Complementary and Integrative Health (CIH) approaches to medical care include trained medical providers working closely with patients to incorporate both alternative (e.g., acupuncture, yoga, meditation, etc.) and conventional medicine into standard medical care. While the effectiveness of CIH therapies is a well-studied topic, less is known about their use and adoption within large health care systems. As with other therapeutic modalities, use and adoption of CIH therapies is impacted by a myriad of interacting factors at the patient, provider, and organizational levels. This three-paper dissertation explored some of these factors through a service delivery and policy lens, with an aim to provide policy makers and other health systems with data on whether and how novel, non-pharmaceutical therapeutics are being integrated into the conventional health system. In Chapter 2 (Study 1), I used a longitudinal design to measure use of CIH therapies funded by the Department of Veterans Affairs (VA) for a defined cohort of Veterans over a three-year period. I compared the proportion of users in Flagship and non-Flagship VA medical centers (VAMCs) pre-and mid-implementation of a three-year pilot aimed at expanding provision of CIH therapies. Flagship VAMCs received considerable financial and implementation support from central VA administration to assist with expanding availability and accessibility to CIH therapies and other Whole Health System services. Non-Flagship VAMCs were expected to also expand access to the eight mandated CIH therapies, but without the additional financial or technical support provided to Flagship VAMCs. From pre-implementation to two years post-implementation of the three-year pilot, the percent of users increased by an absolute value of 3.1% system-wide for this population (from 10.2% to 13.3%). Increases were observed for Veterans in both Flagship and non-Flagship VAMCs, but were significantly greater at Flagship VAMCs, particularly in the final study year. In Chapter 3 (Study 2), I used a cross-sectional design to examine organizational characteristics associated with use of VA-funded CIH therapies. VAMCs are required to provide access to eight CIH therapies for Veterans, but can choose whether to provide these services directly or via referral to community-based providers. Direct provision of CIH therapies within VAMCs is resource intensive, as it requires program development, hiring and training of staff, and system level changes that support incorporation into standard medical care. However, overreliance on VA-funded community care increases risk of care fragmentation and negatively impacts resources available for internal VAMC use. This study found that rurality, Flagship status, and receipt of targeted Whole Health System grants were not associated with provision of more VA-funded CIH therapies. I also found that VAMCs with fewer VA-based CIH therapies available provided as many or more total CIH visits on average as VAMCs with more VA-based CIH therapies, due to greater reliance on VA-funded community care. Chapter 4 (Study 3) was a qualitative study that assessed Veteran and provide knowledge and attitudes towards CIH therapies, as well as perceived barriers to CIH uptake. Data included interviews with 17 Veterans with chronic pain and opioid use disorder (OUD) and 45 providers from five VAMCs in the southwestern US. It found that Veterans and providers had good knowledge of CIH therapies as effective and important treatment options based on personal experience and recognition of need for multi-modal treatments that include NPIs, particularly for Veterans with chronic pain. As a result, they were generally enthusiastic about integrating CIH therapies into treatment plans as an NPI option for chronic pain. However, providers had more mixed attitudes towards using CIH therapies for Veterans with OUD because they noted this population is more resistant to using CIH therapies and is more unstable. Veterans interviewed for this study did not express those fears and largely wanted access to these therapies. Providers also noted several system-level challenges impacting use of CIH therapies through the VA, including lack of availability, the absence of central directory showing availability of CIH therapies within VAMCs, and the bureaucratic community care referral system.
