Evaluating a Holistic and Collaborative Model of Military Health: Clients’ Perspectives

Healthcare is seeing an increasing number of clients seeking Complementary and Alternative (CAM) therapies for the treatment of mental and physical healthcare need. A University in Southeastern North Carolina uses a unique interprofessional team-based practice model that embodies complementary and alternative approaches to the psychosocial health of military families. Military affiliated clients (177) completed a Client Satisfaction feedback survey, which determined if holistic services provided met their physical and mental health needs. Survey findings concluded that the clients’ health status in most areas improved. Of the 175 who responded to the survey item, 87% (n=154) indicated that they felt “much better than before” coming to the Institute. Qualitative measures revealed descriptors of “awesome”, amazing”, “wonderful” and “a blessing”. Of their overall experience at the Institute. This holistic model has the capacity to inform and advance military health through the use of CAM treatment modalities for chronic pain, posttraumatic stress disorder, depression, anxiety, using the complement and collaboration of interprofessional teams.


Introduction
Increased communication and coordination of community support services are vital to ensure optimal care for our nation's military personnel, veterans, and their families.Many of our nation's soldiers and veterans are at risk for psychological symptoms [1,2] that are not only stressful for them, but their family members as well.In fact, there is a significant delay in seeking treatment due to the perceived fear of stigmatization and career loss, which further puts the soldier, veteran, or family member at risk of more psychological

Background Military health
Multiple deployments increase stress on the family before and after a soldier's return.The soldier that once left home is not the soldier who returns, nor is the family that was left behind while deployed.It is estimated that 20-39% of all cases seen by the veterans administration are for Posttraumatic Stress Disorder (PTSD) [4].PTSD affects 13% of soldiers returning from Iraq or Afghanistan and 10% of gulf war veterans who have experienced combat [5].The spouse, children, or families also suffer from the aftermath of these sequelae.Delay in seeking treatment either from fear of stigmatization or career loss or simply wait-time for their mental health appointments on military installations could have fatal consequences or place undue psychological burden on the soldier, veteran, or family.
A study conducted by Hoge, Castro, and Messer [6] reported that 17% of soldiers returning from Iraq screened positive for PTSD, depression, and generalized anxiety, which was nearly twice the rate (9.3%) observed among soldiers before deployment.An estimated 37% of Iraq war veterans accessed mental health services in the year after returning from home [7].Another concern is that approximately 3% of active duty service members have attempted suicide during their military career [8].Estimates for service members who conceal their suicidal thoughts and who attempted suicide (77.9%) is greater compared to those who died by suicide (65.84%) [9].These staggering statistics of psychological distress alone challenges the need for adequate resources to meet mental health concerns and places more responsibility on the support of communities to do so.

Holistic approach
The practice of holistic medicine is incorporating the biological, psychological, sociological, culturally, and spiritual aspect of the person, with the focus on the whole person, and realizing that this whole is greater than the sum of any one part [10].Complementary and alternative therapies take into account the whole person, mind, body, and spirit [11].The Institute of Medicine [12] charged the medical community to acknowledge that effective pain management requires holistic biopsychosocial therapies that focus on the whole patient, both physically and mentally.
Health care is seeing an increasing number of clients seeking Complementary and Alternative (CAM) therapies for the treatment of their mental and physical health care needs [10,13].In fact, military personnel use alternative medicine and stress reduction therapies more often than the general public [14].Further, the US Army increasingly supports holistic pain management for wounded warriors and is changing its narcotic focused approach to pain management [15].Moreover, the Army Pain Management Task force has called for the use of integrative and alternative measures such as acupuncture, meditation, cognitive behavioral therapies, in combination with conventional medicine for a comprehensive approach to care [16,17].
Acupuncture has demonstrated success in relieving tension headaches and migraines that can occur due to stress and chronic pain conditions Vickers, Cronin, & Maschino, [18].A study reported by McPherson and Schwenka [13] of 291 soldiers, veterans, and spouses revealed that 81% use ONE or more CAM therapies, with massage ranking high on utilization.Inaddition, in this sample, pain, stress, and anxiety were the most common reasons for selected CAM.Most endorsed their use of these services if offered at the medical treatment facility (69%) or would self-pay (24%), whereas 44% were undecided.
A study released by the National Center for Health Statistics [19] showed evidence that out of the 31,000 adult respondents who were surveyed, 62% used some form of CAM, especially when mega-vitamin and prayer therapy were included as homeopathic approaches.However, with exclusion, only 36% endorsed its use [10].Some of the common CAM therapies that were reported were mind-body relaxation techniques, massage, chiropractic, acupuncture, herbs and supplements.

