Abstract
Integrative health care (IH) is an approach to health that utilizes biomedical and social determinants of health to promote health and prevent disease, focusing on primary, secondary, and tertiary prevention, and utilizing not only the clinician–patient relationship but also how the family and community contribute to health promotion and disease. IH is a nascent area of practice within public health training. However, many people with a graduate degree in public health have a clinical profession that contributes to integrative primary health. To support the development of a competency-based education for IH, the National Center for Integrative Primary Healthcare convened an interprofessional leadership team to develop 10 “meta-competencies” in integrative primary health care. Following the development of the meta-competencies, individual members of the leadership team worked with colleagues within their profession to develop subcompetencies for specific professions for each meta-competency, including public health. The meta-competencies and public health subcompetencies were used to develop an online 33-hour introductory IH course: “Foundations in Integrative Health.” The public health subcompetencies were used to guide the development of a case study for a 6-hour unit, “Interprofessional Practice in Community Settings and Systems at Large,” on how to conduct and utilize a community health assessment that focused on health equity issues related to diabetes, which can also be taken as a stand-alone course.
Integrative health care (IH) is an approach to health that utilizes biomedical and social determinants of health to promote health and prevent disease, focusing on primary, secondary, and tertiary prevention, and utilizing not only the clinician–patient relationship but also how the family and community contribute to health promotion and disease. IH reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, health care professionals and disciplines to achieve optimal health and healing. (Academic Consortium for Integrative Medicine & Health, 2016)
IH incorporates concepts, therapies, and practitioners from conventional medicine and evidence-based complementary and alternative medicine.
To move the development of IH competencies into all the health professions involved in primary care—including public health—the National Center for Integrative Primary Healthcare (NCIPH) in the United States was funded by the Health Resources and Services Administration to advance the incorporation of competency- and evidence-based IH curricula and best practices into primary care education and practice. An important gap filled by the NCIPH is the development of a set of competencies and a course that are relevant to and appropriate for use across the entire interprofessional spectrum of primary care practitioners including public health (Kligler et al., 2015). This is an example of how to better integrate public health with primary care (Institute of Medicine, 2012).
The Patient Protection and Affordable Care Act (PPACA) addresses IH (Section 2706 of the Act, Public Law 111-148) as a part of developing interprofessional teams to improve health equity and health outcomes. According to the PPACA, a community health team “may include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and medicine practitioners, and physician assistants,” and it also includes nurse practitioners. IH is a nascent area of practice within public health training. However, it is reasonable to see that many people who are working in a clinical profession also have a graduate degree in public health, which may contribute to integrative primary health. Additionally, the public health profession has a long history of embracing the interactions among society, culture, medicine, and community health. Embedded within these interactions are integrative primary care health practices.
Integrative health care is a field defined by interprofessional collaboration and provides a perfect platform for this approach within public health training. The Creating Collaborative Care initiative, which focuses on interprofessional education, has four goals that support moving IH education ahead as a part of public health education (Blue, Mitcham, Smith, Raymond, & Greenberg, 2010). These goals are (1) students will acquire teamwork competencies; (2) students will acquire knowledge, including the values and beliefs, of health professions different from their own discipline that will enable them to define interprofessional health care delivery or research; (3) students will apply their teamwork competencies in a collaborative, interprofessional health care delivery or research learning setting; and (4) students will demonstrate their teamwork competencies in collaborative, interprofessional health care delivery or translational research contexts.
Public health education is critical to the system-wide implementation of IH as public health professionals work in both public and private sectors that provide and set up systems for IH. These settings include local, state, and tribal government agencies such as health departments, parks and recreation, urban development, and even transportation. Public health professionals are also leading national and international agencies that address health issues. Public health professionals work in health care settings such as hospitals, community health centers, and numerous nonprofit agencies. In the private sector, public health professionals work with health care organizations, insurance companies, and in the food, biotech, and pharmaceutical fields along with many others that focus on improving the quality of life.
A number of current trends in public health education further support the connection between public health as a profession and this integrative primary care effort. In the United States, the Council on Linkages Between Academia and Public Health Practice has identified eight core competency domains for skills that are needed by public health professionals (Council on Linkages Between Academia and Public Health Practice, 2014). These are Analytical/Assessment, Policy Development/Program Planning, Communication, Cultural Competency, Community Dimensions of Practice, Public Health Sciences, Financial Planning and Management, and Leadership and Systems Thinking. These skills overlap with those needed to implement integrative primary health care into the fabric of the public health system. The Interprofessional Education Collaborative competency domains on (1) values/ethics for interprofessional education, (2) the roles and responsibilities of interprofessional practitioners, (3) interprofessional communications, and (4) the competency on teams and teamwork also are core competencies for integrative primary health care to be properly integrated into the public health care system (Dow, DiazGranados, Mazmanian, & Retchin, 2014). Similarly, the Association of Schools and Programs of Public Health (ASPPH) has focused on developing competency-based education that supports integrative primary health care with its curricula competency projects for Preparedness & Response, Global Health, Women’s Health, and the Master of Public Health (ASPPH, 2016).
Public health and primary care providers need to work together to establish the systems required to effectively implement IH. In addition to the relevance of integrative health as an example of interprofessional training, a number of schools and programs of public health are now starting to bring into the curriculum examples of non-allopathic approaches to health that can be incorporated into public health interventions. Combining integrative health with public health offers the possibility to better reach the World Health Organization’s definition of health as not just the absence of disease (World Health Organization, 1948).
