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5.2 Complementary medicine will be offered by more mainstream providers.
The American Hospital Society Trend Prediction regarding CAM and mainstream providers was heartily agreed upon by a full 78 percent of experts surveyed. As many attest, the increasing emphasis upon integration of medical care will be an important trend in the United States.
The hands-on ministration of healthcare is changing in remarkable ways. The patient's commonplace visit to a medical clinic, for example, may in some settings no longer follow standard conventional medical models. Imagine the man who visits his medical doctor for a particular health complaint. After a thorough history and physical, the physician refers the man to a specialist down the hall. Not a cardiologist or a hematologist, but in this instance it may be an acupuncturist, a naturopath, or a homeopathic practitioner, or one of many other complementary medicine specialists.
This vignette is an example of the trend toward integrative medical practice; more recently coined "blended medicine," in which physicians and practitioners from conventional and alternative fields of practice collaborate on the joint treatment of a patient (Brauer & Simon, 2000). True blended medicine is a sharing and combining of various conventional medical approaches with other alternative therapies. Most, if not all, of the therapies integrated with today's medical therapies have their roots in long-standing practices of other cultures. As this medical phenomenon matures during 2000 and beyond, perhaps a more appropriate moniker will be "contemporary ancient therapies" (CAT), a term coined by the author. Such a term marries the practices with acknowledgment of the therapies' ancient roots now applied in modem, contemporary practice.
Americans are embracing complementary and alternative medical therapies (CAM) in ever-increasing numbers. In I 993, at least one-third of Americans reported using alternative therapy, at the cost of approximately $ I 3 billion annually (Eisenberg, et al, 1993). by 1997 that figure grew to $27 billion spent on non-conventional medical or preventive care (Eisenberg, et aI, 1998). The number of annual visits to CAM care providers far exceeds the number of visits to a patient's own primary physician or nurse practitioner. For example, a 1998 report showed that on average patients made 12 visits to CAM providers and only 7 visits to a conventional provider (Eisenberg, et aI, 1998).
Another study found that physicians refer patients to CAM therapists, most notably to acupuncturists (43 percent), followed by chiropractors (40 percent), and massage therapists (21 percent) (Astin, et aI, 1998). Such a study suggests that many physicians refer patients to CAM therapists, or are practicing some of the more common and well known forms of CAM in there own offices. Evidence supporting this phenomenon is another study which showed that 6.5 percent of Americans reported visits for both CAM therapy and conventional medical care (Dross & Rosenheck, 1999). The researchers suggest that the reports of using unconventional care (CAM) were not higher numbers perhaps because more physicians are integrating CAM therapies into conventional practices. Moreover, CAM therapies are becoming more of a complement to medical care than an alternative to such care.
In addition to CAM provider visits, patients are buying and using herbal remedies and other nutritional supplements, often under their own "self-selection" with no deliberate medical or CAM provider consultation.
This change is taking place rapidly, and challenges case managers and others who work with patients to learn more about CAM and the implications for patient assessment, referrals, and healthcare outcomes.
Alternative medicine has a major presence and persuasive attraction in the Western world. For many consumers and integrative medicine providers, CAM is seen as a way to reinvolve patients in care and for the patient to restore their personal control over health and illness (Schuster, 1997). The patient-empowered status of care is new for much of the medical community and a challenge to insurers and providers alike. Until recently, little was known about HMO's-which lie at the center of our U.S. managed care system-¬attitudes toward CAM.
In response to this shift in healthcare practices, in March of 2000 the President officially appointed the White House Commission on Complementary and Alternative Medicine Policy, with assurance of education and training of healthcare professionals as one of its primary functions (Office of the Press Secretary, 2000).
The driving forces in the move to integrative medicine require nursing professionals to rethink staff competency, patient assessment, and patient-focused care. Nursing professionals at all levels of care and management need to understand CAM trends and therapies to better integrate these concepts into healthcare policy, standards of care, and ethical nursing decisions.
The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institute for Health (NIH) considers alternative medicine to consist of practices outside of the "typical" or dominant system for managing health and disease (National Institutes of Health, 1993). Alternative treatments are also those not generally found in U.S. medical schools or available in U.S. hospitals. Yet, CAM therapies are becoming mainstream offerings.
While many people think of visits to the chiropractor or an acupuncturist, or ingestion of Echinacea to ward off colds as alternative therapies, others include therapies such as meditation and metaphysical approaches. CAM includes a wide range of therapies not traditionally a part of conventional medical care. Chinese medicine, herbal medicine, massage therapy, reflexology, aromatherapy, and many other holistic practices are considered CAM therapies in the U.S. CAM is most often embraced as a wellness or a health maintenance model. There is the basic belief that mind and body are one, and that nature has a healing power.
