Integrative Medizin und Gesundheit

3.3 Conclusion

This chapter has described how on a popular movement for an alternative to the dominant brand of medicine became known as “integrative health and medicine” and began to penetrated into and shift the kind of medicine people would find in the nation’s mainstream delivery organizations. Importantly, the majority of services of integrative medical doctors, of naturopathic physicians, chiropractors, acupuncturists, yoga therapists and others used by people in the US continue to be directly accessed in communities, outside of the dominant payment and delivery system. They remain “alternatives,” chosen by patients for their care and by practitioners because they believe them to have greater value in health and medicine than the mainstream of US medicine accords them. The integration of these services is thus typically engaged by each individual, often with an integrative practitioner’s guidance, and coordinated to greater and lesser extent with conventionally practicing physicians. Communication with conventional practitioners about such services remains low.

It is a paradoxical truism that, while the movement has come a long way, at the same time it has only just begun. In mid-2020, a new initiative was announced that grew out of this activity and is expected to leverage change toward integrative models more rapidly. The wealthiest woman in the world, Alice Walton, partnered with the former Veterans Administration “whole health” leader, Tracy Gaudet, MD, to found the Whole Health Institute. The announce plan was, among other things, to take from the knowledge and models developed inside the VA and spread them through civilian health and medicine. To lead change in hospitals and medical delivery organizations, Gaudet brought in Lori Knutson, RN, BC-HN, the professional known to have the most experience in the US in successfully building integrative and wellbeing programs in major medical delivery organization.

While a full plan is only emerging, a sense of its scope can be seen not only in Knutson’s hiring but also in two announced initiatives (Weeks 2020b). One is partnership with Whole Health ED, an organization targeting placement of integrative health-oriented programs in K-12 education. Among these: mind body programs, experiences in nature, creative arts therapies, healthy eating, school vegetable gardens, and more. The other is a plan to create a new medical school to be shaped around fostering whole health values and principles. Walton has shared interest in influencing health and medicine via Whole Health Institute initiatives throughout the US, and globally. The possibilities are grand when a yet unannounced portion of Walton’s $ 54-billion net worth will be committed. The transformational ideas of the Sixties, carried by consumers and organizers of a grassroots movement, appear to have expansive opportunities for continuing convergence, and leadership, ahead.

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Dr. h.c. John Weeks

John Weeks has served since 1983 in multiple leadership roles in the emergence and growth of field of integrative health and medicine including as a writer, organizer, keynote speaker, executive director, adviser, and consultant. He has worked with agencies and institutions such as the World Health Organization, National Institutes of Health, American Hospital Association, Pan American Health Organization, the Washington State Office of the Insurance Commissioner on integration strategies. For 25 years his Integrator newsletter and blog served as the principal chronicle of the field. From 2016–2020, he served as Editor-in-Chief of JACM-Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine) and prior columns in other media. He attended Stanford University for 3 years. Four institutions have granted him honorary doctorates.

4 Patientenzentrierte Versorgung

Jördis Maria Zill, Stefan Zeh und Isabelle Scholl

Zusammenfassung

Patientenzentrierung wird heute als zentrales Element einer modernen Gesundheitsversorgung gefordert. Auch die Integrative Medizin stellt sich hinter diese Prämisse bzw. sieht diese als Teil des Ergebnisses der Umsetzung eines integrativen medizinischen Ansatzes.

Unter dem Begriff Patientenzentrierung wird ein Ansatz verstanden, bei welchem die Patientin oder der Patient mit ihren oder seinen individuellen Präferenzen, Bedürfnissen und Werten im Mittelpunkt steht und damit in jeder Phase der Gesundheitsversorgung die Entscheidungen lenkt. Heutzutage wird Patientenzentrierung im Gegensatz zum traditionellen krankheitsorientierten Ansatz als Merkmal und Voraussetzung einer qualitativ hochwertigen Gesundheitsversorgung betrachtet. Gleichzeitig wird Patientenzentrierung auch als fundamentaler Bestandteil für die Arbeit in der Integrativen Medizin beschrieben.