To support the development of competency-based education for IH, the NCIPH convened an Interprofessional Leadership Team in 2015 that had representation from primary care residency training programs, nursing, public health, pharmacy, behavioral health, and complementary and integrative health professions. The Leadership Team went through an extensive consensus process over a 1-year period to develop 10 meta-competencies in integrative primary health care (Kligler et al., 2015). Following the development of the meta-competencies, individual members of the leadership team worked with colleagues within their profession to develop subcompetencies for specific professions for each meta-competency. The approach taken to develop the public health subcompetencies was to ensure that they aligned with existing public health competencies. Thus, they are based on the Council on Linkages Core Competencies for the Public Health Workforce (see phf.org) and are associated with 9 of the 10 meta-competencies. The subcompetencies for the 10th meta-competency on ethical standards were adapted from the National Association on Healthcare Quality (see nahq.org). Draft public health competencies were created and distributed to a sample of academic deans and directors of schools and graduate programs who were members of ASPPH for review. Comments focused on having subcompetencies linked to the ASPPH Framing the Future and competency activities (ASPPH, 2016). Competencies were reworded and then finalized by the public health representative on the NCIPH interprofessional leadership team.
To make the subcompetencies feasible and useful for curriculum development only three subcompetencies were developed for the first nine meta-competencies, and four subcompetencies address ethical standards (Table 1). We also made sure that the subcompetencies addressed the Council on Linkages’ domains for the public health workforce with a greater emphasis on domains associated with administrative areas of public health. For example, seven of the public health subcompetencies address policy development and program planning skills, five subcompetencies address financial planning and management skills, and two to three subcompetencies address the other core domains for Analytical/Assessment Skills, Communication Skills, Cultural Competency Skills, Community Dimensions of Practice Skills, Public Health Science Skills, and Leadership and Systems Thinking Skills. The cognitive level of learning focused on higher levels of thinking for the competencies that are already primarily associated with public health education, and then, knowledge and comprehension were the focus when it was thought that the domains were more novel within public health education.
Integrative Primary Health Care Public Health Subcompetencies.
Note. NCIPH = National Center for Integrative Primary Healthcare.
These competencies should be used to guide the incorporation of the key elements of integrative primary care into public health training and practice settings. These integrated competencies should also align with the Interprofessional Education Collaborative competencies that have been endorsed by ASPPH (Interprofessional Education Collaborative Expert Panel, 2011). The specific competencies will provide the basis for developing an integrative health curriculum for public health professionals who support primary care. Next steps for the NCIPH project as a whole include strategies for adoption of the competencies within primary care disciplines and broad dissemination of competencies, curriculum, and related resources through the NCIPH and partner organizations. Furthermore, given the growth of IH practices and the recognition of the value of interprofessional teams, these competencies will support the training of public health professionals to support the triple aim of health care that focuses on population health, experience of care, and cost for care (Berwick, Nolan, & Whittington, 2008). Similarly, public health competencies that address integrative primary care also focus on the triple aim of health equity: implement health in all policies, expand understanding of health, and strengthen community capacity (Jarris, Savage-Narva, & Lupi, 2016).
The purpose of these competencies is to develop an active-based learning curriculum. The meta-competencies and public health subcompetencies have been used to develop an online 33-hour introductory IH course, “Foundations in Integrative Health.” The public health subcompetencies were used to guide the development of a case study for a 6-hour unit, “Interprofessional Practice in Community Settings and Systems at Large,” on how to conduct and utilize a community health assessment that focused on health equity issues related to diabetes, which can also be taken as a stand-alone course. The case study used the concept of salutogenesis to demonstrate how the creation of healthy communities focuses not only on the health care services but also on the physical environment, community programs, and the professionals who work in these programs and culture (Lindstrom & Eriksson, 2006; Rakel & Sanders, 2013). Public health subcompetencies from each of the 10 meta-competencies are addressed in the course. For example, based on the outcomes of the Diabetes Prevention Program, the case study addressed how to use a community health assessment for program planning and evaluation, how to incorporate diverse perspectives to support integrative approaches to primary health, how to provide mechanisms to create interprofessional teams, and how to incorporate ethical standards of practice into a community intervention (Diabetes Prevention Program Research Group, 2002). The course was pilot tested with 96 preventive medicine and public health professionals in educational training programs in the United States and revised based on feedback from the pilot study and is now available online through NCIPH (see https://nciph.org/curriculum.html on how to access the course).
Primary care and public health also have shared goals for population health improvements, community engagement, the development of aligned leadership, sustainability in health care delivery, the collaborative use of data and information, and development of the workforce needed to support the integration of primary care and public health. An Institute of Medicine report recommended that that there be an emphasis on integrating primary care and public health curricular and clinical experiences that will lead to improved health outcomes (Institute of Medicine, 2012). Although there is a current paucity of coordinated curricula between academic public health and clinical programs, there are several opportunities for them to be developed. The identified competencies from this project can help guide the development of simulation exercises, field-based courses, service learning courses and internships to enhance interprofessional education experiences in urban and rural settings, and within private and public health care systems (Sabo et al., 2015; Taren et al., 2001).
Additionally, the Institute of Medicine has defined integration as “the linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health” (Institute of Medicine, 2012, p. 3). It is essential that primary care and public health professionals move from just mutual awareness of their professional roles to cooperation, to collaboration, and to partnership until there is a full merger of these two fields.
In conclusion, public health competencies are now available to provide guidance on how public health professionals can support integrative health into health care services. These should be used as a guide to create competency-based curricula for credit-bearing courses and for continuing education units. Finally, these competencies can help guide accreditation agencies to assess the role of public health within interprofessional training.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project described was supported by Grant Number UE1HP27710 from the Health Resources and Services Administration, an operating division of the U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.