Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency,... Abstract Introduction Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and “hands on” clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program’s implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings. INTRODUCTION U.S. adults spend an estimated $30 billion out-of-pocket on complementary and integrative medicine (CIM) approaches each year, over half of which is attributed to back pain treatments.1 Results from the 2002–2012 National Health Interview Survey signifies a growing use of CIM over the past decade.2 The resolute demand for CIM therapies has, in turn, engaged stakeholders, health systems, and policy makers to create complex solutions for the changing market.3 The Military Health System (MHS) and Veterans Health Administration (VHA) are no exceptions. CIM (e.g., chiropractic/osteopathic manipulation, acupuncture, yoga, massage, biofeedback, mind-body therapies) use significantly increased among active-duty service members (SM) from 2010 to 2015, with most military installations providing at least one type of CIM therapy.4 Although Veterans’ and SM utilization of CIM therapies has increased, and at higher rates than their civilian counterparts,5 CIM accessibility remains variable. CIM services today are largely dependent on location and referring provider attitudes,4,6 and are not covered by health insurance. Given the utility of CIM for the treatment of pain,7–12 combined with the salience of pain-related conditions and problems (e.g., opioid misuse) in the MHS and VHA,13–19 it is essential to bolster CIM accessibility for non-pharmacological pain treatments for SM and Veterans. The Department of Defense (DoD) Pain Management Task Force (PMTF)20 partnering with the VHA National Pain Management Program21,22 recognize the potential value of CIM therapies as effective supplementary therapies to reduce dependence on opioids for pain management within the VHA and MHS. Notwithstanding this recognition, routine access to CIM services within the MHS and VHA continues to be hampered by barriers to this care. CIM therapies are not covered by the DoD health insurance, TRICARE, and there is an inconsistent pattern of CIM therapies offered across military installations.23,24 Studies of VHA providers and patients indicate that both lack information regarding which CIM therapies are available.25,26 Furthermore, providers may not necessarily know how CIM treatments can be integrated early into pain management plans.25,26 Additionally, both military providers and SM are subject to regular job relocations, whereby providers and SM must seek information regarding CIM options with each relocation. Though research has yet to quantify the degree to which relocation impedes CIM access, previous findings indicate discontinuity of care is associated with increased hospitalizations27 and lower quality care.28 Therefore, SM may invariably be less likely to receive consistent CIM services due to the transient nature of military life, as well as when they transition to civilian or VHA medical care after military service. For SM and Veterans who respond favorably to CIM therapies and are satisfied with such treatments, service discontinuation may negatively impact health across time. Lastly, research suggests challenges in credentialing and hiring CIM providers, as uniform position descriptions and requisites are lacking.25 Taken together, increasing CIM accessibility involves all echelons of the healthcare system, ranging from patients to policy makers. To address barriers to CIM access, collaborators from the VHA and MHS developed, implemented, and evaluated a systems-wide auricular acupuncture training program aimed at educating a variety of providers (e.g., medics and corpsmen, nurses, physical therapists, physicians) in a protocol-driven auricular acupuncture technique called battlefield acupuncture (BFA). BFA is a simple and standardized auricular acupuncture protocol in which semi-permanent needles are placed at specific points on the exterior auricle of the ear, where they remain for up to several days.29 In a review of randomized control trials, auricular acupuncture provided significant analgesia over sham or control interventions in 12 of 15 studies and across several pain conditions with one trial showing mixed results, and two trials showing no treatment differences between auricular acupuncture and electroacupuncture or general acupuncture.30 BFA does not require advanced acupuncturist credentialing, is utilized by MHS medical professionals for a variety of conditions and symptoms, and training is open to a number of provider types within the MHS. However, robust randomized clinical trials examining BFA efficacy, including studies comparing BFA to other forms of auricular acupuncture, have yet to be completed and data is limited to small trials.31,32 After weighing the evidence of auricular acupuncture, including gaps in BFA-specific studies, and implementation qualities noted to be favorable,33 the BFA-protocol for auricular acupuncture was selected as a feasible vehicle to promote CIM exposure and accessibility across health systems. The project was further tasked to sustain the BFA training system and to expand acupuncture availability by assisting MHS and VHA physicians in completing an accredited 300-hr medical acupuncture program and becoming local and regional faculty for training providers in BFA. In terms of medical acupuncture, meta-analyses of patients with chronic pain indicate acupuncture improves functioning and reduces pain to a greater degree than no treatment and sham treatments, albeit the effects are short-term.11,34–37 Moreover, reported pain reduction is similar across a number of conditions, such as back and neck pain, osteoarthritis, and chronic headaches,35 and across different acupuncture styles.38 The generalizability of treatment effects across different pain-related conditions provided further indication that a medical acupuncture training program would also have broad applicability across different clinics and patient populations. Taken together, the present evaluation describes the Acupuncture Training Across Clinical Settings (ATACS) curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. METHODS Training Sites BFA training site selection was structured at the beginning of the project to ensure trainees had the ability to provide treatment within their practice locations. Sites were selected based on a combination of several factors, including: presence or absence of a holistic center, pain management clinic, a VA site within 50 miles to a DoD site (or vice versa), medical acupuncturist(s), potential BFA trainers/providers, administrative support, IT support, and research assets. Also considered were the types of clinical populations served; the type of VA facility, whether the site was a joint VHA-military site, the estimated cost of training, and the degree of command support. After the project team rank ordered a list of 192 potential sites based on these factors, a representative set of MHS and VHA sites were selected, including 15 VAs, 20 Air Force, 20 Army, and 15 Navy training sites. As training progressed across sites, so did interest from other MHS and VHA clinical sites. Thereafter, site selection was driven mainly through interested parties asking for training, per site leadership approval, and the availability of assets to complete training. Training sites were required to have a designated space in which training could occur during a specified time, for preferably more than 20 trainees. BFA Trainees BFA trainees were recruited at each training site utilizing a variety of methods. Because each MHS and VHA site was unique in aspects ranging from the type of clinic or medical specialization requesting BFA training to credentialing differences, trainee recruitment was site-specific, and no overarching, formal recruitment plan was needed. Providers who were interested in completing the BFA training were asked to complete an online registration via a Research Electronic Data Capture survey. As part of registration, potential trainees were informed that their “responses will be added to those of other participants and reported in the aggregate to a wider audience.” Eligible providers are shown in Table I. Table I. Eligible Providers for Battlefield Acupuncture Training. Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  Table I. Eligible Providers for Battlefield Acupuncture Training. Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  BFA Faculty BFA faculty led the BFA trainings. Faculty were required to have completed the BFA training, in addition to completing a 300-hr medical acupuncture course or equivalent training, or having demonstrated proficiency in conducting and teaching a BFA course. As the project and BFA training interest expanded, the demand for additional BFA faculty became significant. As a result, the project dedicated resources to training additional providers in medical acupuncture. BFA Provider Training Content and Structure BFA provider training content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts (SMEs) and feedback from providers who completed BFA training. Course content was developed to be applicable to the MHS and VHA environments. Training included a 4-hr didactic and “hands on” clinical training program. Course objectives were to: review acupuncture history, clinical significance and evidence for its use; understand patient selection criteria; provide educational information for patients regarding acupuncture; obtain and document consent; gain proficiency in needling technique (e.g., needle locations, needle placement); identify, understand, and convey post-procedure instructions and precautions; correctly complete clinical charting and Electronic Health Record (EHR) coding to include coding of the encounter; and obtain appropriate credentialing. Lectures, videos, demonstrations, and hands-on practice with both silicone ears and live models ensured trainees had adequate opportunities to understand and administer BFA through a variety of teaching methods. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Each training course concluded with the written exam. A course evaluation was completed at the conclusion of the training. Surveys and Data Collection After completing the online registration, which included questions assessing demographic and clinical practice aspects, trainees attended the 4-hr BFA training at their respective sites. At the end of the training, they were asked to complete a course evaluation. Trainees were asked the degree to which they agreed with the statement “I would recommend this training to a colleague,” using a 5-point Likert scale (strongly disagree to strongly agree). They were also asked to provide their overall rating of the trainer and BFA course on a 5-point Likert scale (not effective to very effective). At 1-mo post-training, trainees were asked to complete an online follow-up assessment. In the follow-up assessment, trainees were asked to report their current clinical BFA use (use, do not use), number of patients they administer BFA to per week (none, 1–10, 11–20, 21–30, 31–50, >50), conditions treated with BFA (headache, neck/shoulder pain, back pain, joint pain, neuropathic pain). Questions assessed provider satisfaction with BFA as a pain treatment on a 4-point Likert scale (quite dissatisfied, indifferent/mildly dissatisfied, mostly satisfied, very satisfied) and the degree to which their opioid prescribing habits changed since BFA training (greatly increased, somewhat increased, no change, somewhat reduced, greatly reduced). Lastly, trainees were asked to rate the degree to which a challenge or obstacle impeded their delivery of BFA treatment to patients. Scores were placed on a 5-point Likert scale ranging from 1 (low challenge) to 5 (high challenge), and the 16 challenges were ranked from highest to lowest challenge. RESULTS BFA Trainees From January 2014 to August 2016, 2,712 healthcare providers completed an ATACS training program. They were on average, 41-yr old, (SD = 12 yr), and nearly equally split by gender (51% male, 49% female). Training locations are depicted in Figure 1. Most providers had an MD or DO degree (44%). Providers reported a range of medical specialties, most common of which included family medicine (27%) and internal medicine (13%). Most providers reported practicing their specialty less than 5 yrs (34%) or 5–10 yr (20%) and 68% indicated they saw more than 10 patients for pain-related conditions each week. Finally, only 28% indicated acupuncture (11% auricular acupuncture, 19% BFA, 5% licensed acupuncture, 8% medical acupuncture) was available at their practice locations. FIGURE 1. View largeDownload slide Battlefield Acupuncture training site locations within the USA. FIGURE 1. View largeDownload slide Battlefield Acupuncture training site locations within the USA. BFA Faculty After completing specialized training, 113 providers (49% men, 51% women) were approved to be BFA training faculty. Like BFA trainees, most had an MD or DO degree (48%). Providers had a background in many medical specialties, the most common of which were family medicine (32%) and internal medicine (12%). The majority treated more than 10 patients each week for a pain-related condition (71%). Approximately 32% indicated acupuncture (11% auricular acupuncture, 25% BFA, 4% licensed acupuncture, 5% medical acupuncture) was available at their practice locations. BFA Trainee perspectives Course-evaluation surveys were administered at the end of BFA training. Providers rated the training favorably such that 99% indicated they would recommend the training to a colleague, 99% rated their training instructor as being effective or very effective, and 99% rated their overall training as effective or very effective. At 1-mo post-training, 553 providers (20% of all program participants) completed a follow-up survey. Of these providers, 160 (29%) reported using BFA in their own clinical practice. The majority of providers who used BFA reported providing BFA to 1–10 patients each week (94%) and were satisfied with BFA as a pain treatment (92%). Lastly, 194 providers rated the extent to which their opioid prescribing habits changed since BFA training. The majority (75%) reported no prescribing behavior changes since training. The remaining respondents indicated that they somewhat reduced (18%) and greatly reduced (6%) their opioid prescribing. One respondent indicated that their opioid prescribing had greatly increased since training. In the 1-mo post-training assessment, providers were asked to rate the degree to which a particular challenge or obstacle impeded their delivery of BFA treatment to patients. Of the 16 noted challenges, lack of defined BFA privileging standards at the provider’s practice location, and lack of a supervisor with BFA privileges were the highest rated challenges. Whereas lack of BFA skills confidence, lack of sufficient guidance and planning to conduct BFA treatment, and patient interest in BFA were the lowest rated challenges. Rated challenges are shown in rank order in Table II. Table II. Provider Challenges to Using Battlefield Acupuncture. Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Each challenge was rated on a scale from 1 (low) to 5 (high) level of challenge. Table II. Provider Challenges to Using Battlefield Acupuncture. Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Each challenge was rated on a scale from 1 (low) to 5 (high) level of challenge. DISCUSSION In the present cross-agency project, 2,712 medical providers were trained to deliver BFA, a standardized auricular acupuncture protocol. During the course of the project, enthusiasm for additional trainings at various MHS and VHA sites outpaced the original projections and necessitated training more faculty members to deliver auricular acupuncture trainings. When the program ended, over 100 providers became faculty members to help sustain auricular acupuncture availability within the MHS and VHA. Active-duty MHS providers are more transient than their civilian counterparts and experience job relocations on a regular basis. Overall, gaps in CIM care and altogether discontinuation may occur due to lack of trained providers within the MHS. When a CIM provider relocates, a military treatment facility may no longer be able to provide the same treatments to patients. By increasing the number of faculty within the MHS, not only are the active-duty faculty members able to train auricular acupuncture at new practice locations to prevent a single-provider/unique-treatment situation, but auricular acupuncture is proliferated as faculty move to military treatment facilities across the MHS. However, this is tempered with the fact that if, for example, a medical acupuncturist leaves a military treatment facility, the MHS does not require a medical acupuncturist to be placed or trained within that same military treatment facility. Thus, the Air Force Surgeon General recommended auricular acupuncture to be an accessible treatment at all Air Force military treatment facilities. Within the VHA, several steps were taken to create a “sustainment” program for ATACS.22 First, the auricular acupuncture training program was incorporated in the VHA’s Pain Management Mini-Residency, which also includes a follow-up preceptorship. Second, the VHA created an Acupuncture Community of Practice for acupuncture trainees and practitioners, with monthly seminars and an online resource library on VA Pulse to ensure providers could access ATACS information and training materials. Third, primary care-based acupuncture and other CIM treatments are component of the VHA’s Opioid Safety Initiative39 and National Pain Strategy.40 Taken together, sustaining auricular acupuncture treatment availability within the VHA was bolstered by increasing the number of faculty, educational opportunities, and resources available to providers. There was a significant barrier to obtaining privileges to administer auricular acupuncture within their practice locations. This difficulty was identified early in the project based on provider and trainee feedback. Within both agencies, there was a lack of uniformity to privileging. Additionally, there were identified challenges due to lack of policy on which providers could administer BFA. In part, this was also due to differences in state-level policies regarding acupuncture treatment and provider licensing. Presently, there is no federal medicine policy on the use of acupuncture within government healthcare facilities. Thus, as part of the ATACS program implementation, developers and stakeholders responded to trainee feedback by examining privileging procedures in both the MHS and VHA. Further, a review of policy regarding the administration of BFA by non-privileged providers (e.g., medics, RN) was performed. In this cross-agency exploration, MHS and VHA members worked to create credentialing and privileging guidance that would maximize availability of acupuncture services while ensuring appropriate federal standards for medical diagnosis and treatment were maintained. This was accomplished through the establishment of a tiered system where non-prescribing healthcare providers could perform the BFA-protocol auricular acupuncture under the supervision of a privileged provider. An example of the proposed tiered system is provided in Table III. Implementation of this policy remains under review by both the VA and DoD at this time. Table III. Proposed DoD Tiered Acupuncture Services Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Level 2 protocols include BFA, National Acupuncture Detoxification Association, Auricular Trauma, and/or Lumbar Pens. Table III. Proposed DoD Tiered Acupuncture Services Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Level 2 protocols include BFA, National Acupuncture Detoxification Association, Auricular Trauma, and/or Lumbar Pens. The original programmatic goals of ATACS were achieved, surpassed, and expanded. The program illuminated several challenges that were beyond the scope of the project. First, the lack of specific billable codes and consistent charting for CIM therapies makes it difficult to track, monitor, measure, and study the use of CIM modalities within a pragmatic context. Second, privileging across the MHS and VHA is highly variable, and though progress was made in this area for individual locations, not all trainees were able to administer the standardized auricular acupuncture protocol at their practice locations. Further, there are still no policies within the Federal system addressing the practice of various CIM modalities by non-privileged providers. Third, there is no designated department for CIM practice within the DoD. Many federal clinics provide CIM therapies for a variety of conditions, but do not have a unifying body to guide implementation and steer policy. As such, there is not a centralized directory of providers who administer CIM techniques across the agencies. Therefore, an active-duty MHS patient who finds benefit in a particular CIM may face undue barriers when attempting to find similar services at his/her new DoD facility or VHA location after relocating to a new DoD facility or after transitioning to VA care. The challenges identified in this project may provide valuable insight into present obstacles to CIM practices and assist with CIM implementation policies within the MHS and VHA. Further federal medicine research evaluating the impact of this acupuncture approach on beneficiary satisfaction and healthcare costs is warranted. The present ATACS program had a number of strengths. First, this was a cross-agency exercise with a wide-spread CIM training program (acupuncture). Second, this program was timely in light of the ongoing opioid crisis41 because it provided a non-opioid, non-pharmacological treatment for pain. Third, the training format, structure, and organization made auricular acupuncture implementation not only feasible, but also paved the road for future evaluation and possible implementation of other wide-spread CIM training programs. The project showed that a standardized auricular acupuncture treatment can be integrated into the clinical work flow, despite many challenges. Fourth, provider training in BFA was shown to be beneficial by addressing the need for more acupuncture trained providers in response to the increased CIM utilization among active-duty and veteran SM. The project suggested that a significant number of provider types can be trained in a standardized CIM treatment protocol, with the potential to reach a wider patient population. Fifth, the project goals and outcomes were