By fusing CIM and group visits together as a delivery care model, the hope is that the whole becomes greater than the sum of the parts while also creating increased access to CIM for different patient populations and medical settings. With the exception of group acupuncture models, the IGVs described in this issue have several things in common: A group of 6 to 20 patients meet in one location for a duration ranging from 60 to 120 min Presence of more than one health care provider often an interdisciplinary team Creation of ground rules, such as confidentiality, for group interactions Experience of interactive learning activity or complementary therapy Facilitated patient education and discussions on relevant health topics Opportunity for socializing or community building within the groups Health assessment occurring in the group setting.
This special focus issue also allowed us to bring together an editorial group and an advisory team with different expertise and perspectives in the research, implementation, and real-world running of group-delivered care. As editors, we decided to seek out submissions highlighting innovative ways group-based models were emerging and being studied. Therefore, we excluded group-based care models already well established with a rich evidence base and covered by health insurance such a psychotherapy, cognitive behavioral therapy, and the diabetes prevention program. We are grateful to the authors of the ∼40 submissions in response to the call for articles. The articles represented diverse types of methodology including mixed method clinical trials, surveys, qualitative interviews, and a scoping review.
Group-based interventions are a long-standing type of care delivery. Notably in the context of IGVs, group models characterize some of the most well-studied integrative medicine interventions such as mindfulness-based stress reduction (MBSR), relaxation response, and Dean Ornish's cardiovascular rehabilitation program. (In his accompanying editorial, Weeks notes the remarkable cost-effectiveness from these group approaches.) The scoping review by Parikh et al. offers a historical background on the research and trends seen in the integrative medical group visits in the United States and Canada since the 1990s. Moving beyond the delivery of patient care in a traditional one-on-one clinical encounter, group-based care may add additive factors not available in one-on-one care such as decreasing loneliness. Indeed, using group-based care to address social isolation and other psychosocial factors of health is a theme highlighted in Bruns et al.'s study of an integrative pain management program for vulnerable safety net patients. Geller's commentary on the “group inclusion effect” further delves into the understudied mechanisms of why IGVs may provide powerful benefits not seen in one-on-one care.
Group-Delivered Interventions and Families: Supporting Well-Being and Preventive Care
Two studies in this issue examine the delivery of group care for families. Kwan et al. reported on a group-based naturopathic education for parents of children aged 0–6 years attending publicly funded community centers in Ontario, Canada. This naturopathic group program promotes healthy lifestyle behaviors and wellness in children and families. Gullett et al.'s study on CenteringParenting, group well-child care, using mixed methods, captures both the perspective of a participant—“…I like the community aspect the best. The idea of it takes a community to raise a child takes place here. Especially since I don't have one elsewhere…”—and the program staff—“Sense of community is really beneficial especially for moms who lack resources and interactions with other moms.” They report that attendance at well-child care visits in the first 15 months of life was significantly higher in CenteringParenting groups than in the standard of care. Both these models have promise for the delivery of high-quality care and sustainability in low-income communities.
Group-Delivered Interventions and Low Income, Diverse Patient Populations: Improving Access
Most of the articles in the special issues focused on understudied or underserved patient populations (e.g., Bruns, Kwan, Gullett, Charlot). As noted at the beginning of this editorial, low-income patients often do not have disposable income to spend on evidence-based CIM or, if covered, the type of insurance that covers such services. The infrastructure for health and well-being is often lacking. Safe places to exercise, yoga classes, mind–body programs, acupuncture clinics, and stores that sell healthy food are less frequently located in low-income neighborhoods or available in the evenings after the workday. This underscores the potential value in the delivery of CIM in local familiar outpatient clinical settings, such as a neighborhood health center. Both access and affordability are addressed.
Many of the submissions highlight creative solutions and engagement with the local community to increase access to such therapies. Moreover, delivering group-based care for low-income diverse patients comes with a responsibility to provide care that is sensitive to complex social conditions. For example, Scharfer, from the People's Organization of Community Acupuncture, discusses the community-based group acupuncture model and the importance of training providers in trauma-informed care. D'Amico et al. adapted an IGV with a smoking cessation curriculum to address unmet needs of low income and racially diverse smokers with cancer. Their research demonstrates the value of tailoring interventions for cultural context and for health literacy.
Group-Delivered Interventions for Chronic Disease Management: Addressing Implementation Challenges and Sustainability
Several of our studies focused on improving management of chronic disease. These included patients across the cancer continuum, and people with depression and chronic pain (Charlot, Cohen, Thompson-Lastad, and Bruns). In their article, Improving Access to Integrative Oncology Through Group Medical Visits: A Pilot Implementation Project, Thompson-Lastad et al. concluded that group visits are a financially viable alternative to individual integrative oncology visits with revenue from group visits exceeding the revenue potential of 6 h of individual visits by an average of 38%. Cohen et al. discuss a quality improvement pilot to address unmet needs of cancer survivors. They highlight initial successes of an evidence-based reimbursable model and opportunities to improve referrals and systematically integrating the program as part of care for all survivors.
Yaguda et al. from the Levine Cancer Center at Atrium Health in North Carolina, in a thoughtful commentary, share their transition from an individual acupuncture program to a group-delivered acupuncture model. The model hit a remarkable trifecta in value-based medicine: improved access, reduced wait times, and reduced cost to patients. Kakareka et al. showed how integrating teaching kitchens with shared medical appointments “suggest a sustainable and effective approach to integrative medicine in healthcare.”
The scalability of CIM is often limited by the insufficient number of experienced trained integrative medicine providers licensed to work or located in low-income settings. An important study on A Mindfulness Based Intervention for Low-Income African-American Women with Depressive Symptoms Delivered by an Experienced Instructor versus a Novice Instructor demonstrated that existing staff at a federally qualified health center could be trained to deliver an adapted version of MBSR. While group-based interventions typically focus on patients, O'Brien et al. demonstrate an innovative use of group-based acceptance and commitment therapy for nurses and nurse aides in long-term care residential settings. O'Brien et al.'s study tackles a key issue in sustainable care: enhancing the well-being of providers by reducing physical injury in the workplace and mitigating burnout.
Concluding Comment
We bring forward this issue to contribute to the growing research evidence, to explore the sustainability, and to spotlight how IGV can increase access to therapies known to advance health and well-being that are not typically covered by health insurance or available to less-resourced populations. This issue touches on several of the strengths and weaknesses of IGV models. It also underscores the need for new methods and trial designs to understand and optimize the mechanisms of how group-delivered interventions improve patient care. Taken as a whole, we are encouraged by the developments of IGV to address unmet needs of underserved and vulnerable patients and providers. Clearly these methods improve access to interprofessional CIM. We venture to add that the research that led to this special issue, and the articles included in it, makes the case that increased attention to optimal utilization of integrative group visits will advance the quality of care for a broad range of populations and conditions.