Interprofessional collaborative practice model
Interprofessional collaboration (IPC) is an essential prerequisite for effective and efficient patient and family centered care (American Association of Colleges of Nursing (AACN)), [20]; College of Nurses of Ontario (CNO), [21].A multidisciplinary team approach is an evidence-based approach to improving health outcomes for the patient and no less effective in improving the quality of primary care treatment of anxiety and depression [22].
The overarching need for interprofessional collaboration is the notion that teams accomplish more together than they do separately (The Josiah Macy Jr. Foundation (JMF), [23]; National League of Nursing (NLN), [24]).A collaborative team approach leads to improved patient outcomes and satisfaction and increased health professionals' efficiency and job satisfaction [25].The model of such partnerships depicted in figure 1 underscores our efforts toward an interprofessional team-based approach that embodies psychosocial health and wellness of military families.This article showcases the results of a client feedback survey of a viable HRSA funded interprofessional collaboration model of clinical practice.The practice has a complement of licensed psychologists, social workers, nurse practitioners, massage therapists, interdisciplinary students, and an acupuncturist.This focused-holistic approach to behavioral health included complementary and alternative therapies as treatment options for chronic pain, PTSD, and other co-morbidities [26,27].

Setting
A university in Southeastern North Carolina uses a unique interprofessional collaborative team-based practice model that offers psychosocial health to military families in its Health Resources and Services Administration (HRSA) funded Collaborative Institute for Interprofessional Education and Practice (CI-PEP).CI-PEP is important in offering additional mental health services to military personnel in North Carolina, a state with great psychiatric demands as a result of its third rank total military personnel and active duty military personnel per capita.These large numbers strain the veteran administration systems to keep up with the needed services for this population.CI-PEP offers evidence-based prevention, early intervention, and promotion of psychosocial wellness based on theories of protective factors and resilience.This underpinning supports the mental wellness promotion and quicker access to services that are minimally available, accessible, or affordable to this population.
CI-PEP, spearheaded by nursing faculty, has offered free integrated and holistic services to 750-plus military personnel, veterans, and their families with an emphasis on pain management, bio-behavioral and psychosocial wellness, veteran women's health, as well as family integration.Treatment modalities offered include CAM (massage, acupuncture/acupressure, and migun wellness), individual and couples counseling, support groups (mindfulness based therapies), health education, and coordination of referrals in a military and veteran culturally-informed environment.The migun thermal massage bed used for services offers the effects of acupressure, acupuncture, heat-therapy (moxibustion), chiropractic, and massage.This FDA approved physical therapy thermal massage system provides 30-45 minutes of pure relaxation and meditation by uniquely integrating traditional Eastern medicine with Western technology to provide massage like no other.CI-PEP is open two days per week and has a robust history of averaging 45-55 clients per two days for all services.Additionally, 104 couples receive services together, which denote our efforts toward psychosocial wellness, family reintegration and stability around deployment issues.CI-PEP is state approved as a child care drop-in center, further supporting the family and making it easier to receive these services.CI-PEP is supported by a dynamic interprofessional team of licensed psychologists, nurse practitioners, licensed social workers, massage therapists, an acupuncturist, and grounded by an active advisory board representing community and military leaders.CI-PEP also provides a supervised interprofessional clinical training site for undergraduate and graduate students majoring in nursing, social work, and counseling psychology.It is designed to graduate interprofessional students who are capable of providing high-quality well-coordinated care through an Interprofessional Collaborative Practice (IPCP) model of education, with educational outcomes achieved to meet the biopsychosocial health care needs of diverse populations, including military families.CI-PEP provides community support services for service members and their families and offers an opportunity to evaluate the efficacy of this interprofessional, innovative and collaborative practice model of military health.
Clients are accepted as walk-ins or scheduled appointments and can self-select any services identified in the model.Counseling services and treatment modalities, including mindfulness based therapies, are led by licensed psychologists and intern students from the University's counseling Psychology Department.Holistic approaches are assessed by a fourth generation Acupuncturist holding a masters and doctoral degrees in oriental medicine.The Acupuncturist is a licensed independent contractor who has years of expertise in treating acute and chronic pain and offered multiple treatments for pain and skin revitalization such as the five-element approach and the Korean four-needle technique.Massage therapy is often the main entry to other services and provided by two licensed massage therapists, one being a registered nurse.Psychoeducational groups, facilitated by a psychiatric nurse practitioner and nursing students are also offered to clients.Licensed clinical social workers and social work students serve as the bridge to community referrals and outreach.They are also instrumental in providing case management for homeless veterans and facilitate veteran peer support through locally-affiliated veteran support agencies.

Methodology Participants
Program evaluation and research was approved by the University's Institutional Review Board (IRB).Participants were a convenient sample of 177 military affiliated clients (females; 102; males; 75); ages ranged from 26 to 65 and older who received services at CI-PEP (Table 1) and were asked their perspective on the quality of services they received.Of the clients surveyed during the data collection period, 139 (79%) visited 1 to 9 times, 30 (17%) visited between 10 and 19 times, 7 (4%) had 20 or more visits, and one did not indicate the number of visits.

Procedure
A pre-post treatment amended brief client feedback survey via a likert scale was administered to each client at the end of each new service visit, regardless of how many times they had visited.The purpose of the amended survey was to get immediate satisfaction feedback and allow for the opportunity to respond to client needs in a faster turnaround time frame.The client feedback survey included seven (7) items with a section for general comments, which were used as qualitative measures.Question number one (1) and not in table 2, asked participants to identify the service (e.g., acupunture, individual / family / group, massage or migun wellness) they used that day so we could capture appraisal of all services.Thus, table 2 continues with question number two (2).