consistent with the Institute of Medicine recommendations for health profession schools to include CIM as part of the standard curriculum.42 As a result of the project, the VHA included BFA training in their Pain Mini-residency and follow-up preceptorship. Although not assessed during this project, the experience gained by federal medicine providers with this simple CIM auricular acupuncture technique could encourage additional exploration of CIM generally in Federal healthcare systems. In light of these strengths, there are limitations to the ATACS program and its evaluation. First, outcome data are highly limited as the provider response rate to the follow-up surveys was low and patient perspectives (e.g., satisfaction with auricular acupuncture treatment) were not obtained. Combined with non-uniform privileging, as well as variability in coding, it is difficult to draw meaningful conclusions regarding the pragmatic impact of ATACS and its cost-effectiveness within the MHS and VHA. However, with improved and uniform procedures, future studies can examine aspects of clinical impact and cost-effectiveness of auricular acupuncture, as well as other CIM techniques, across both agencies. Overall, the ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program’s implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings. Funding Joint Incentive Fund (JIF) from the Departments of Defense and Veterans Affairs (Award #: HU001-14-1-0002). Acknowledgments Elyse Greenberg, RN, Lac, RYT; Yolanda S. Williams, MPH; Megan Vaughan, RN; Jacklyn Talley. REFERENCES 1 Nahin RL, Stussman BJ, Herman PM: Out-of-pocket expenditures on complementary health approaches associated with painful health conditions in a nationally representative adult sample. J Pain  2015; 16( 11): 1147– 62. Google Scholar CrossRef Search ADS PubMed  2 Clarke TC, et al.  : Trends in the use of complementary health approaches among adults: United States, 2002–2012. Natl Health Stat Report  2015; 79: 1– 16. 3 Herman PM, Coulter ID: Mapping the health care policy landscape for complementary and alternative medicine professions using expert panels and literature analysis. J Manipulative Physiol Ther  2016; 39( 7): 500– 9. Google Scholar CrossRef Search ADS PubMed  4 Williams VF, Clark LL, McNellis MG: Use of complementary health approaches at military treatment facilities, active component, U.S. Armed Forces, 2010–2015. MSMR  2016; 23( 7): 9– 22. Google Scholar PubMed  5 Goertz C, et al.  : Military report more complementary and alternative medicine use than civilians. J Altern Complement Med  2013; 19( 6): 509– 17. Google Scholar CrossRef Search ADS PubMed  6 Jou J, Johnson P: Nondisclosure of complementary and alternative medicine use to primary care physicians: findings from the 2012 national health interview survey. JAMA Intern Med  2016; 176( 4): 545– 6. Google Scholar CrossRef Search ADS PubMed  7 Cramer H, et al.  : A systematic review and meta-analysis of yoga for low back pain. Clin J Pain  2013; 29( 5): 450– 60. Google Scholar CrossRef Search ADS PubMed  8 Ward L, et al.  : Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: a systematic review and meta-analysis. Musculoskeletal Care  2013; 11( 4): 203– 17. Google Scholar CrossRef Search ADS PubMed  9 Sielski R, Rief W, Glombiewski JA: Efficacy of biofeedback in chronic back pain: a meta-analysis. Int J Behav Med  2016; 24( 1): 25– 41. Google Scholar CrossRef Search ADS   10 Nahin RL, et al.  : Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc  2016; 91( 9): 1292– 1306. Google Scholar CrossRef Search ADS PubMed  11 Furlan AD, et al.  : Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine (Phila Pa 1976)  2005; 30( 8): 944– 63. Google Scholar CrossRef Search ADS PubMed  12 Furlan AD, et al.  : Massage for low-back pain. Cochrane Database Syst Rev  2015; ( 9): CD001929. 13 Ramirez S, et al.  : Misuse of prescribed pain medication in a military population – a self-reported survey to assess a correlation with age, deployment, combat illnesses, or injury? Am J Ther  2016; 24( 2): e150– 6. Google Scholar CrossRef Search ADS   14 Knox J, et al.  : The incidence of low back pain in active duty United States military service members. Spine (Phila Pa 1976)  2011; 36( 18): 1492– 500. Google Scholar CrossRef Search ADS PubMed  15 Ilgen MA, et al.  : Opioid dose and risk of suicide. PAIN  2016; 157( 5): 1079– 84. Google Scholar CrossRef Search ADS PubMed  16 Toblin RL, et al.  : Chronic pain and opioid use in us soldiers after combat deployment. JAMA Intern Med  2014; 174( 8): 1400– 1. Google Scholar CrossRef Search ADS PubMed  17 Lew HL, et al.  : Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev  2009; 46( 6): 697– 702. Google Scholar CrossRef Search ADS PubMed  18 Higgins DM, et al.  : Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/operation New Dawn veterans. Pain Med  2014; 15( 5): 782– 90. Google Scholar CrossRef Search ADS PubMed  19 Haskell SG, et al.  : Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clin J Pain  2012; 28( 2): 163– 7. Google Scholar CrossRef Search ADS PubMed  20 Pain Management Task Force, Final Report. 2010. 21 Kerns RD, et al.  : Implementation of the Veterans health administration national pain management strategy. Transl Behav Med  2011; 1( 4): 635– 43. Google Scholar CrossRef Search ADS PubMed  22 Gallagher RM: Advancing the pain agenda in the veteran population. Anesthesiol Clin  2016; 34( 2): 357– 78. Google Scholar CrossRef Search ADS PubMed  23 Integrative Medicine in the Military Health System Report to Congress. 2013, Department of Defense: Washington, DC. 24 Petri RP Jr., Delgado RE: Integrative Medicine Experience in the U.S. Department of Defense. Med Acupunct  2015; 27( 5): 328– 34. Google Scholar CrossRef Search ADS PubMed  25 Fletcher CE, et al.  : Perceptions of providers and administrators in the Veterans Health Administration regarding complementary and alternative medicine. Med Care  2014; 52( 12 Suppl 5): S91– 6. Google Scholar CrossRef Search ADS PubMed  26 Fletcher CE, et al.  : Perceptions of other integrative health therapies by Veterans with pain who are receiving massage. Rehabil Res Dev  2016; 53( 1): 117– 26. Google Scholar CrossRef Search ADS   27 Gill JM, Mainous AG III: The role of provider continuity in preventing hospitalizations. Arch Fam Med  1998; 7( 4): 352– 7. Google Scholar CrossRef Search ADS PubMed  28 Atlas SJ, et al.  : Patient–physician connectedness and quality of primary care. Ann Intern Med  2009; 150( 5): 325– 35. Google Scholar CrossRef Search ADS PubMed  29 Niemtzow RC: Battlefield acupuncture. Medical Acupunct  2007; 19( 4): 225– 8. Google Scholar CrossRef Search ADS   30 Zhao H-J, et al.  : Auricular therapy for chronic pain management in adults: a synthesis of evidence. Complement Ther Clin Pract  2015; 21( 2): 68– 78. Google Scholar CrossRef Search ADS PubMed  31 Estores I, et al.  : Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial. J Spinal Cord Med  2016; 40( 4): 432– 8. Google Scholar CrossRef Search ADS PubMed  32 Moss DA, Crawford P: Ear acupuncture for acute sore throat: a randomized controlled. Trial. J Am Board Fam Med  2015; 28( 6): 697– 705. Google Scholar CrossRef Search ADS   33 Knutson L, et al.  : Development of a hospital-based integrative healthcare program. J Nurs Adm  2013; 43( 2): 101– 7. Google Scholar CrossRef Search ADS PubMed  34 Yuan J, et al.  : Effectiveness of acupuncture for low back pain: a systematic review. Spine (Phila Pa 1976)  2008; 33( 23): E887– 900. Google Scholar CrossRef Search ADS PubMed  35 Vickers AJ, et al.  : Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med  2012; 172( 19): 1444– 53. Google Scholar CrossRef Search ADS PubMed  36 MacPherson H, et al.  : Influence of control group on effect size in trials of acupuncture for chronic pain: a secondary analysis of an individual patient data meta-analysis. PLoS ONE  2014; 9( 4): e93739. Google Scholar CrossRef Search ADS PubMed  37 Vickers AJ, Linde K: Acupuncture for chronic pain. JAMA  2014; 311( 9): 955– 6. Google Scholar CrossRef Search ADS PubMed  38 MacPherson H, et al.  : Characteristics of acupuncture treatment associated with outcome: an individual patient meta-analysis of 17,922 patients with chronic pain in randomised controlled trials. PLoS ONE  2013; 8( 10): e77438. Google Scholar CrossRef Search ADS PubMed  39 Lin LA, et al.  : Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. Pain  2017; 158( 5): 833– 9. Google Scholar CrossRef Search ADS PubMed  40 Kerns RD, et al.  : Implementation of the veterans health administration national pain management strategy. Transl Behav Med  2011; 1( 4): 635– 43. Google Scholar CrossRef Search ADS PubMed  41 Quality, C.f.B.H.S.a., Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health, S.A.a.M.H.S. Administrations, Editor. 2016: Washington, DC. 42 Institute of Medicine Committee on Advancing Pain Research, C. and Education, The National Academies Collection: Reports funded by National Institutes of Health, in Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011, National Academies Press (US) National Academy of Sciences.: Washington (DC). Author notes The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Uniformed Services University, Departments of the Army, Navy or Air Force, Department of Defense, Department of Veterans Affairs, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project

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Oxford University Press
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Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
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0026-4075
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Abstract

Abstract Introduction Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and “hands on” clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program’s implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings. INTRODUCTION U.S. adults spend an estimated $30 billion out-of-pocket on complementary and integrative medicine (CIM) approaches each year, over half of which is attributed to back pain treatments.1 Results from the 2002–2012 National Health Interview Survey signifies a growing use of CIM over the past decade.2 The resolute demand for CIM therapies has, in turn, engaged stakeholders, health systems, and policy makers to create complex solutions for the changing market.3 The Military Health System (MHS) and Veterans Health Administration (VHA) are no exceptions. CIM (e.g., chiropractic/osteopathic manipulation, acupuncture, yoga, massage, biofeedback, mind-body therapies) use significantly increased among active-duty service members (SM) from 2010 to 2015, with most military installations providing at least one type of CIM therapy.4 Although Veterans’ and SM utilization of CIM therapies has increased, and at higher rates than their civilian counterparts,5 CIM accessibility remains variable. CIM services today are largely dependent on location and referring provider attitudes,4,6 and are not covered by health insurance. Given the utility of CIM for the treatment of pain,7–12 combined with the salience of pain-related conditions and problems (e.g., opioid misuse) in the MHS and VHA,13–19 it is essential to bolster CIM accessibility for non-pharmacological pain treatments for SM and Veterans. The Department of Defense (DoD) Pain Management Task Force (PMTF)20 partnering with the VHA National Pain Management Program21,22 recognize the potential value of CIM therapies as effective supplementary therapies to reduce dependence on opioids for pain management within the VHA and MHS. Notwithstanding this recognition, routine access to CIM services within the MHS and VHA continues to be hampered by barriers to this care. CIM therapies are not covered by the DoD health insurance, TRICARE, and there is an inconsistent pattern of CIM therapies offered across military installations.23,24 Studies of VHA providers and patients indicate that both lack information regarding which CIM therapies are available.25,26 Furthermore, providers may not necessarily know how CIM treatments can be integrated early into pain management plans.25,26 Additionally, both military providers and SM are subject to regular job relocations, whereby providers and SM must seek information regarding CIM options with each relocation. Though research has yet to quantify the degree to which relocation impedes CIM access, previous findings indicate discontinuity of care is associated with increased hospitalizations27 and lower quality care.28 Therefore, SM may invariably be less likely to receive consistent CIM services due to the transient nature of military life, as well as when they transition to civilian or VHA medical care after military service. For SM and Veterans who respond favorably to CIM therapies and are satisfied with such treatments, service discontinuation may negatively impact health across time. Lastly, research suggests challenges in credentialing and hiring CIM providers, as uniform position descriptions and requisites are lacking.25 Taken together, increasing CIM accessibility involves all echelons of the healthcare system, ranging from patients to policy makers. To address barriers to CIM access, collaborators from the VHA and MHS developed, implemented, and evaluated a systems-wide auricular acupuncture training program aimed at educating a variety of providers (e.g., medics and corpsmen, nurses, physical therapists, physicians) in a protocol-driven auricular acupuncture technique called battlefield acupuncture (BFA). BFA is a simple and standardized auricular acupuncture protocol in which semi-permanent needles are placed at specific points on the exterior auricle of the ear, where they remain for up to several days.29 In a review of randomized control trials, auricular acupuncture provided significant analgesia over sham or control interventions in 12 of 15 studies and across several pain conditions with one trial showing mixed results, and two trials showing no treatment differences between auricular acupuncture and electroacupuncture or general acupuncture.30 BFA does not require advanced acupuncturist credentialing, is utilized by MHS medical professionals for a variety of conditions and symptoms, and training is open to a number of provider types within the MHS. However, robust randomized clinical trials examining BFA efficacy, including studies comparing BFA to other forms of auricular acupuncture, have yet to be completed and data is limited to small trials.31,32 After weighing the evidence of auricular acupuncture, including gaps in BFA-specific studies, and implementation qualities noted to be favorable,33 the BFA-protocol for auricular acupuncture was selected as a feasible vehicle to promote CIM exposure and accessibility across health systems. The project was further tasked to sustain the BFA training system and to expand acupuncture availability by assisting MHS and VHA physicians in completing an accredited 300-hr medical acupuncture program and becoming local and regional faculty for training providers in BFA. In terms of medical acupuncture, meta-analyses of patients with chronic pain indicate acupuncture