Worldwide, 70 to 90 percent of people use what the U.S. considers CAM therapies (Fetrow & Avila, 1999). In the United States nearly three-quarters of the population desire alternative healthcare options, which has ignited phenomenal growth of CAM services. Most of those using alternative care use it in addition to their traditional medical care. A study released in 1998 showed that seventy-four percent of adults use CAM along with conventional care, and another fifteen percent use CAM in place of conventional medical care (Landmark Healthcare, 1998).
To a large extent, the desire for more control over personal health has fueled the growth. Further trends that have spurred this movement and will continue to increase the demand for CAM choices include:
Third-party payers-HMOs, MCOs (managed care organizations)--are paying close attention to the billions of dollars exchanging hands in the CAM therapy world. In response to the public's growing interest, most managed care plans offer benefits for chiropractic, acupuncture, and massage therapy (Landmark Healthcare, 1997). Many MCOs have already begun to integrate CAM with conventional medical providers. Some offer benefits for hypnotherapy, biofeedback, acupressure, and reflexology.
As expected, therapies most popular with consumers are often those aimed at treatment of or alleviation of the symptoms of chronic health conditions. In addition, many adults seek alternative modalities for health promotion and the prevention of disease.
The National Institutes for Health divides CAM therapies into seven broad categories. The classification system was designed by the National Center for Complementary and Alternative Medicine (NCCAM) to assist in prioritizing applications for research grants on CAM therapies (NIH, 1999). Table 1 lists and briefly describes each of these seven categories.
While these broad categories are useful for cataloging various types of CAM therapies for research purposes, the specific types of therapies integrated into conventional
practice may include:
Table 2 briefly describes several of the more prominent CAM therapies, in non¬technical terms that case managers can use while discussing these therapies with patients, families, significant others, and caregivers. This discussion of CAM therapies is important to facilitate identifying patients and family understanding of the therapies they are using or intend to use in the future.
Integration of CAM therapies has not been without significant challenges. Many medical providers are not willing to consider CAM unless a considerable body of literature points to clinical trials and other studies that validate the clinical effectiveness of a given therapy. Acupuncture, a therapy most widely embraced by conventional physicians, is also the most studied of the ancient therapies in modern times. In 1997 the NIH published its consensus statement on acupuncture, and many medical schools soon followed with post-graduate training programs in medical acupuncture (NIH, 1997).
Many integrative medical practices exist within multidisciplinary health care centers, often called "healing centers," which range from small clinics to major hospitals. The American Holistic Health Association qualifies such centers as institutional members if they offer a minimum of three healing modalities staffed by at least three healthcare practitioners (American Holistic Health Association, 2000). Such centers can be found in Arizona, California, Colorado, Georgia, Iowa, Nevada, New Jersey, New York, Ohio, Pennsylvania, Virginia, and Washington State (AHHA). In other cities, traditional not-for-profit hospitals are adding various alternative therapies for a variety of applications, including cancer care, cardiac surgery, and other acute care conditions.
In the Dales, Oregon, the Mid-Columbia Medical Center sponsors a conference series on "Health .and Spirituality" which draws equal numbers of providers and clergy (American Hospital Association, 2000).
Perhaps the most significant factor in physician and organizational acceptance of CAM therapies and development of protocols is the variation in licensure. Some therapies become part of a conventional physician's practice through additional training, such as acupuncture or Homeopathic medicine. Other therapies are long-standing practices carried out by unlicensed care providers, such as massage therapy or guided imagery. However, certification programs exist that may help to assure adequate training and experience of such practitioners. For example, the American Holistic Nurse's Association offers certificate programs in therapeutic imagery, healing touch, aromatherapy and other holistic modalities (American Holistic Nurses' Association, 2000).
Further information about CAM therapies can be obtained from the NCCAM Clearing House, and information on accessing this center is provided in the references (NIH, NCCAM). The therapies popular with the American public, as well as with large numbers of those in other countries, are not likely to be therapies most nurses learned about in their generic educational program.
While most people pay for CAM therapies out-of-pocket, many say the availability of alternative therapy is important in choosing a health plan. The CAM/integrative medicine market is growing fast and consumers are driving many HMOs to consider coverage. Third-party payers are paying close attention to the billions of dollars exchanging hands in the CAM therapy world. In spite of this close attention, not all HMO's have fully embraced the concept of routine reimbursement for CAM care, which is a key concern in the future of integrative medicine. However, there is recent evidence that HMO's currently cover some of these therapies, or plan to in the near future.
