Applying New Models of Care to Meet Patient Needs in Integrative Oncology

An increasing number of cancer patients are seeking complementary and integrative medicine approaches.^1,2 Despite the considerable growth of integrative medicine offered in academic cancer centers,³ patient demand frequently outpaces availability. The Osher Center for Integrative Medicine at the University of California San Francisco (UCSF), for instance, previously closed its integrative oncology (IO) practice to new patients due to a >6 month wait time.

To achieve quality integrative cancer care, we must identify barriers to access and test models to address these barriers. A growing body of literature examines the safety, effectiveness, and patient centeredness of IO care. Some of our recent efforts focus on addressing the other three domains of healthcare quality defined by the Institute of Medicine (IOM): timely, efficient, and equitable care.⁴

Timely care reduces delays. Due to lengthy wait times for appointments, cancer patients are often unable to see an integrative oncologist during active treatment, arguably the most critical time to receive integrative care. Barriers to timely care include longer visits and the limited number of trained providers. IO visits are frequently 60–120 min, which results in fewer patients being seen within a typical clinic. Although this visit length is important to the practice of IO—facilitating comprehensive, coordinated, and holistic care—it reduces availability.

Efficient care improves coordination, which is a challenge at large cancer centers with multiple campuses and separate specialty clinics. Equitable care includes providing quality care irrespective of geographic location, socioeconomic status, or other individual and social factors. Barriers to equitable care include challenges posed by traditional in-person visits for patients who live far away. For example, 80% of UCSF cancer patients live outside of San Francisco and commute an average of 67 miles through Bay Area traffic for their medical appointments.

To overcome these barriers (Table 1), we are exploring new models of care. We are piloting IO group visits, wherein 8–10 cancer patients and caregivers meet with an integrative oncologist for a series of visits on specific IO topics (e.g., nutrition, supplements, and mind–body medicine). We are also studying interventions that provide patient education on self-care utilizing digital health technology. Aspects of IO (e.g., some mind–body interventions) lend themselves well to this scalable format. Embedding integrative practitioners in oncology clinics, infusion centers, or inpatient settings is another model that improves efficiency, as patients being seen for their usual oncologic care can simultaneously receive elements of IO care. Embedding can also allow for more coordinated and truly integrated care. Support between visits by health coaches and the use of telemedicine can motivate patients to adhere to diet and lifestyle regimens and help to optimize in-person time with providers.

Table 1.

Quality Aims for Integrative Oncology Care and Models to Achieve That Care

Quality aimsa	Barrier to quality IO care	Proposed model to address barrier
Timely	IO visits are time intensive, which limits the number of available appointments.	Implement IO group visits for patients actively receiving chemotherapy.
	A limited number of providers have specific training in IO.	Provide IO training to oncologists and other physician and nonphysician providers.
Efficient	Patients with cancer are juggling multiple appointments, in different locations.	Embed integrative medicine within existing oncologic care (e.g., acupuncture during chemotherapy infusion).
	Lack of coordination between biomedical providers and integrative medicine providers is burdensome for staff and patients.	Harmonize scheduling workflows and offer interprofessional care where patients can see an oncologist and an IO provider in the same visit.
Equitable	Geographic distance between patients and cancer centers is considerable.	Implement support through health coaches between visits through telemedicine.
	Insurance coverage for IO clinical services is uneven.	Provide education through affordable digital health technology.

^aThe six aims for improving quality healthcare (Institute of Medicine)⁴ are safe, effective, patient-centered, timely, efficient, and equitable care.

IO, integrative oncology.

Triaging patients into the appropriate model of care is important for delivering effective and quality IO care. In some healthcare systems, an integrative oncologist may be expected to serve as a gatekeeper to complementary or integrative modalities. Given the limited number of integrative oncologists, it is important to consider ways to more judiciously and selectively (rather than routinely) use the integrative oncologist in this role. Clinical protocols and institutional guidelines can guide the use of complementary modalities for routine situations, such as for uncomplicated post-treatment survivorship care. A trained and experienced acupuncturist, for example, could provide IO care for select patients. Whereas an integrative oncologist may be better utilized in medically complex situations, such as for a patient receiving a complex chemotherapy regimen. In addition to potentially allowing the more efficient use of resources, another advantage is that this approach emphasizes interprofessional care. However, out-of-pocket costs to patients have to be considered.

Patient-centered, safe, and effective IO care should be a part of comprehensive cancer care that meets the high-quality standards set by the IOM.⁴ Addressing the barriers to timely, efficient, and equitable care is necessary in order for IO to realize its full potential. The study of new models of care, by themselves and in combination, should be a focal point for the field of IO in its next stage of evolution.

Acknowledgment

This work was made possible by support from the Helen Diller Family Foundation.

Author Disclosure Statement

No competing financial interests exist.