The UCSD Center for Integrative Medicine: Vision, Development and - - PowerPoint PPT Presentation

The UCSD Center for Integrative Medicine: Vision, Development and Future Directions

Gene A. Kallenberg, MD Executive Director, Center for Integrative Medicine Professor & Chief, Division of Family Medicine Vice Chair, Department of Family Medicine and Public Health University of California, San Diego

Introduction

• Our goal for this visit is to share our concept, our strategic

plan and the principles that have guided our efforts in the hope that those interested in Integrative Medicine here at PUC, a similarly science-focused academic health center, will find them useful in developing your own path.

• We will also present both primary care and specialty care

(oncology) viewpoints on incorporating an integrative medicine approach to patient care.

• Beyond this modest goal lies the potential for inter-

institutional collaboration that could enlighten us both.

What IS Integrative Medicine?

“Healing-oriented medicine that takes account

• f the whole person, including aspects of
• lifestyle. It emphasizes the therapeutic

relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies.”

University of Arizona

The Defining Principles of Integrative Medicine

• Patient and practitioner are partners in the healing process.
• All factors that influence health, wellness, and disease are taken into

consideration, including mind, spirit, and community, as well as the body.

• Appropriate use of both conventional and alternative methods

facilitates the body's innate healing response.

• Effective interventions that are natural and less invasive should be

used whenever possible.

• Integrative medicine neither rejects conventional medicine nor accepts

alternative therapies uncritically.

• Good medicine is based in good science. It is inquiry-driven and open

to new paradigms.

• Alongside the concept of treatment, the broader concepts of health

promotion and the prevention of illness are paramount.

• Practitioners of integrative medicine should exemplify its principles and

commit themselves to self-exploration and self-development.

• University of Arizona

UCSD Center for Integrative Medicine

• Vision

The UCSD Center for Integrative Medicine will create a model

• f whole-person healthcare that maximizes both caring and

curing.

• Mission

Through collaboration in practice, teaching and research of

healing-oriented medicine the UCSD Center for Integrative Medicine is dedicated to changing health care in a way that engages each individual's unique values and empowers them to achieve optimal health and well-being in all aspects of life.

What We Do

• Clinical Care

Offer integrative services throughout the UCSD Health System (HS) wherever patients are treated in whatever manner we can contribute to their healing process and well-being. This includes all outpatient clinics, the emergency room and all hospital inpatient units.

• Services offered:

IM consultations, OMT, acupuncture, massage/energy work, classes in MBSR, Natural Healing & Cooking, Yoga, Tai-Chi and Qi-Gong

• Education

Educate peer faculty, staff and learners at all levels in the Health System about the types of IM services available, the science supporting them, when they are appropriate to employ and their effectiveness in practice.

What We Do

• Research

Conduct research assessing the efficacy and effectiveness of IM services on patient care: clinical outcomes, cost of care and patient satisfaction (Triple Aim).

• Community Collaboration

Convene and meet with interested members of the San Diego community to foster understanding of how IM services can affect their well-being and clinical care, and to promote safe and effective use of IM services to improve their health and help them play active roles in their own care.

Who We Are -- cim.ucsd.edu

• 6 family physician MDs  IM consultations
• 1 preventive medicine / nutrition & natural medicine MD,

PhD, MPH  nutrition consultations

• 5 doctors of osteopathy  osteopathic manual therapy
• 7 Licensed acupuncturists
• 2 massage/energy-acupressure therapists
• 2 psychologists & multiple instructors  MBSR classes at
• ur Center for Mindfulness
• Multiple instructors  Natural Healing and Cooking Classes
• Tai-Chi, Yoga and Qi-Gong instructors
• Total ~35 individuals

Administrative Structure

• Clinical Services
• Executive Director (.3)
• Managing Director (1.0)
• Administrative Asst. (.75)
• Medical Director (.05)
• Director of Acupuncture/Massage (.2)
• Inpatient Director (.25)
• Education
• Education Director
• Medical Student Education Director (.05)
• Residency Education Director (.1)
• Research
• Director of our Center of Excellence in Research and Teaching of Integrative

Health (.5)

• Director of the Krupp Endowment for IM Research (.05)
• Community Collaboration
• Director of Community Collaboration (.05)

Why Develop a Center for Integrative Medicine?