improves functioning and reduces pain to a greater degree than no treatment and sham treatments, albeit the effects are short-term.11,34–37 Moreover, reported pain reduction is similar across a number of conditions, such as back and neck pain, osteoarthritis, and chronic headaches,35 and across different acupuncture styles.38 The generalizability of treatment effects across different pain-related conditions provided further indication that a medical acupuncture training program would also have broad applicability across different clinics and patient populations. Taken together, the present evaluation describes the Acupuncture Training Across Clinical Settings (ATACS) curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. METHODS Training Sites BFA training site selection was structured at the beginning of the project to ensure trainees had the ability to provide treatment within their practice locations. Sites were selected based on a combination of several factors, including: presence or absence of a holistic center, pain management clinic, a VA site within 50 miles to a DoD site (or vice versa), medical acupuncturist(s), potential BFA trainers/providers, administrative support, IT support, and research assets. Also considered were the types of clinical populations served; the type of VA facility, whether the site was a joint VHA-military site, the estimated cost of training, and the degree of command support. After the project team rank ordered a list of 192 potential sites based on these factors, a representative set of MHS and VHA sites were selected, including 15 VAs, 20 Air Force, 20 Army, and 15 Navy training sites. As training progressed across sites, so did interest from other MHS and VHA clinical sites. Thereafter, site selection was driven mainly through interested parties asking for training, per site leadership approval, and the availability of assets to complete training. Training sites were required to have a designated space in which training could occur during a specified time, for preferably more than 20 trainees. BFA Trainees BFA trainees were recruited at each training site utilizing a variety of methods. Because each MHS and VHA site was unique in aspects ranging from the type of clinic or medical specialization requesting BFA training to credentialing differences, trainee recruitment was site-specific, and no overarching, formal recruitment plan was needed. Providers who were interested in completing the BFA training were asked to complete an online registration via a Research Electronic Data Capture survey. As part of registration, potential trainees were informed that their “responses will be added to those of other participants and reported in the aggregate to a wider audience.” Eligible providers are shown in Table I. Table I. Eligible Providers for Battlefield Acupuncture Training. Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  Table I. Eligible Providers for Battlefield Acupuncture Training. Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  Types of Providers Eligible to Participate in Battlefield Acupuncture Training  Acupuncturists Air Force medics Army medics Chiropractors Dental hygienists Dentists Dieticians Medical doctors Navy corpsmen and hospital corpsmen  Nurse practitioners Nutritionists Occupational therapists Occupational therapy assistants Orthodontists Physician assistants Physical therapists  Physical therapy assistants Psychologists Psychology technicians Registered nurses Rehabilitation therapists Respiratory therapists  BFA Faculty BFA faculty led the BFA trainings. Faculty were required to have completed the BFA training, in addition to completing a 300-hr medical acupuncture course or equivalent training, or having demonstrated proficiency in conducting and teaching a BFA course. As the project and BFA training interest expanded, the demand for additional BFA faculty became significant. As a result, the project dedicated resources to training additional providers in medical acupuncture. BFA Provider Training Content and Structure BFA provider training content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts (SMEs) and feedback from providers who completed BFA training. Course content was developed to be applicable to the MHS and VHA environments. Training included a 4-hr didactic and “hands on” clinical training program. Course objectives were to: review acupuncture history, clinical significance and evidence for its use; understand patient selection criteria; provide educational information for patients regarding acupuncture; obtain and document consent; gain proficiency in needling technique (e.g., needle locations, needle placement); identify, understand, and convey post-procedure instructions and precautions; correctly complete clinical charting and Electronic Health Record (EHR) coding to include coding of the encounter; and obtain appropriate credentialing. Lectures, videos, demonstrations, and hands-on practice with both silicone ears and live models ensured trainees had adequate opportunities to understand and administer BFA through a variety of teaching methods. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Each training course concluded with the written exam. A course evaluation was completed at the conclusion of the training. Surveys and Data Collection After completing the online registration, which included questions assessing demographic and clinical practice aspects, trainees attended the 4-hr BFA training at their respective sites. At the end of the training, they were asked to complete a course evaluation. Trainees were asked the degree to which they agreed with the statement “I would recommend this training to a colleague,” using a 5-point Likert scale (strongly disagree to strongly agree). They were also asked to provide their overall rating of the trainer and BFA course on a 5-point Likert scale (not effective to very effective). At 1-mo post-training, trainees were asked to complete an online follow-up assessment. In the follow-up assessment, trainees were asked to report their current clinical BFA use (use, do not use), number of patients they administer BFA to per week (none, 1–10, 11–20, 21–30, 31–50, >50), conditions treated with BFA (headache, neck/shoulder pain, back pain, joint pain, neuropathic pain). Questions assessed provider satisfaction with BFA as a pain treatment on a 4-point Likert scale (quite dissatisfied, indifferent/mildly dissatisfied, mostly satisfied, very satisfied) and the degree to which their opioid prescribing habits changed since BFA training (greatly increased, somewhat increased, no change, somewhat reduced, greatly reduced). Lastly, trainees were asked to rate the degree to which a challenge or obstacle impeded their delivery of BFA treatment to patients. Scores were placed on a 5-point Likert scale ranging from 1 (low challenge) to 5 (high challenge), and the 16 challenges were ranked from highest to lowest challenge. RESULTS BFA Trainees From January 2014 to August 2016, 2,712 healthcare providers completed an ATACS training program. They were on average, 41-yr old, (SD = 12 yr), and nearly equally split by gender (51% male, 49% female). Training locations are depicted in Figure 1. Most providers had an MD or DO degree (44%). Providers reported a range of medical specialties, most common of which included family medicine (27%) and internal medicine (13%). Most providers reported practicing their specialty less than 5 yrs (34%) or 5–10 yr (20%) and 68% indicated they saw more than 10 patients for pain-related conditions each week. Finally, only 28% indicated