A study in 1999 found that two-thirds of HMO's (67 percent) offer at least one form of alternative care, with the most common offerings chiropractic (65 percent) and acupuncture (35 percent) (Landmark, 1997). In addition, some states are enacting legislation that requires health insurance policies to cover certain alternative therapies. Many states now have laws requiring insurance companies to cover licensed chiropractic care. In these cases the medical doctor acts as the gatekeeper and decides which cases constitute medical necessity. In many other health plans, such as PacifiCare of Oregon, and Health Net in California, self-referral with no pretreatment authorization required is a primary feature.
Washington is the first state to implement a law that went into effect in 2000, requiring managed care plans and insurance companies to cover all licensed and certified alternative therapies, including acupuncturists, naturopaths, midwives, and other care providers (Rabkin, 1999). This type of legislation will create economic integration of medical systems allowing much more freedom of choice.
It makes sense that American HMOs would welcome the concept of integrative medicine. HMOs originated from a wellness model and it seems that it would be in their best interest financially to maintain their members' level of wellness to allay the burden of the costs of chronic disease. Some of the more "integrated" plans offer benefits for hypnotherapy, biofeedback, acupressure, and reflexology.
Oxford Health Plans found that 75 percent of its members desired alternative treatment and services, and launched the first CAM program in 1997 with a credentialed provider network of over 2,800 providers (Daily, 1999). Like Oxford, other HMOs are moving forward with CAM offerings. As of early 2000, recent plans included:
Those managed care organizations that have already added CAM benefits have found several benefits to this change:
There are also barriers to implementing integrative plans into HMOs. As HMOs have added coverage for certain CAM therapies, they have found that several issues must be addressed for adequate integration. Some of these concerns include:
An additional concern is mostly a financial issue. There currently is a lack of well-defined criteria for what insurance should or should not pay (Daily). Utilization management guidelines do not yet exist for CAM, which presents a challenge for HMOs to make appropriate care decisions. As more HMOs offer benefits for integrative medical care, data may be collected on the outcomes of such care in terms of cost, resource utilization, effectiveness, and client satisfaction.
While these barriers pose potential snares for CAM integration, there are ways to improve the picture. Some HMOs have been successful in aggressively educating their providers and members about the CAM benefits they offer (Daily). In addition to education, a well-developed referral system is essential so that patients can navigate the still immature system of CAM referrals within conventional care.
Irrespective of HMO's plans to cover CAM/integrative medicine therapies, some healthcare providers are moving ahead with their own programs. Americans want alternative choices in healthcare, and as previously noted, already pay for the majority of CAM out-of-pocket. Attracting those private pay clients is helping many providers maintain revenue within a prospective payment system. Some providers within the post acute care continuum are adding CAM therapies to draw clients to their services. For example, Cathedral Village, a continuing care retirement center in Philadelphia, offers Tai Chi and message therapy for residents (Adkins, 2000). Providers who have integrated such programs are not only generating revenue for services provided, they are also improving the health of their residents through the benefits of "research-proven" exercise regimens’.
Chances are someone you know relies on herbal medicine for some health needs. It is a fact that the American field of medicine and pharmaceuticals is changing. At least 32 percent of Americans report using herbal products for personal health needs, and the herbal market is estimated to be a nearly $6 billion annual business (Fetors & Avila). Americans are seeking alternatives to conventional care, and herbal remedies have become a large part of this trend. More than 500 herbal products are marketed in retail grocery and drug stores, mail order houses, and on the Internet, yet none of the products are regulated by the FDA the way conventional drugs are. Consumer’s self-prescribe herbal remedies, most often without professional consultation, or without adequate information, and many do not tell their healthcare providers about their use of herbal supplements.
This section reviews the trends around herbal product use, managed care organizations (MCO) response to this trend, and the FDA's attempts to regulate an unregulated market. The issues surrounding this changing healthcare paradigm are important to all nurses and their patients. Table 3 defines key words important in herbal medicine.
There is currently unlimited and undistracted access to herbal therapies in the U.S., and anyone may purchase and ingest herbal remedies at will. The reasons for use of herbal remedies are as numerous as the kinds of herbal products available. While there is no "typical" herbal remedy user, women account for a large percentage of herbal therapy purchases. Some people report that they use herbals to manage a chronic illness, such as osteoarthritis or asthma. Others, hoping to allay the effects and processes of aging, take supplements for vigor, alertness, and cardiovascular health. Still others turn to herbal remedies episodically, to fight a cold or to improve sleep, in much the same way mainstream over-the-counter cold remedies or sleeping pills are used.