• Our patients used these services and approaches to their own

medical care and self-care already ($34-49B and ~350m visits)

• A patient-centered approach to care was being increasingly and

more broadly recommended across US healthcare and is being taught in our health professional schools

• Data was beginning to support the efficacy of IM interventions
• IM approaches were potentially very cost-effective for control of

many chronic diseases that were a source of substantial healthcare spending

• IM approaches were increasingly being used to complement

allopathic, Western medical approaches (i.e. no longer alternative, but complementary or integrative)

Competitor Analysis

49% 41% 45% 36%

Patient Demand Attracting New Patients Increased Clinical Effectiveness Differentiation from Competition

Top Reasons Major Hospitals are Offering CAM

Most major healthcare organizations offer CAM services and many do so by establishing IM programs. These institutions have decided to offer these services primarily to meet the demand of patients and to remain competitive in their market. Direct financial contribution by the program was not mentioned by any of the

• rganizations participating in the survey. Projected financial benefits were the result of

expected increases in the patient population receiving services from the organization

Regulatory Change

• The Joint Commission’s New Pain Management Standard:
• Effective January 1, 2015, for Ambulatory Care, Critical Access Hospital,

Home Care, Hospital, Nursing Care Centers and Office-Based Surgery Practice Programs

• Both pharmacologic and non-pharmacologic strategies have a role in the

management of pain. The following examples are not exhaustive, but non- pharmacologic strategies may include the following:

• physical modalities (for example, acupuncture therapy, chiropractic therapy,
• steopathic manipulative treatment, massage therapy, and physical therapy),

relaxation therapy, and cognitive behavioral therapy

www.jointcommission.org/clarification_of_the_pain_management__standard/

The View from the National Center for Complementary and Integrative Health (NCCIH)

• CHARGE: The Director of the Center shall, as appropriate, study the

integration of alternative treatment, diagnostic and prevention systems, modalities and disciplines with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States. S.2420, July 31, 1998

• Individuals, their health care providers, and their health care systems

are all, on a large scale, incorporating various practices which have

• rigins outside of mainstream medicine into multi-pronged treatment

and health promotion approaches.

• This “integrative” trend among providers and health care systems is
• growing. Driving factors include perceived benefit in health or well-

being, emerging evidence in at least some cases that perceived benefits of integrative are real and/or meaningful (e.g., management of chronic pain), and marketing of “integrative care” by health care providers to consumers.

• With few exceptions, data to guide evidence-based decision making

about safety and efficacy are at best preliminary.

PLoS One. 2015 Apr 16;10(4):e0124344. doi: 10.1371/journal.pone.0124344. eCollection 2015.

Standardised mindfulness-based interventions in healthcare: an

• verview of systematic reviews and meta-analyses of RCTs.

Gotink RA1, Chu P2, Busschbach JJ3, Benson H4, Fricchione GL5, Hunink MG

Abstract

BACKGROUND: Mindfulness-based therapies are being used in a wide range of common chronic conditions in both treatment and prevention despite lack of consensus about their effectiveness in different patient categories. OBJECTIVE: To systematically review the evidence of effectiveness MBSR and MBCT in different patient categories. METHODS: A systematic review and meta-analysis of systematic reviews of RCTs, using the standardized MBSR or MBCT programs. We used PRISMA guidelines to assess the quality of the included reviews and performed a random effects meta-analysis with main outcome measure Cohen's d. All types of participants were considered. RESULTS: The search produced 187 reviews: 23 were included, covering 115 unique RCTs and 8,683 unique individuals with various conditions. Compared to wait list control and compared to treatment as usual, MBSR and MBCT significantly improved depressive symptoms (d=0.37; 95%CI 0.28 to 0.45, based on 5 reviews, N=2814), anxiety (d=0.49; 95%CI 0.37 to 0.61, based on 4 reviews, N=2525), stress (d=0.51; 95%CI 0.36 to 0.67, based on 2 reviews, N=1570), quality of life (d=0.39; 95%CI 0.08 to 0.70, based on 2 reviews, N=511) and physical functioning (d=0.27; 95%CI 0.12 to 0.42, based on 3 reviews, N=1015). Limitations include heterogeneity within patient categories, risk of publication bias and limited long-term follow-up in several studies. CONCLUSION: The evidence supports the use of MBSR and MBCT to alleviate symptoms, both mental and physical, in the adjunct treatment of cancer, cardiovascular disease, chronic pain, depression, anxiety disorders and in prevention in healthy adults and children.