acupuncture (11% auricular acupuncture, 19% BFA, 5% licensed acupuncture, 8% medical acupuncture) was available at their practice locations. FIGURE 1. View largeDownload slide Battlefield Acupuncture training site locations within the USA. FIGURE 1. View largeDownload slide Battlefield Acupuncture training site locations within the USA. BFA Faculty After completing specialized training, 113 providers (49% men, 51% women) were approved to be BFA training faculty. Like BFA trainees, most had an MD or DO degree (48%). Providers had a background in many medical specialties, the most common of which were family medicine (32%) and internal medicine (12%). The majority treated more than 10 patients each week for a pain-related condition (71%). Approximately 32% indicated acupuncture (11% auricular acupuncture, 25% BFA, 4% licensed acupuncture, 5% medical acupuncture) was available at their practice locations. BFA Trainee perspectives Course-evaluation surveys were administered at the end of BFA training. Providers rated the training favorably such that 99% indicated they would recommend the training to a colleague, 99% rated their training instructor as being effective or very effective, and 99% rated their overall training as effective or very effective. At 1-mo post-training, 553 providers (20% of all program participants) completed a follow-up survey. Of these providers, 160 (29%) reported using BFA in their own clinical practice. The majority of providers who used BFA reported providing BFA to 1–10 patients each week (94%) and were satisfied with BFA as a pain treatment (92%). Lastly, 194 providers rated the extent to which their opioid prescribing habits changed since BFA training. The majority (75%) reported no prescribing behavior changes since training. The remaining respondents indicated that they somewhat reduced (18%) and greatly reduced (6%) their opioid prescribing. One respondent indicated that their opioid prescribing had greatly increased since training. In the 1-mo post-training assessment, providers were asked to rate the degree to which a particular challenge or obstacle impeded their delivery of BFA treatment to patients. Of the 16 noted challenges, lack of defined BFA privileging standards at the provider’s practice location, and lack of a supervisor with BFA privileges were the highest rated challenges. Whereas lack of BFA skills confidence, lack of sufficient guidance and planning to conduct BFA treatment, and patient interest in BFA were the lowest rated challenges. Rated challenges are shown in rank order in Table II. Table II. Provider Challenges to Using Battlefield Acupuncture. Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Each challenge was rated on a scale from 1 (low) to 5 (high) level of challenge. Table II. Provider Challenges to Using Battlefield Acupuncture. Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Provider Challenges to Using BFA Treatment at 1-mo Post-BFA Training in Descending Order (Most Challenging to Least Challenging)  Challenge  Mean (SD)  Lack of defined BFA privileging  3.38 (1.56)  Lack of defined credentialing process  3.23 (1.65)  Lack of a supervisor with BFA privileges  2.98 (1.72)  Short clinical visit time  2.46 (1.45)  Inability to gain authorization to administer BFA  2.32 (1.59)  Inability to complete timely follow-up with patients receiving BFA  2.28 (1.47)  Difficulty scheduling BFA treatments  2.23 (1.41)  Not enough time to explain BFA treatment and document treatment  2.12 (1.28)  Lack of colleague referral of patients for BFA treatment  2.11 (1.37)  Lack of interest in BFA capability at practice location  2.07 (1.35)  Lack of BFA treatment and procedure codes  2.05 (1.41)  Inability to purchase BFA supplies at practice location  2.05 (1.41)  Inability to order BFA supplies at practice location  2.03 (1.34)  Lack of patient interest in BFA  1.82 (1.13)  Lack of sufficient guidance and planning to conduct BFA treatment  1.74 (1.18)  Lack BFA skills confidence  1.59 (0.99)  Each challenge was rated on a scale from 1 (low) to 5 (high) level of challenge. DISCUSSION In the present cross-agency project, 2,712 medical providers were trained to deliver BFA, a standardized auricular acupuncture protocol. During the course of the project, enthusiasm for additional trainings at various MHS and VHA sites outpaced the original projections and necessitated training more faculty members to deliver auricular acupuncture trainings. When the program ended, over 100 providers became faculty members to help sustain auricular acupuncture availability within the MHS and VHA. Active-duty MHS providers are more transient than their civilian counterparts and experience job relocations on a regular basis. Overall, gaps in CIM care and altogether discontinuation may occur due to lack of trained providers within the MHS. When a CIM provider relocates, a military treatment facility may no longer be able to provide the same treatments to patients. By increasing the number of faculty within the MHS, not only are the active-duty faculty members able to train auricular acupuncture at new practice locations to prevent a single-provider/unique-treatment situation, but auricular acupuncture is proliferated as faculty move to military treatment facilities across the MHS. However, this is tempered with the fact that if, for example, a medical acupuncturist leaves a military treatment facility, the MHS does not require a medical acupuncturist to be placed or trained within that same military treatment facility. Thus, the Air Force Surgeon General recommended auricular acupuncture to be an accessible treatment at all Air Force military treatment facilities. Within the VHA, several steps were taken to create a “sustainment” program for ATACS.22 First, the auricular acupuncture training program was incorporated in the VHA’s Pain Management Mini-Residency, which also includes a follow-up preceptorship. Second, the VHA created an Acupuncture Community of Practice for acupuncture trainees and practitioners, with monthly seminars and an online resource library on VA Pulse to ensure providers could access ATACS information and training materials. Third, primary care-based acupuncture and other CIM treatments are component of the VHA’s Opioid Safety Initiative39 and National Pain Strategy.40 Taken together, sustaining auricular acupuncture treatment availability within the VHA was bolstered by increasing the number of faculty, educational opportunities, and resources available to providers. There was a significant barrier to obtaining privileges to administer auricular acupuncture within their practice locations. This difficulty was identified early in the project based on provider and trainee feedback. Within both agencies, there was a lack of uniformity to privileging. Additionally, there were identified challenges due to lack of policy on which providers could administer BFA. In part, this was also due to differences in state-level policies regarding acupuncture treatment and provider licensing. Presently, there is no federal medicine policy on the use of acupuncture within government healthcare facilities. Thus, as part of the ATACS program implementation, developers and stakeholders responded to trainee feedback by examining privileging procedures in both the MHS and VHA. Further, a review of policy regarding the administration of BFA by non-privileged providers (e.g., medics, RN) was performed. In this cross-agency exploration, MHS and VHA members worked to create credentialing and privileging guidance that would maximize availability of acupuncture services