Wissenschaftliche Studien weisen auf die hohe Relevanz von Patientenzentrierung für gesundheitsbezogene Outcomes hin. Dabei erschweren jedoch unterschiedlich verwendete Definitionen von Patientenzentrierung die Vergleichbarkeit der Studien. Ein integratives Modell zur Patientenzentrierung fasst bestehende Definitionen und Konzepte zusammen und kann damit Orientierung für weitere Forschungsarbeit und Ansatzpunkte in der Umsetzung liefern.

Die Umsetzung von Patientenzentrierung kann sowohl auf individueller Ebene (des einzelnen Leistungserbringers oder des einzelnen Patienten) als auch auf der Ebene von Gesundheitseinrichtungen und auf übergeordneter Ebene des Gesundheitssystems erfolgen. Derzeitige Barrieren der Umsetzung beinhalten insbesondere ein eingeschränktes Verständnis von Patientenzentrierung bei den einzelnen Behandlern, einen mangelnden Eingang des Konzepts in die Führungsebene und in die Organisationskultur von Gesundheitseinrichtungen und Vergütungssysteme, die durch Fehlanreize einer Förderung entgegenwirken.

Dennoch ist in den letzten 20 Jahren konsequente Förderung von Patientenzentrierung, wie zum Beispiel durch das Bundesministerium für Gesundheit (BMG), ein Wandel in der Gesundheitsversorgung in Deutschland zu beobachten. Dies zeigt sich konkret in mehreren Forschungsschwerpunkten zu Patientenzentrierung, in dem politischen Einbezug von Patientenvertreterinnen und -vertretern und in der Etablierung verschiedener Aktionsbündnisse zur Umsetzung von patientenzentrierten Aktivitäten.

Insgesamt ist das Thema Patientenzentrierung in seiner Relevanz unbestritten, jedoch fehlt es an einer flächendeckenden koordinierten Umsetzung. Dabei ist es Aufgabe von Wissenschaftlerinnen und Wissenschaftlern, die Wirksamkeit von Interventionen zu Patientenzentrierung zu untersuchen und Ergebnisse zusammenzuführe, genauso braucht es die Bereitschaft von Gesundheitseinrichtungen, neue Strukturen zu etablieren, um Patientenzentrierung in der Organisationskultur und auf Ebene der Individuen erlebbar zu machen. Gleichzeitig braucht es eine Etablierung von kontinuierlichen Qualitätsüberprüfungen der erlebten Patientenzentrierung aus Patientensicht sowie eine konsequentere Verankerung von Patientenzentrierung auf der Systemebene, zum Beispiel in Versorgungsleitlinien und Vergütungsmodellen.

Summary

Patient-centeredness is in demand as a core element of modern healthcare. Integrative medicine endorses this premise and considers it as part of the successful implementation of an approach in Integrative Medicine.

The term patient-centeredness describes an approach that puts the patient’s individual preferences, needs, and values first and lets this prioritization guide clinical decisions in all areas of healthcare delivery.

Today, patient-centeredness is seen as a countermodel to the traditional disease-centered approach. It is a key attribute and requirement of high-quality care. It is also described as a fundamental part of Integrative Medicine.

Study results indicate the association of patient-centeredness with health-related outcomes. However, since various definitions of patient-centeredness have been employed, the comparability of the studies is fairly limited. An integrative model of patient-centeredness comprises existing definitions and concepts and can, therefore, be used for guiding future research and implementation.

Patient-centeredness can be implemented at the level of individual health professionals and patients, at the level of individual healthcare institutions as well as at the level of the health care system.

Current barriers to its effective implementation are, in particular, the limited understanding of patient-centeredness of the individual health professionals, and the lack of leadership-level championing for the concept as well as within the organizational culture of healthcare institutions. Moreover, current payment models disincentivize the implementation of patient-centeredness.