Many patients don't feel comfortable revealing their herbal supplement use to healthcare providers. Among patients who visit conventional medical providers, one-third use herbal supplements and many fail to disclose this fact to their main health care provider (Eisenberg, 1997). Compounding this issue is that few conventional providers have learned how to ask about herbal therapies, or what to do with that information once it is collected. If the healthcare provider does not ask, or gives a negative impression about herbal remedies, the patient is not likely to reveal personal use of herbal remedies.
Herbal supplements are big business in the U.S. Full-color ads in health magazines, women's magazines, and other media have fueled the rapid growth in herbal sales, as have online shopping via the Internet.
As herbal sales have grown, so have the dollars aimed at research on these therapies. While some of the results have been published in medical journals, few consumers have ready access to such information. Instead, individuals often rely on word of mouth recommendations and anecdotal reports of the efficacy of a particular herbal product. Both the longstanding herbal use in other cultures, and recent research, has shown that many herbal remedies are beneficial in the prevention or treatment of illness, or for general well-being (Fetors & Avila).
Consumer demand for herbal remedies is evident in the growth of the U.S. botanical market at a rate of 15 to 20 percent a year (Kurtzweil, 1999). In response to this trend, MCOs have shown an interest in integrating botanicals into managed care.
The lack of modern biomedical data to justify herbal medicines has been a major reason for not including these therapies in benefit plans. With that in mind, MCOs are addressing the need for data similar to those involving traditional drugs: effectiveness, safety, quality, and price (Leaders, 1998). Experts assert that approval of herbal products as drugs by the FDA would ensure safe manufacturing processes (Leaders). FDA approval would be a solid basis for accepting botanicals into managed care formularies and for reimbursement by third-party payers.
As research on herbal therapies shows their efficacy in healthcare, it may become common to see managed care plans allowing reimbursement for select herbal therapies. While many consumers may welcome third-party coverage for herbal products, many others may fear the loss of self-selection of herbal therapies should the FDA declare that these products must be regulated as drugs. This issue will need to be addressed should insurance companies cover herbal remedies.
Prior to the late 1930s, none of the medicines in this country-both herbal and conventional-were well regulated (Fetors & Avila). After several incidents, some of which lead to patient deaths, the Federal Food, Drug, and Cosmetic Act was passed. The act was edited in 1962-adding that drugs must be safe and effective-and is still in place today and mandates that all drugs sold in the U.S. cannot be marketed until proven safe (Fetors & A vial). Herbal remedies were not a part of the 1962 mandate, and the FDA does not test or authorize dietary supplements, a class of products in which herbal therapies currently reside in the U.S.
In 1994, Congress passed the Dietary Supplement Health and Education Act (DSHEA). The law grand fathered most herbal supplements into a new class of products labeled as "dietary supplements" which allowed them to remain on the market (Kurtzweil). Under this act, herbal products may be sold as long as the product labels are neither misleading nor claiming to treat a specific illness. Once an herbal product is marketed, the FDA has the responsibility to prove that a supplement is unsafe before it can restrict the product's sale or use (Food & Drug Administration, 1999).
Since the DSHEA was passed, the FDA has published several rulings and clarifications on the law. For example, in1997 the FDA published warnings about ephedrine alkaloids, marketed as ephedrine, Ma huang, etc., and the hazards of using these products. In addition to FDA guidance, individual states have the authority to take steps to restrict the sale of potentially harmful supplements within their jurisdiction (FDA).
Another primary concern related to the passage of the DSHEA is the "health claims" that manufacturers use to sell their products. It is not appropriate for a supplement manufacturer to claim that a particular product will cure or prevent disease. In 1997, the President's Commission on Dietary Supplement Labels made a distinction between structure-function claims and disease claims (FDA). A product can claim to have an effect on the body's structure or function, including the effect on a person's well-being, without FDA authorization. However, the claim must be true and not misleading, and must be accompanied by the disclaimer previously mentioned.
By mid-1999 the FDA was focusing on three issues surrounding dietary supplements: 1) the definition of disease, 2) common conditions associated with natural states, and, 3) implied disease claims (Kurtzweil). These controversial issues were to a large extent raised by consumers and supplement manufacturers who argued that many health-related conditions, such as hot flashes with menopause, and the effects of natural aging processes, are neither abnormal nor diseases. The FDA was encouraged to distinguish between products aimed at "treating disease" and products aimed at health maintenance and the normal health consequences of life or disease. The FDA recently made that distinction.
The FDA's final rule that defines the types of statements that can be made concerning the effect of a dietary supplement on the structure of function of the body, was published in January 2000 (FDA, 2000). The rule permits claims that do not relate to disease. These include health maintenance claims, other non-disease claims, and claims for common, minor symptoms associate with life stages (FDA). This final rule precludes express disease claims ("prevents osteoporosis") and implied disease claims without prior FDA approval, and may result in labeling changes for supplements.