while ensuring appropriate federal standards for medical diagnosis and treatment were maintained. This was accomplished through the establishment of a tiered system where non-prescribing healthcare providers could perform the BFA-protocol auricular acupuncture under the supervision of a privileged provider. An example of the proposed tiered system is provided in Table III. Implementation of this policy remains under review by both the VA and DoD at this time. Table III. Proposed DoD Tiered Acupuncture Services Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Level 2 protocols include BFA, National Acupuncture Detoxification Association, Auricular Trauma, and/or Lumbar Pens. Table III. Proposed DoD Tiered Acupuncture Services Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Levels of Acupuncture  Minimum Training Requirements  Eligible Providers  Proof of Training  Level 1: BFA  4-hr training program approved by the VA National Pain Management Program / Integrative Health Coordinating Center (NPMP, IHCC) and the Air Force Acupuncture and Integrative Medicine (AIM) Center  Privileged providers and provider extenders  Certificate of training and supervised treatment of patients  Level 2: Standardized Acupuncture Protocols  8+ hr training program approved by the VA NPMP / IHCC and the Air Force AIM Center  Privileged providers and eligible provider extenders  Certificate of training and supervised treatment of patients  Level 3: Comprehensive Acupuncture  300-hour training program approved by the American Board of Medical Acupuncture  Physicians, licensed acupuncturists and other non-physician privileged providers practicing under the supervision of a physician  Certificate of training and supervised treatment of patients  Level 2 protocols include BFA, National Acupuncture Detoxification Association, Auricular Trauma, and/or Lumbar Pens. The original programmatic goals of ATACS were achieved, surpassed, and expanded. The program illuminated several challenges that were beyond the scope of the project. First, the lack of specific billable codes and consistent charting for CIM therapies makes it difficult to track, monitor, measure, and study the use of CIM modalities within a pragmatic context. Second, privileging across the MHS and VHA is highly variable, and though progress was made in this area for individual locations, not all trainees were able to administer the standardized auricular acupuncture protocol at their practice locations. Further, there are still no policies within the Federal system addressing the practice of various CIM modalities by non-privileged providers. Third, there is no designated department for CIM practice within the DoD. Many federal clinics provide CIM therapies for a variety of conditions, but do not have a unifying body to guide implementation and steer policy. As such, there is not a centralized directory of providers who administer CIM techniques across the agencies. Therefore, an active-duty MHS patient who finds benefit in a particular CIM may face undue barriers when attempting to find similar services at his/her new DoD facility or VHA location after relocating to a new DoD facility or after transitioning to VA care. The challenges identified in this project may provide valuable insight into present obstacles to CIM practices and assist with CIM implementation policies within the MHS and VHA. Further federal medicine research evaluating the impact of this acupuncture approach on beneficiary satisfaction and healthcare costs is warranted. The present ATACS program had a number of strengths. First, this was a cross-agency exercise with a wide-spread CIM training program (acupuncture). Second, this program was timely in light of the ongoing opioid crisis41 because it provided a non-opioid, non-pharmacological treatment for pain. Third, the training format, structure, and organization made auricular acupuncture implementation not only feasible, but also paved the road for future evaluation and possible implementation of other wide-spread CIM training programs. The project showed that a standardized auricular acupuncture treatment can be integrated into the clinical work flow, despite many challenges. Fourth, provider training in BFA was shown to be beneficial by addressing the need for more acupuncture trained providers in response to the increased CIM utilization among active-duty and veteran SM. The project suggested that a significant number of provider types can be trained in a standardized CIM treatment protocol, with the potential to reach a wider patient population. Fifth, the project goals and outcomes were consistent with the Institute of Medicine recommendations for health profession schools to include CIM as part of the standard curriculum.42 As a result of the project, the VHA included BFA training in their Pain Mini-residency and follow-up preceptorship. Although not assessed during this project, the experience gained by federal medicine providers with this simple CIM auricular acupuncture technique could encourage additional exploration of CIM generally in Federal healthcare systems. In light of these strengths, there are limitations to the ATACS program and its evaluation. First, outcome data are highly limited as the provider response rate to the follow-up surveys was low and patient perspectives (e.g., satisfaction with auricular acupuncture treatment) were not obtained. Combined with non-uniform privileging, as well as variability in coding, it is difficult to draw meaningful conclusions regarding the pragmatic impact of ATACS and its cost-effectiveness within the MHS and VHA. However, with improved and uniform procedures, future studies can examine aspects of clinical impact and cost-effectiveness of auricular acupuncture, as well as other CIM techniques, across both agencies. Overall, the ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program’s implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings. Funding Joint Incentive Fund (JIF) from the Departments of Defense and Veterans Affairs (Award #: HU001-14-1-0002). Acknowledgments Elyse Greenberg, RN, Lac, RYT; Yolanda S. Williams, MPH; Megan Vaughan, RN; Jacklyn Talley. REFERENCES 1 Nahin RL, Stussman BJ, Herman PM: Out-of-pocket expenditures on complementary health approaches associated with painful health conditions in a nationally representative adult sample. J Pain  2015; 16( 11): 1147– 62. Google Scholar CrossRef Search ADS PubMed  2 Clarke TC, et al.  : Trends in the use of complementary health approaches among adults: United States, 2002–2012. Natl Health Stat Report  2015; 79: 1– 16. 3 Herman PM, Coulter ID: Mapping the health care policy landscape for complementary and alternative medicine professions using expert panels and literature analysis. J Manipulative Physiol Ther  2016; 39( 7): 500– 9. 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Administrations, Editor. 2016: Washington, DC. 42 Institute of Medicine Committee on Advancing Pain Research, C. and Education, The National Academies Collection: Reports funded by National Institutes of Health, in Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011, National Academies Press (US) National Academy of Sciences.: Washington (DC). Author notes The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Uniformed Services University, Departments of the Army, Navy or Air Force, Department of Defense, Department of Veterans Affairs, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Military MedicineOxford University Press

Published: Mar 26, 2018

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