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Pain Med. 2015 Jan 13. doi: 10.1111/pme.12685. [Epub ahead of print]

Acupuncture Provides Short-Term Pain Relief for Patients in a Total Joint Replacement Program.

Crespin DJ1, Griffin KH, Johnson JR, Miller C, Finch MD, Rivard RL, Anseth S, Dusek JA.

Abstract

OBJECTIVE: Given the risks of opioid medications, nonpharmacological strategies should be considered for total joint replacement

• patients. We investigated acupuncture as an adjunct therapy for postsurgical pain management in a total joint

replacement program by examining which total hip and knee replacement patients elected to receive acupuncture and the effect of acupuncture on short-term pain. DESIGN: A total joint replacement program using fast-track physiotherapy offered elective postsurgical acupuncture to all patients, at no additional cost, as an adjunct therapy to opioids for pain management. SETTING: The Joint Replacement Center at Abbott Northwestern Hospital, a 630-bed teaching and specialty hospital in Minneapolis, Minnesota from 2010 to 2012. SUBJECTS: Our sample included 2,500 admissions of total hip (THR) and total knee replacement (TKR) patients. METHODS: Self-reported pain was assessed before and after acupuncture using a 0-10 scale and categorized as none/mild (0-4) and moderate/severe pain (5-10). RESULTS: Seventy-five percent of admissions included acupuncture. Women (Odds Ratio: 1.48, 95% Confidence Interval (CI): 1.22, 1.81) had higher odds of receiving acupuncture compared to men, and nonwhite patients (Odds Ratio: 0.55, 95% CI: 0.39, 0.78) had lower odds of receiving acupuncture compared to white patients. Average short-term pain reduction was 1.91 points (95% CI: 1.83, 1.99), a 45% reduction from the mean pre-pain score. Forty-one percent of patients reported moderate/severe pain prior to receiving acupuncture, while only 15% indicated moderate/severe pain after acupuncture. CONCLUSIONS: Acupuncture may be a viable adjunct to pharmacological approaches for pain management after THR or TKR.

J Complement Integr Med. 2015 Jun 1;12(2):111-5. doi: 10.1515/jcim-2014-0055.

Trends in publications on complementary and alternative medicine in the medical literature.

Treister-Goltzman Y, Peleg R.

Abstract

BACKGROUND: Public interest in and demand for complementary and alternative medicine (CAM) services have increased in recent years throughout the Western world. The aim of the study was to assess trends in publications on CAM in the medical literature between 1963 and 2012 and to compare them with overall trends in publications on medical issues. METHODS: A search of the literature was conducted on CAM and integrative medicine using the PubMed and Google Scholar search engines with key search terms. RESULTS: Articles on CAM began to appear in the medical literature 50 years ago. Over the years there has been an increase in the number of publications. On PubMed the increase was from 15,764 to 144,288 articles from 1963 to 2012. In the decade between 1963 and 1972 publications on CAM comprised 0.81% of all the articles appearing in PubMed. Over the course of the 50 years, the percentage increased more than twofold to 1.92% from 2003 to 2012. On Google Scholar there were 27,170 citations related to CAM between 1963 and 1972. This increased to 2,521,430 between 2003 and 2012. CONCLUSIONS: Over the last 50 years there has been an increase in scientific publications on CAM in general, and on specific CAM treatments in particular.

Developing a Center for Integrative Medicine

Key Developmental Principles

• What’s in a name?
• Alternative words:
• Holistic, Wellness, Alternative, Complimentary, Health
• Our initial choice: The UCSD Center for Integrative Medicine
• Current changes in the field:
• Consortium for Academic Health Centers in Integrative Medicine

(CAHCIM)  Academic Consortium for Integrative Medicine and Health (ACIMH)

• National Center for Complementary and Alternative Medicine

(NCCAM) National Center for Complementary and Integrative Health (NCCIH)

• American Board of Integrative and Holistic Medicine (ABIHM) 

American Board of Integrative Medicine (ABoIM) and the Academy

• f Integrative Health and Medicine (AIHM)
• Our new name: The Center for Integrative Medicine and Health