The fact that a plant is natural does not automatically mean that the products made from that plant are innocuous and safe. Hundreds of herbal remedies are available today, many of which do not have well-documented research and publication of side effects and serious toxicity (Fetors & Avila). In spite of the many promising uses of herbal remedies, they can cause adverse reactions and side effects much like conventional medications. For example, one study found that asthma patients were hospitalized for complications related to self-treatment with herbal remedies (Fetors & Avila).
Therein lies one of the greatest risks of herbal remedies. Like other over-the counter medications, the unregulated herbal products may be abused. Abuse can come in the form of improper use of the product, lack of knowledge of the herb's intended effects and side effects, ingesting herbal remedies concurrently with prescription drugs, or failure to inform conventional providers of herbal products used.
In addition, patients with potentially life-threatening illness or serious symptoms are at risk when seeking herbal remedies while foregoing medical evaluation. In some instances, seeking medical advice earlier could mean the difference between life and death, as with atypical chest pains or bleeding.
Most people are familiar with the FDA's Med Watch program designed to track and record drug reactions and interactions. Healthcare providers or consumers can report adverse effects of a drug or an herbal product, confidentially, by telephone or the Internet. Healthcare providers who suspect a patient has suffered serious harmful effects or illness due to herbal supplement use should report the event. Table 4 explains how to make a report to Med Watch.
Fewer people are aware that in 1993 the FDA established the Special Nutritionals Adverse Event Monitoring System (SN/AEMS) (Office of Special Nutritionals, 2000). The SN/AEMS monitors adverse events (illness or injury) reports associated with use of a special nutritional product, including dietary supplements. The reports come via Med Watch, FDA field offices, other Federal, State, or local public health agencies, and letters or phone calls from consumers and healthcare providers.
The SN/AEMS web page can be accessed for information on reported adverse events. Actual online reporting is through the Med Watch homepage. The FDA stresses that there may not be enough information online to assert a direct relationship between a supplement and adverse event. It is however, a source of information on numerous herbal supplements and possible adverse events.
The demand for CAM therapies continues to grow in the U.S. Lack of herbal product standardization and standardized "prescriptive" use presents risks and challenges for clients who choose to use herbal therapies. By becoming knowledgeable of the benefits of herbal therapies as well as the associated risks, nurses can advocate for client safety and choice.
Table 5 lists several websites to access for information on herbal therapies, and general information on CAM therapies.
For the following patient scenario, consider the questions at the end of the scenario, and then compare your answers to the case discussion at the end.
Brenda A., RN, CCM, is a case manager for the orthopedic and neurological medical and surgical units at a large community hospital. This morning during case management rounds, Brenda has read the chart of a woman who has had post-worth surgery complications. Brenda is concerned about the discharge needs of this patient, as she seems to have done poorly after a simple outpatient surgery nearly six weeks earlier. The nurse's assessment notes mention briefly that Mrs. Carol Sterling, 68 years of age, was admitted to the Neurological unit the day after New Year with complaints of unusual seizure-like activity, frequent nosebleeds, and problems with control of her blood glucose level. Brenda locates the Day shift nurse and asks about Mrs. Sterling' status. The nurse confirms that the patient has several home needs that she hasn't fully assessed today, but hopes that the case manager can find out more than yesterday's PM shift did.
Brenda enters Mrs. Sterling' room and finds an outgoing, but nervous woman who looks younger than her age. While assessing Mrs. Sterling, Brenda learns that Carol lives alone in a one-bedroom apartment, and has been recovering from a right total knee replacement (TKR) she had six weeks earlier. Mrs. Sterling shakes her head as she waves her hand over her right leg.
"I haven't felt the same since this surgery. Think someone made a mistake?"
Brenda asks the patients what she has done at home to care for herself since the surgery.
Mrs. Sterling hesitates, and then sighs as though distressed. "I've tried just about everything. I've had headaches, knee pain, and backaches. And sleep? Hardly any for days on end." She winces as she adjusts her position in bed, and then continues. "If it weren't for my neighbor, Linda, I doubt I could even have made it past two weeks at home,”
Brenda acknowledges her friend's help, and then asks how she helped her.
"Linda is amazing! She knows all these things about herbs, and helped me with all my complaints, most of the time."
With a few more brief questions, Brenda learns that Carol used various herbal supplements and herbal teas, and magnet therapies during her recovery from surgery at home. With this knowledge, Brenda is better prepared to collaborate with Carol as a safe discharge plan is begun. In addition, Brenda plans to consult with the primary physician about a patient-centered plan.