Nevertheless, there is a visible change in healthcare delivery in Germany, mostly due to the consistent promotion of patient-centeredness, for example, from the Federal Ministry of Health (German: Bundesministerium für Gesundheit [BMG]).

This can be witnessed by the numerous funding priority-programs on patient-centeredness, the involvement of patient representatives at health policy levels, and the establishment of various alliances for the implementation of patient-centered activities.

Overall, the topic of patient-centeredness is undoubtedly very relevant, however, even though nationwide coordinated implementation is still lacking.

Research on the effectiveness of interventions to foster patient-centeredness need to go hand in hand with the willingness of healthcare institutions to establish new structures to make patient-centeredness perceptible within the organizational culture, and on an individual level. At the same time, we need the continual patient-reported quality measurement of experienced patient-centeredness. Last but not least, patient-centeredness needs stronger implementation at the health care system level, for example, within national clinical practice guidelines and payments models.

4.1 Einleitung

Der Begriff Patientenzentrierung (engl. patient-centeredness) oder der im deutschen Sprachgebrauch häufiger verwendete Begriff Patientenorientierung wird heutzutage in den meisten Beschreibungen eines qualitativ hochwertigen Gesundheitswesens verwendet. Aber was verbirgt sich eigentlich hinter diesem Schlagwort? Dieses Kapitel gibt einen Überblick zur Entstehung, den Inhalten und der Relevanz des Konzeptes, sowie zum aktuellen Stand der Umsetzung in der Versorgung und zur Bedeutung von Patientenzentrierung in der Integrativen Medizin.

Anfang dieses Jahrtausends benannte das damalige Institute of Medicine (IOM) (heute: National Academy of Medicine [NAM]) Patientenzentrierung als eine von sechs Säulen zur Definition von Qualität im Gesundheitswesen und brachte damit das jahrzehntealte Konzept wieder zurück auf die Agenda (Berwick 2002; Committee on Quality of Health Care in America – Institute of Medicine 2001). Bereits in den 60er-Jahren beschrieb die Psychoanalytikerin Enid Balint (1969) Patientenzentrierung als das Verständnis des Patienten als einen einzigartigen Menschen. Der Mediziner George L. Engel (1977) ergänzte das biopsychosoziale Modell, nach welchem kulturelle, soziale und psychologische Faktoren, als auch der Kontext des Versorgungssystems, mit in Diagnosestellung und Behandlung einbezogen werden sollten.

Der Quadruple-Aim-Ansatz (Bodenheimer u. Sinsky 2014) in Anlehnung an Berwick et al. (2008) fordert die Konzentration auf vier Ziele zur Verbesserung des Gesundheitswesens:

1. bessere Patientenerfahrungen in der Gesundheitsversorgung,

2. bestmöglicher Gesundheitsstatus für alle Bevölkerungsgruppen,

3. höhere Wirtschaftlichkeit und

4. bessere Arbeitsbedingungen und Wohlbefinden der Leistungserbringer.

Die Verbesserung der Patientenzentrierung nimmt im ersten Ziel dieses viel beachteten Konzeptes eine zentrale Rolle ein.

Auch in Deutschland hangelte sich das Konzept der Patientenzentrierung hoch auf die Agenda. Seit dem Jahr 2000 werden die gesundheitspolitischen Rahmenbedingungen für mehr Bürger- und Patientenzentrierung weiterentwickelt. So wurden in den letzten zwanzig Jahren verschiedene Förderschwerpunkte zur Patientenorientierung ins Leben gerufen.

Auf legislativer Ebene wurden 2013 die Rechte der Patienten sowie der Behandelnden in Hinblick auf Patientensicherheit, Patienteninformation und -beteiligung im „Gesetz zur Verbesserung der Rechte von Patientinnen und Patienten“ (Patientenrechtegesetz) verankert (BMG 2013).