Led by Barbara Bokhour, PhD, QUERI EPCC-VA
examines the implementation and impact of VA’s transformation to a Whole Health system of care, which empowers and equips Veterans to take charge of their health and wellbeing.
Complementary and integrative health (CIH) therapies (i.e., acupuncture, yoga, and meditation) are increasingly being incorporated into healthcare policy and systems, including the VA healthcare system. This reflects a growing evidence base and increasing patient demand for non-pharmacologic and non-traditional healthcare options (Taylor et al, 2019). In 2017–2018, VA medical centers (VAMCs) offered an average of five CIH therapies, and VA policy now mandates coverage for eight evidence-based CIH therapies. Yet, while CIH therapy offerings are expanding, implementation challenges remain. New implementation practices can provide resources, create cultures of innovation, champion evidence-based practices, and encourage staff engagement, thereby creating a positive climate for innovation and practice implementation. In safety net settings, such as VA, this support may additionally help overcome financial and organizational constraints that challenge implementation.
Researchers sought to examine VA healthcare system leaders’ reasons for providing or withholding concrete support for CIH therapies in early-adopting VAMCs as part of QUERI’s Center for Evaluating Patient-Centered Care in VA (EPCC-VA). The study was led by Stephanie Taylor, PhD, who is currently the principal investigator for QUERI’s Complementary and Integrative Health Evaluation Center (CIHEC), and an investigator with HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP).
In a recent study of 3,346 Veterans, 52% used any of 26 CIH approaches, 44% used massage therapy, 37% used chiropractic, 34% mindfulness, 24% meditation, and 25% yoga. Overall, 84% said they were interested in trying and/or learning more about at least one CIH approach. (Taylor et al, 2019
This analysis included 12 executives and 34 leaders of key VA clinical services. Working closely with contacts (often CIH providers) at each site, investigators identified at least two local executive and department-level leaders from VA services that interfaced frequently with CIH, including primary care, mental health, physical medicine and rehabilitation, and pain treatment services. Study participants were recruited from VAMCs across the country in both urban and rural areas.
VA leaders’ decisions to provide or withhold support for CIH therapies were driven by considerations across multiple levels, including:
- Individual attitudes/knowledge, perceptions of evidence, and personal experiences;
- Interpersonal interactions with trusted brokers, patients, and loved ones, colleagues, and/or staff;
- Organizational concerns surrounding relative priorities, local resources, and metrics, quality, and safety; and
- System-level policies.
VA leaders were particularly influenced by individuals responsible for implementing CIH treatment strategies in their facilities. These trusted brokers were respected and spanned the boundaries between traditional providers and holistic services. Leaders entrusted them with CIH implementation, provided needed resources, and engaged with them to develop sustainable CIH programs for Veterans.
The following includes specific feedback from executives and leaders of key VA clinical services.
Individual level considerations
Individual considerations that influenced leaders’ decision-making included attitudes and knowledge regarding CIH, perceptions of the evidence, and leaders’ own experiences engaging in CIH therapies. Leaders expressed variable knowledge about CIH, ranging from expertise to limited awareness. Experiencing CIH therapies personally swayed many leaders’ decisions to provide support.
I had a personal experience, too, with yoga and other kinds of exercise because I hurt my back really bad a few years ago, [so] personally I knew that this worked. –Chief of Staff, Site 5
I’m a nurse, so I followed the medical model my whole life. As I’ve gotten older, I got more familiar with chiropractic, which was kind of the voodoo medicine back in the ’90s. It’s kind of come into its own. So it’s just, I think, part of an evolution of my own healthcare knowledge. –Assistant Director, Site 6
I have always been kind of a skeptic. [Until I] actually got to see some of it in action. I started actually going to acupuncture. I was doing yoga twice a week [at a recent federal leadership training]. To change a skeptic, you have to put them in there and show them what it’s going to do. It’s hard to say ‘Well, I love yoga, I support it,’ if you’ve never done something like that before. –Associate Director, Site 7
Interpersonal level considerations
Interpersonal interactions with others influenced leaders’ decision-making by reshaping attitudes, communicating evidence, demonstrating demand, and navigating barriers. For example, individuals delivering CIH and heading its implementation played a crucial role in leaders’ provision of support. Leaders highlighted these individuals’ abilities to develop programs and bridge communication between biomedical and holistic providers – and across different leaders.
