HOW HEALTHY are you? You might answer the question with information about your weight, your diet, your blood pressure, your pre-existing conditions or chronic ailments. But just as important might be how much money you make, how you cope with stress, and how far you have to drive to the pharmacy or grocery store — or whether you drive at all.
In other words, there are more factors that determine your health than those that typically come to mind. This isn’t big news. But it’s unlikely that the last time you had a check-up the doctor asked, for instance, if you’re anxious about your family bank account and suggested talking to a therapist right there at the office — or connected you to a social-services worker onsite to discuss financial support programs.
The term for this more holistic approach to well-being is called “integrated healthcare.” The term is common in the more academic corners of health and medicine institutions, but putting it into widespread practice is a slow, sometimes complicated process. But many people and organizations in the valley are working to make it a reality.
In practice, integrated healthcare is pretty simple. For instance, at Volunteers in Medicine of Southern Nevada — an organization providing healthcare for low-income patients — they distribute gift cards to help clients with their rent and groceries. It’s not a mere philanthropic perk. It typifies Volunteers in Medicine’s philosophy of considering the patient’s health more than just the state of their physical body.
“We can prescribe someone insulin all day long. But if they don’t have a refrigerator to put it in, or they don’t have a sanitary environment or the right foods to eat to help them to manage their diabetes, their situation isn’t going to change,” says Tabitha Pederson, chief operating officer of VMSN.
What does integrated care include? A better question is what doesn’t it include? “It’s a list of things that impact someone’s health and their ability to live a healthy life, but these things don’t necessarily have to do with medicine,” Pederson explains. “It’s food, it’s legal issues, it’s transportation. It’s even the neighborhood you live in. It’s community violence. So we provide primary care, but also mental health services, social services, and dentistry, all in one building for our patients.” The VA Southern Nevada Healthcare System and Nevada Health Centers (a statewide nonprofit network of clinics serving rural, uninsured, and underinsured clients) also practice versions of integrated healthcare. But there are a few obstacles in the way of more widespread adoption of the practice.
One is education. Because integrated healthcare often requires collaboration between disciplines, practitioners have to learn to understand where their expert knowledge ends and where another’s begins — and when to pass the baton, so to speak. In the academic setting, learning how to deliver integrated, collaborative care is called interprofessional education. Roseman University of Health Sciences incorporates interprofessional education into its curriculum.
“In a nutshell, what we’re trying to do is move from being in our separate silos to a more integrated system to improve the health of our communities,” says Dr. Thomas Hunt, professor and chair of the Department of Family Medicine and Community Medicine at Roseman. “Interprofessional education starts with getting students of various disciplines into the classroom, working together, learning from each other, learning with each other. But we’re really trying to move that needle to interprofessional practice and education. So it’s great that you and I are from different disciplines and we’re learning together. It’s more important that we practice together.” For example, in Roseman classes that involve simulated patient cases, a pharmacy student and a nursing student assess and discuss the patient’s data, and then present it to the physician. “Then together, we work on a plan using each of our focuses so we can have a comprehensive plan of care for the patient,” says Hunt.
Notice how this is different than the usual flow-chart of healthcare, in which decisions typically come from the doctor. In integrated healthcare, a nurse’s assessment might turn up issues that a doctor might never consider. Hunt says, “(A nurse) might look into things like, what’s going on in your home? What are some of the extraneous factors that may be affecting your health? Where do you live? What neighborhood? What’s your transportation?” The term for these factors is social determinants of health.
UNLV also weaves interprofessional education into its curriculum. In 2014, the UNLV School of Social Work received a $1.4 million federal grant to educate social work master’s students in integrated healthcare. Over three years, the grant program trained 108 students on applying their expertise in integrated healthcare settings such as Volunteers in Medicine of Southern Nevada, with a focus on patients with chronic health conditions and mental health conditions. The grant program was considered such a success, UNLV made the integrated healthcare training a permanent course.
“I particularly love integrated healthcare because what we’re seeing is that when a person comes into treatment, usually the first place we’re going to see them is in the emergency room or their doctor’s office,” says Natasha Mosby, a lecturer in UNLV’s School of Social Work and program coordinator for the Integrated Behavioral Healthcare Grant. “The research over the past 20 years shows that if we can integrate that behavioral healthcare system right inside of those spaces, it results in better outcomes for those patients.”
As integrated care evolves, it takes many different shapes, some of which you might not even recognize as integrated care. Mosby gives an example. “When I take my kiddos to the doctor, I recently noticed on those little iPads that they’re asking questions about not just their development, but just their mood and temperament. I asked the doctor, ‘If I answer yes, that I’m having trouble comforting my kiddo at night or she’s having nightmares, what’s the next step?’ And the next step is that he gives this information to the nurses, who might connect us to services for my kid. It may be bigger than something just medical. Providers now are thinking about how they can provide patients with resources they need outside this particular setting.”
One other obstacle to integrated care is cultural — specifically, our collective tendency to lionize doctors as heroes and mavericks (just watch any network medical drama for that). Passionate dedication to care is admirable, but true integrated care also requires checking any egos at the door.
“It used to be that the doctor just barks orders and everybody tries to follow around,” says Hunt. “But we know that in integrated care, we all should have an equal say in what happens.”