Integral to professional case management roles is application of the case management process.
Case management responds to the care needs of clients along a care continuum, rather than confining services within one setting. Care coordination is particularly important for the client who uses CAM therapies without the guidance of a primary healthcare provider. The process is similar to patients receiving conventional care, yet with patients seeking or using alternative care the case manager may need to include new approaches.
Assessment and Case identification
Case managers conduct assessments to determine individual client needs. The case manager collects information from a variety of sources, including the patient, providers, patient's family, employer, and payer. The past medical history and how medical Resources have been utilized is also reviewed, along with the current diagnosis and treatment plan. As with any client case, the case manager becomes familiar with the diagnosis, the patient's understanding of his or her condition, therapy expected, and the expected outcomes. In addition, the case manager should identify any alternative or controversial therapy the client is using.
Within the hospital setting, the case manager or discharge planner typically begins work with patients and family during acute hospitalization. Assessment data in the hospital comes from physician notes, nursing admission notes, and documentation of other multidisciplinary team members. Data is also collected or clarified through dialogue with the client and family, and direct care providers. Bedside nurses can often provide further information not found in the client's medical record.
To identify a client's use of CAM therapies, the case manager screens the admission materials for mention of alternative therapies. For example, the nursing admission record may mention non-prescription herbal medicines, or that acupuncture has been tried to relieve chronic back pain.
While it is hoped that patients feel comfortable telling the physician or the nurse about their CAM usage, it is also possible that no mention of CAM usage will be recorded in the patient's chart. Often this data is missing because care providers do not have adequate tools or methods to ask about CAM usage. Experts have also found that many patients do not reveal their alternative practices to physicians or nurses (Lazar, O'Connor, 1997). One study found that up to 70 percent of people who use CAM therapies do not share this information with their health care provider (Landmark, 1998).
Within an extended care setting, assessment data would be obtained from similar sources as in the acute hospital. In addition, the patient's family members or caretakers may be the best sources of information on past or current CAM therapies used, particularly if the patient has cognitive dysfunction or difficulty communicating.
A ware that Mrs. Sterling's present illness was serious enough to require acute hospitalization, Brenda knows that she needs to begin wrapping up the admitting assessment. But, without knowledge of why Mrs. Sterling has both prescription drugs and herbal medicines in her bag, the plan of care will get off to a poor start. Brenda also knows that a non-confrontational style is best with Mrs. Sterling, as she seems uncomfortable about the colorful bottles on her bed. The questions that the nurse asks are Based on an assessment model that guides healthcare providers in learning about a patient's use of alternative therapies (Ulrich & Hodge, 1999).
In a safe, supportive, empowering and nonjudgmental interaction, Brenda should ask open-ended questions such as "what things do you do to improve or maintain your health?" Asking Mrs. Sterling her evaluation of the effectiveness of the feverfew, ginger, gingko and valerian will help Brenda assess Mrs. Sterling's level of knowledge associated with her use of the botanicals.
Another way to initiate dialogue about the mixture of drugs in her bag is for Brenda to share with Mrs. Sterling that she has seen similar situations in which patients present with a cornucopia of pharmaceuticals. This strategy lets the patient know that the nurse is willing to discuss the topic and that her disclosure of herbal use is not shocking.
Brenda should also assess Mrs. Sterling's level of risk associated with the use of herbal supplements. She should be cognizant of her patient's economic status and her motivation in using the supplements. If the patient responds that she is looking for a cure for her conditions and is "willing to pay what ever it takes," she is at risk for fraud. Additionally, if Mrs. Sterling's family is unaware of her use of medicinal herbs, she may be making decisions in isolation, a situation that exposes Mrs. Sterling to greater risks.
When she asks Mrs. Sterling when she began taking the herbal remedies, Brenda is glad she asked. Mrs. Sterling had considerable knee pain and headaches while recuperating at home, for which she took the prescription oral analgesic around the clock. Then she starting having heartburn and nausea, and her neighbor gave her a half- filled bottle of Ginger capsules, claiming they would cure her "upset stomach." This neighbor Bought Mrs. Sterling a bottle of Feverfew, as the herb was known to allay the pain of migraine headache. Several weeks after surgery, Mrs. Sterling began taking Gingko Biloba, hoping to clear the "foggy feeling" she had in her head. At the same time, she had some difficulty sleeping, so began taking Valerian root extract each night before bedtime, because an ad in a women's magazine said promising things about that herb. Lastly, she says she had been getting daily shots of Lovenox for a short time after surgery, and then her doctor put her on Coumadin tablets.