[What matters is] having [a CIH lead] who’s got some oomph, some leadership experience and respect to champion these integrative approaches, ‘cause internists look at this very, you know, ‘woo woo.’ –Primary Care Chief, Site 7
I have to tell you that Dr. (CIH contact), she is very special; she is really a most dedicated professional [and] has really grown the program. [She] is very credible. – Participant, Site 6
It seems a little far-fetched, (but) when Dr. (chiropractor) got here he taught us, scientifically what’s going on. He can speak intelligently about what he does. It was not hocus pocus. –Rehabilitation Chief, Site 7
Organizational level considerations
Organizational considerations, including organizational priorities, availability of resources, and quality/safety metrics, influenced leaders’ support for CIH. Leaders supported CIH when it aligned with organizational priorities, with chronic pain and opiate de-prescribing being particularly salient. For others, CIH was appealing when perceived as a mechanism to address other operational priorities such as ‘‘employee engagement, operational excellence, and cultural transformation.’’ Limited resources also influenced organization choices.
[There are] many different moving things. Integrative health – it’s not top-of-the-line right now. But pain is, and primary care. That’s why [CIH is] top there. –Chief of Staff, Site 1
I was told, ‘How can we offer yoga when people aren’t getting their colonoscopies?’ The director now has so many eggs in the basket that she can’t fry, she’s not going to start yoga, or acupuncture. –Women’s Health Director, Site 1
So it was really, it was decisions about resources. When you go to a budget hearing and your ICU – if beds shut down because you don’t have enough nurses and that’s on the list and then [asking for funding for] the integrative medicine nurse is on the list, what wins? The integrative medicine nurse kept losing because of these other pressing clinical needs. –Chief of Staff, Site 5
System level considerations
Organizational policy, bureaucracy, and interorganizational networks comprised outer context considerations that influenced leaders’ decision-making. For some leaders, legislation, VA policy, and initiatives arising from policy prompted CIH implementation and facilitated buy-in.
The demand for integrative health services has dramatically grown, directly related to the opioid safety [policy] and trying to reduce the use of long-term opioid therapy. –Chief of Staff, Site 3
There was this [national] memo that also came out that every [VA] facility should have at least two or three CIH modalities. Acupuncture is, of course, one of the CIH modalities, and we thought, you know, this would be a good way of getting [acupuncture] incorporated. –Pain Chief, Site 1
I would love to see how people at other VAs are integrating chiropractic care into their facility, and any other good examples of how the programs are working. I think that’s one of the advantages of working in VA, because [of] the ability to share information between VAs. It’s definitely an advantage of working in a system. You can “steal” the best ideas from all the other VAs and try to incorporate them into yours. –Primary Care Chief, Site 5
These findings provide a more nuanced understanding of leaders' role in implementation and their motives for providing or withholding support for new practices. As healthcare organizations, researchers, and practitioners seek to implement new practices, they should consider the multifaceted and multilevel nature of leaders' considerations and how these inform implementation. Such understandings can provide insight into sources of leverage to garner support.
As healthcare systems continue to seek leaders’ support for complementary and integrative health treatment choices, implementation strategies must attend to broader organizational priorities and system-level challenges beyond individual characteristics alone. Anchoring implementation efforts in what matters most to leaders can foster their provision of support. In addition, selecting respected individuals to lead implementation can raise legitimacy.
*This study was funded by VA’s Office of Patient-Centered Care and Cultural Transformation (OPCC&CT), and the Quality Enhancement Research Initiative (QUERI).
Bolton R, Bokhour B, Dvorin K, Wu J, Elwy AR, Charns M, and Taylor S. Garnering support for complementary and integrative health implementation: A qualitative study of VA healthcare organization leaders. The Journal of Alternative and Complementary Medicine. 2021;27(1):581-588.