Data analysis
Qualitative and quantitative measurements were used to evaluate the extent the establishment of the Interprofessional Collaborative Practice (IPCP) of CI-PEP resulted in providing holistic psychosocial services to military families.The collection of both qualitative and quantitative data provided a comprehensive view of the services received by the clients and the impact of collaboration on holistic services.
Analyses of quantitative data consisted primarily of descriptive statistics represented by frequencies of participant responses.Qualitative data were conducted via content analysis for emerging themes that explained or provided greater insight into the meaning of the survey frequencies.The program evaluator and a team of quality metric staff independently coded the repetitive emerging themes.The coders reviewed with each other their themes and reached a consensus where there were differences.Only themes for which a consensus was reached were included in the final data.This procedure was used to ensure a degree of interrater reliability.

Results
As shown in table 2, clients were asked to provide feedback of their general experiences of the various services they received at the Institute.The impact on physical and mental health and the perceived reduction in visits to their primary care physician were also measured.

Qualitative findings
The comments provided by the participants openly supported the frequency findings presented in the previous sections of this summary.For example, the comments regarding the overall services were considered "excellent" by 94% of the clients and the most popular descriptor of the services include "excellent" and "great".The other descriptors of the overall experience at the Institute included "awesome", "amazing", "wonderful" and "a blessing".
Interactions with providers and staff: When commenting on the interactions with the providers and staff, the clients' comments included, but were not limited to, the following: "Professional", "personable", "informative", "listens to me", "courteous", and "friendly and accommodating".

The outcome of experience:
Comments more specific to the results of the experience included: • "Thank you for the emotional transition".
• "I feel like a new person".
• "My joints and muscles feel a lot better".
• "The Migun services are helpful for chronic pain".
• "Thank you for being here".
• "Please find funding so you can stay.You are a blessing".

Concerns or improvements:
In addition to providing comments about the overall experience, the interactions with providers and staff, and outcomes of the experiences, clients also identified ways in which the Institute could be more helpful to them.
• "Less time between services".(massage therapy) • "The Migun bed [was] just a little rough on the tailbone".
• "No signs on the building, bad directions from the police department".

Discussion
The clients indicated that the overall holistic services were excellent (94%), the services exceeded their expectations (70%), and they were very likely to recommend the services to others (98%).Additionally, the clients indicated that the services would very likely reduce their visits to their primary physician (57%), and the services helped them to feel much better than before visiting the Institute (87%).Finally, nearly all of the clients indicated they would come back to the Institute for the same service (89%), and a few of them (5%) would return for both the same service and a different service.Consistent with other studies and ours, CAM therapies if made available to this population are well utilized, appraised highly, and has positive health outcomes [10,13].
Our lived experience with treating military families are consistent with other studies that support the need to consider alternative forms of mental health delivery in this population.It is imperative that healthcare options are available that remove stigmatization and other barriers to seeking health care [6,9].A belief that holds true for our Institute, as well as other researchers is the closer the collaboration amongst healthcare providers is, the more efficient the team is in diminishing psychological and physical distress of anxiety, PTSD, and pain and suffering for military personnel and families [3].

Limitations
Unfortunately, data represented here is a smaller snapshot of the 750+ military clients served.The amended self-reported client feedback survey reported allowed the opportunity to respond to client needs in a faster turnaround timeframe.The more comprehensive Patient/Client Satisfaction Survey (PCSS) that included the PROMIS 10 scale did not generate the sample size intended due to attempts to capture the clients' perspective after the fourth visit.This included pre-and post-test measures to assess health before and after services and after the fourth visit to the Institute.This generated a higher attrition rate as deployment, lack of response to the online survey, and other variables were evident.However, clients' reports from the PCSS were overwhelmingly positive and consistent with what is reported here.

Implications for Clinical Practice
There is a great need to improve the identification and management of behavioral health conditions in the primary care of  military personnel, veterans, and their families.Holistic CAM approaches have the potential to decrease medical utilization while improving patient functioning and alleviating suffering.One goal of using holistic approaches is by helping individuals gain a proper balance of life.With the military population, one could conclude that this balance is altered by adjustments the soldier and family have to make more often than the general public.Since the effects on psychological and physical health improved for participants in our study, health care must be the catalyst for recognizing the essentials of ensuring protective factors are in place.Interprofessional Collaborative (IPC) models such as the one depicted not only provided family stabilization but demonstrated the effects on health through stress reduction, alleviation of pain, and early interventions that has the capacity to prevent exacerbation of psychological stress.IPC models like CI-PEP considers the whole person, mind, body, and spirit as an embodiment of wellness promotion of military families.

Table 1 :
Demographics of Sample-N=177 (Survey Period Fall 2014/Spring 2015).Services included were Migun Wellness, acupuncture, massage, and counseling.Further survey questions and responses are depicted in table 2 of the client feedback survey.
J Altern Complement Integr Med ISSN: 2470-7562, Open Access Journal DOI: 10.24966/ACIM-7562/100007 Volume 2 • Issue 1 • 100007 How likely will your visits at the Institute reduce the number of visits you typically make to your primary care physician?