As Mrs. Sterling finishes explaining why she is taking herbal remedies, Brenda thanks her for her honesty and then quickly completes the assessment. The information the nurses and the case manager have gathered needs to be critically reviewed. Brenda knows that it is very likely the prescription medications and herbal medicines are not a safe mix, and that Mrs. Sterling's plan of care must address this issue.
Each registered nurse is obligated to act as a patient advocate for safe and effective care. This advocacy role obligation is part of the ANA standards of clinical practice that apply to all licensed RN's in the U.S., and a primary duty of all case managers. As an advocate, the case manager must utilize the assessment data to build an individualized plan of care to improve or lessen the severity of identified patient problems.
Brenda calls the pharmacy to learn more about Mrs. Sterling's herbal products, and then places a call to the patient's admitting physician. As she consults with the physician, Brenda learns that she had no prior knowledge of Mrs. Sterling's herbal remedies, other than the fact that the patient had mentioned she was going to take "some supplements to speed up her healing process." Dr. Smyth assumed she was talking about vitamins.
Armed with new knowledge of Mrs. Sterling's self-medication, the doctor orders additional lab tests to determine the patient's current platelet count, her clotting time, and her serum Dilating level. In addition, the patient is put on seizure precautions, due to probable negative interaction between the Dilating and the Ginkgo, and possibly the Valerian. Also, the physician orders finger-stick blood glucose levels every four hours with sliding scale coverage.
Before hanging up, Brenda tells the physician she plans to begin patient teaching about herbal remedies and safe practices. The physician agrees, and also asks Brenda to tell Mrs. Sterling not to take any of the medications she brought from home until the exact cause and severity of her current illness is understood.
As soon as Brenda learned that the herbal remedies Mrs. Sterling was using might have affected her chronic health conditions in a negative manner, Brenda took action. She knew that waiting until later, or tomorrow when the physician did rounds, would delay a timely plan of care. The delay could lead to patient injury.
As a patient advocate, the case manager is obligated to use professional judgment in how and why to inform other care team members of a patient's self-prescribed therapies. In general, any admixture of prescription medications with herbal remedies is a red flag. Also, unusual symptoms or exacerbation of symptoms in a patient previously under adequate symptom control is a cause for concern. If herbal remedy use is known or suspected, the nurse should take steps to confirm what products are being used.
On the other hand, many individuals self-prescribe herbal remedies episodically, for short-term or seasonal use. For example, Echinacea is becoming common as a means to treat upper respiratory symptoms. While episodic use of an herbal product may not pose any problem, it is important to also assess other short-term medication a patient may be taking. For example, individual's taking Tetracycline should avoid ingesting St. John's Worth, as both products can cause severe photosensitivity (Fetors). It is wise to encourage the patient to discuss new prescriptions with the prescribing physician or a pharmacist, and to also consider herbal products the patient is already taking or plans to take.
In every area of patient care, documents relevant to the case manager's work setting serve as the starting point for data collection. Regardless of setting, the case manager reviews the client's medical record and case history. When CAM usage is identified or suspected, the case manager further assesses patient and family understanding of the alternative therapy. This assessment should include:
Key questions can assist in identifying the types of treatments the client has used.
For example, asking "what are you doing to maintain your health?" or "what do you do at home for your health?" can open discussion of CAM therapies the client is using or has used in the past.
A thorough case management assessment assists in identification of significant issues that may interfere with the provision of cost effective, safe, quality care. A thorough and objective assessment is fundamental to successful client outcomes in acute care and other levels of care along the healthcare continuum.
What does this continued trend mean to case managers, discharge planners, and managed care professionals?
The knowledgeable Case Manager can advocate for client safety and choice in CAM therapies in healthcare.
The American Hospital Society, in its Future scan 2000 report, suggests that all healthcare providers’ should embrace the trends in CAM therapies. The report encourages organizations to join the new age of complementary medicine by offering an array of consumer-accepted alternative medicine services and products.
This recommendation from the AHA may prove to be a welcome breath of fresh air for ailing health systems. It can also serve to provide unexpected challenges to those that have not yet begun to integrate conventional medicine with CAM therapies. In both types of circumstances, case managers are well-poised to advocate for their clients as the future of CAM and conventional medical integration unfolds.