UNITED STATES University of Arizona Scripps Center for Integrative Medicine Stanford University School of Medicine Sutter Health System University of California, Irvine University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Southern California University of Colorado Denver School of Medicine University of Connecticut Health Center Yale University School of Medicine University of Miami University of Hawaii at Mānoa Northwestern University Feinberg School of Medicine University of Chicago Pritzker School of Medicine University of Kansas Medical Center University of Kentucky Johns Hopkins University School of Medicine University of Maryland Boston University School of Medicine Harvard Medical School Tufts University School of Medicine University of Massachusetts Medical School Beaumont Health University of Michigan Allina Health, Abbott Northwestern Hospital Mayo Clinic University of Minnesota Rutgers Biomedical and Health Sciences University of New Mexico, School of Medicine Albert Einstein College of Medicine of Yeshiva University Columbia University Medical Center Icahn School of Medicine at Mount Sinai Duke University University of North Carolina at Chapel Hill Wake Forest University School of Medicine Cincinnati Children's Hospital Medical Center Cleveland Clinic The Ohio State University UH Connor Integrative Health Network University of Cincinnati College of Medicine Oregon Health and Science University Milton S. Hershey Medical Center Temple University School of Medicine Thomas Jefferson University University of Pennsylvania University of Pittsburgh Vanderbilt University MD Anderson Cancer Center, University of Texas Texas Tech University University of Texas Medical Branch University of Vermont College of Medicine University of Washington: UW Integrative Health Program Aurora Health Care* University of Wisconsin-Madison George Washington University Georgetown University School of Medicine Veterans Health Administration CANADA University of Alberta* University of Calgary McMaster University University of Toronto MEXICO Universidad Autónoma de Guadalajara Tecnológico de Monterrey School of Medicine

Academic Consortium for Integrative Medicine and Health

Key Developmental Principles

• An academic center must have all 4 academic missions:
• Clinical
• Educational
• Research
• Community Service
• Align and link with KEY institutional and national goals:
• Expansion of our Division’s Patient Centered Medical Home goals
• Institution’s goal of improving “patient experience” as part of

marketing and commitment to quality patient care

• the “Triple Aim” in US Healthcare (better care, better health
• utcomes, lower cost)

Key Developmental Principles

• Distributed “Integrative Medicine” Service – a “virtual center”
• Avoids large up-front costs of creating a “center”
• Supports true integration across the healthcare system
• However, such integration requires culture change in each

area

• Shared use of exam rooms, after-hours sessions, finding

highly qualified IM clinicians, use of students and residents

• Target populations:
• Chronic disease patients and well patients: i.e. everyone!
• Cancer
• Cardiovascular
• Metabolic (diabetes)
• Musculoskeletal / Pain

Key Developmental Principles

• Lead with most EB and in-demand services (OMT, acupuncture,

massage)

• Developed our billing model through benchmarking to price services

competitively and to be able to take revenue from multiple sources (insurance, cash payments, sliding scales, discounts and donors)

• Internal referrals are first priority (~150K UCSD patients)
• Target initial services: Primary Care, Cancer Center, OB-Gyn, Pain,

Orthopedics, Cardiovascular

• Educate peer faculty via as many methods as possible (Clinical Service

meetings, Jointly sponsored GR, Larger specialty-focused IM meetings)

• Identifying IM champions within each specialty
• All referrals and IM service documentation were put into our EMR
• External marketing to community
• We launched our classes as an excellent way to advertise, deliver

specific services (MBSR, healthy nutrition) and generate profit

Key Developmental Principles

• 5 major funding sources:
• Patient revenue (insurance and self-pay)
• Group classes
• Institutional support
• Philanthropy [for uninsured, for specific modality, for specific

diseases, for research]

• Grants / Contracts
• Do not underestimate the costs of start-up efforts
• Leadership and administrative support
• Mission-specific support
• Survey of Academic Consortium Member Centers: an average
• f 4.4 years and $345K to $2.3M, depending on scope/source, to

start up and become “self-sustaining.”

Research on Program Performance

Expected Program Break-Even

Year 1 Year 2 Year 3 Not Expected

Institutional support is necessary to ensure that the program will be able to operate effectively until break-even is reached. Many programs do not achieve revenue neutrality in the first years and about 55% never realize programmatic “break- even”. This largely depends on the definition of “break-even”. Perhaps a better definition is what level of resources is required to provide a given level of services across your institution and where do they come from.

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Brief History of the UCSD CIM Clinical Mission

• 2007 – interest expressed by two of our FM graduates and

discussion with Clinical and Hospital leadership. Their response: “We need to do this, but with quality!”

• 2007-2008 – open meetings to identify interest among staff and

faculty of UCSD Health System

• 2008-2010 – development of initial business plan and initial

commitment of $210K; link with Center for Mindfulness (2002)

• 2010 - Acceptance as 43rd member of Consortium of Academic

Health Centers for Integrative Medicine (ACIMH – 63 members)

• 2011-12 – Inaugural launch conference and commencement of

clinical services with general IM consultations, acupuncture and OMT in Family Medicine and classes in Mindfulness-based Stress Reduction and Natural Healing and Cooking

Brief History of the UCSD CIM Clinical Mission

• 2013-15 - Additional institutional funding commitment of

$200K, donor funding of ~$325K and grant/contract funding of ~$200K

• 2013- expansion of acupuncture to Women’s Health

Clinics, Moores Cancer Center & began Tai Chi classes

• 2014 - Inpatient pilot study, expansion of OMT into

Orthopedics and General Internal Medicine and addition of massage/energy therapies

• 2015 – energy and acupuncture into Pain Clinic, addition
• f Art Therapy and massage to Moores Cancer Center,

discussions with Cardiology and initiation of inpatient services on FM Inpatient Service

• Clinical expansion: steady/continuous

Brief History of the UCSD CIM Educational Mission

• Medical School – required and elective curriculum:
• New Curriculum (POM, PBL) (2012-15)
• Sessions of required lecture/small group introducing IM
• Incorporation of IM concepts in Problem Based Learning cases
• Introduction of “Mindful Practice” in POM small groups – MS1,2,3
• IM electives (2013-15)
• MS 1 & 2 exposure electives; MS3 2-wk. elective; MS4 4-wk. elective
• Residency: Integrative Medicine in Residency (2012-15)
• 200 hour Web-based curriculum with local experiential component
• >25 FM residents participating w/ recent expansion to IM/Geriatrics
• Weil Foundation grant funding x 4 years + local divisional/residency

support

Brief History of the UCSD CIM Educational Mission

• Faculty at UCSD
• Arizona Fellowship training of UCSD faculty – 2 so far (hired 2 others)
• Grand Rounds: Integrative GI Health; Integrative Cardiology
• Staff meetings, presentations, newsletter, email
• Collaborating on Fellowship development with AIHM
• Continuing professional education/CME events/conferences:
• Humanizing Health Care – Aug. 2011
• Integrative Oncology Conference – 2013
• MBSR Bridging the Hearts & Minds of Youth – Feb. 2012 and 2013
• MBSR Self-Compassion and Emotional Resilience – Sept. 2012
• Yoga in Medicine – Jan and July, 2015
• Tai-Chi train the trainer sessions 2014 and 2015
• Public education programs
• Community Meetings  regular Grand Rounds – 2011 - present
• Discussion Groups with UCSD Undergraduate Interest Group and UCSD

MS Holistic and Integrative Medicine Interest Group – 2012 to present

Brief History of the UCSD CIM Research Mission

• Convened all IM researchers at UCSD for the purposes of

communication, cross-fertilization, discussion of research trends, development of collaborative goals and projects (2011- present)

• Connected with IM researchers in San Diego and beyond who

wish to collaborate on IM research efforts (2011- present)

• Practice-based research beginnings
• Developed CIM Questionnaire in EMR (2011-12) with ~600 completed

so far (initial 200 assessed in 2014)

• Inpatient opinions about IM services (2014)
• Continuing monthly JC alternating with Seminar Series – 2012 
• Naming of Paul Mills, PhD – Director, Center of Excellence in

Research and Training in Integrative Health (0.5 FTE) - 2015

• Endowed Research Fund – Krupp CRT – active July, 2015
• Planning for faculty workshop on PBR – Dec. 5, 2015
• Launching of modality assessment PBR efforts – 2015

Practice Based Research

• Practice-based research effort:
• All CIM services are recorded in our EMR
• Uniform web-accessible patient intake form
• Special identification of all CIM patients in EMR for later data recovery

• 202 outpatients who visited the

UCSD Center for Integrative Medicine between July 2011 and May 2013 completed an intake questionnaire prior to being seen by an Integrative Medicine Physician.

• Patients were asked:

“What are your goals for, or what do you hope to accomplish, from this visit?”