References
NCCAM Classification of Alternative Medicine Practices
Category |
Description |
I. Mind-Body Medicine |
Involves behavioral, psychosocial, social, and spiritual approaches to health. Divided into 4 subcategories: mind-body systems; mind-body methods; religion and spirituality; social and contextual areas |
II. Alternative Medical Systems |
Involves complete systems of theory and practice that have been developed outside of the Western medical biomedical approach. Divided into 4 subcategories: acupuncture and Oriental medicine; Traditional Indigenous systems; Unconventional Western Systems; Naturopathy |
III. Lifestyle and Disease Prevention |
Involves theories and practices designed to prevent the development of illness, identify and treat risk factors, or support the healing and recovery process. Concerned with prevention and management of chronic disease. Divided into 3 subcategories: clinical preventative practices; lifestyle therapies; health promotion. |
IV. Biologically-Based Therapies |
Includes natural and biologically-based practices, interventions, and products. Many overlap with conventional medicine's use of dietary supplements. Divided into 4 subcategories: phototherapy or herbalist; special diet therapies; orthomolecular medicine; pharmacological, biological and instrumental interventions |
V. Manipulative and Body-Based Systems |
Refers to systems that are based on manipulation and/or movement of the body. Divided into 3 subcategories: chiropractic medicine; massage and body work; unconventional physical therapies. |
VI. Biofield |
Involves systems that use subtle energy fields in and around the body for medical purposes |
VII. Bioelectromagnetics |
Refers to the unconventional use of electromagnetic fields for medical purposes |
NCCAM website, http://nccam.nih.gov/nccam/what -is-earn/classify.Shtml
Holistic MedicineDoctors (MD or DO) who offer a wide range of both conventional V and alternative person and the doctor patient relationship. |
AcupunctureFine needles inserted into the body along pathways called meridians to ease pain, specific problems. Originated in the Orient. Two types of stimulate organs, or impact acupuncturists: MDs and Dos certified in the technique, usually via medical schools; and unlicensed practitioners who learn the craft in traditional Oriental medicine. |
Therapeutic MassageEmphasis upon easing aches and pains, and reducing maladies that leads to stress. Several different schools of massage, including: deep tissue; European (Swedish acupressure, and Shiatsu). Best known); pressure point (including reflexology, acupressure, and Shiatsu). |
Naturopathic MedicineND is doctor of Naturopathy.ND is granted after 4 years of graduate study, based on study of natural substances and alternative therapies instead of Drugs and surgery. Use homeopathy, herbs, acupuncture, psychology, counseling, general wellness Advice, etc. Can function as a Primary care provider. Eleven states currently regulate and Recognize ND practice. |
OsteopathyDoctors of osteopathy (DO) can do anything from spinal manipulation to extensive Neurological work. They take almost all the same courses as physicians, plus an additional 500 hours on spinal Manipulation. Have same residency requirements, and are recognized in every state as same legal status as Physicians |
BiofeedbackA scientific discipline often used when a patient needs to control pain or find relaxation, in a general or a Specific part of the body. Biofeedback machines measure levels of muscle tension, skin temperature, blood pressure, or brain wave activity, and show the patient the levels so that they may understand how to Control these responses. |
ChiropracticLicensed in all states and often covered by health insurance plans. Vast majority of D.C.s focus upon treating back pain and other conditions through spinal manipulation of the Spine. May also give advice on nutrition, exercise, and general other alternative therapies Wellness. Some branch out into through additional training. |
HomeopathyOften considered one of the More mysterious therapies. Popular in the 19th century and Once more in use today. Extremely dilute solutions of active substances, akin to a vaccination, are used to Prevent or treat illness. Homeopathic is considered the opposite of conventional "Allopathic" medicine. |
AyurvedsaTraditional Indian healing system dating back 4,000 years, rooted in practical Experience. Involves herbs, exercise, stress management techniques including Meditation and massage. Not a licensed field in the U.S. |
Table 2. Source: Compiled from information in Brauer & Simon, 2000, in references.
Table 3 - Key words in Herbal Medicine
| Dietary supplements: Any product intended for ingestion as a supplement to the diet. This now includes vitamins, minerals, antioxidants, herbal products, metabolites, and other Products. |
| Phytomedicine: The use of plants or plant parts to achieve a therapeutic cure. |
| Botanical Medicine: Botanic supplements used as medicine. A term often used in place of Phytomedicine. |
Source: compiled from information in Fetrow & Avila, 1999, in reference list.
Table 4: How to reach the FDA Med Watch or the SN/AEMS
| Call: 1.800.FDA.I088 |
| When making a report, you need to provide: 1. The name, address and telephone number of the person who became ill 2. The name and address of the doctor or hospital providing medical treatment, if applicable 3. Description of the problem 4. Name of the product and the store where it was purchased |
Table 5
National Institutes of Health, National Center on Complementary and Alternative Medicine.
Site offers information for beginners to advanced users of alternative therapies. www.bewell.com
An educational site with several online "ezines," including one focused on alternative medicine.
Publishes Herbs for Health. An informative and thorough journal on herbal remedies, aimed at consumers.
Information on health conditions and complementary therapies.
Information on CAM therapies.