• Patient’s responses were

qualitatively analyzed to derive the most common themes. Additional data regarding demographics and overall self- rated health were gathered.

Study Design

• This study highlights the

possibility that goals of care differ appreciably, even when patients’ self-rated health profiles are similar.

• Goals of care may in

fact be a key difference when determining personalized treatment plans.

• Longitudinal surveys

could be used to assess whether patients’ goals

• f care were met after

IM treatment. Conclusions & Future Directions Variable % n

Gender Female Male 63 37 125 75 Race/Ethnicity Caucasian or White Asian African-American Spanish or Hispanic Origin Other 73 10 6 4 7 145 20 12 7 15 Marital Status Married Never Married Divorced Living with a Partner Widowed Other 55 20 13 8 3 2 110 40 25 15 6 4 Mean Age = 49 (20-92); SD= 15; N = 199

Patient Characteristics

Very poor Poor Fair Good Very good Excellent

Overall, how would you rate your health

• ver the past four weeks?

Self-Rated Overall Health, n = 200 “I want a discussion with the doctor about what is wrong with me.” “[I hope to] discuss the option of acupuncture for my worsening phantom pain.”

11% 35% 54%

“I Hope to Find”: What We Can Learn From Analyzing Patients’ Goals In Integrative Medicine

Jayasree Sundaram, B.A., Lori P. Montross Thomas, Ph.D., Emily A. Meier, Ph.D., Andrea N. Trejo, Stacy Gomes, Ed.D., M.A.Ed., Laura Redwine, Ph.D., Paul Mills, Ph.D., Gene Kallenberg, M.D., Dilip V. Jeste, M.D., and Gordon Saxe, M.D., Ph.D.

Horrigan, B., Lewis, S., Abrams, D., & Pechura, C. (2012). Integrative Medicine in America: How Integrative Medicine Is Being Practiced in Clinical Centers Across the United States. Minneapolis, MN: The Bravewell Collaborative. AARP/NCCAM Survey Report (2011). Complementary and Alternative Medicine: What People Aged 50 and Older Discuss With Their Healthcare Providers. Washington, DC: National Institutes of Health. Montross, L.P., Depp, C., Daly, J., Reichstadt, J., Golshan, S., Moore, D., … Jeste, D.V. (2006). Correlates of Self-Rated Successful Aging Among Community-Dwelling Older Adults. American Journal of Geriatric Psychiatry, 14, 43-51.

References

This work was supported by the National Institute of Mental Health R25 grant MH 071544.

Acknowledgements

UC San Diego

Center for Integrative Medicine

“What’s Wrong With Me?” (n=19) “My hope is for increased well-being in all realms. I hope to find doctors who focus on the whole person and are informed on alternative and conventional medicine.” “Help Make Me a Better Person” (n=61) “I Know What’s Wrong With Me, But I Want a Different Treatment” (n=93)

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Brief History of the Community Collaboration Mission

• Established UCSD as a local leader in CIM efforts, serving

as a convener for the broader IM community in San Diego, and working collaboratively to affect advancement of IM.

Brief History of the Community Collaboration Mission

• 2010 to 2013 – Periodic meetings with interested

community collaborators

• 2011 Launch to present – periodic jointly sponsored IM

events both at UCSD and in the community

• 2012 to present – Involvement of community in Journal

Club/Seminar Series

• 2013 – Development of monthly Community Grand

Rounds

• 2013 – Development of Advisory Board
• 2015 – Practice Based Research workshop

Next Steps

• Confirm our name change to CIMH
• Solidify continuous institutional funding, identify significant

donors and expand of insurance coverage for IM services

• Continue clinical service expansion:
• Inpatient: expand to other services (OB, Pain, BMT, trauma),

continue nursing training and begin aroma therapy

• Outpatient: increase services to Moores Cancer Center and

expand to Cardiac Rehab., other outpatient clinics and our ER.

• Expand our practice-based research efforts
• Expand and evaluate our educational efforts

In Conclusion:

• The principles upon which we planned and executed our

CIM development were essentially sound and have stood the test of time.

• Our ultimate vision remains intact: to assist patients with

IM approaches to improve their healthcare, their health and their wellbeing wherever they are receiving treatment in our system.

• Continuous re-evaluation from the outset is necessary to

keep on track.

• This effort takes time and adequate financial support to get

from launch to institutionalization, but it’s worth the effort.