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The Role of Family and Community in Integrative Preventive Medicine 

The Role of Family and Community in Integrative Preventive Medicine
Chapter:
The Role of Family and Community in Integrative Preventive Medicine
Author(s):

Farshad Fani Marvasti

DOI:
10.1093/med/9780190241254.003.0006
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date: 23 November 2020

Key Concepts

  • ■ Integrative preventive medicine (IPM) is the best approach to control and prevent the chronic diseases of our time that account for the vast majority of healthcare expenses and lives lost.

  • ■ Integrative preventive medicine provides a shift from acute to chronic disease treatment and prevention with the goal of morbidity compression to extend the period of disease-free high-quality life.

  • ■ The role of family and community in IPM is to leverage primary care as the chief means for disseminating and implementing a new integrative model of prevention.

  • ■ Integrative preventive medicine shifts the focus of family and community medicine from reactive “sick” acute care to proactive preventive “health” care.

  • ■ Integrative preventive medicine for family and community goes beyond simply treating each individual by including an assessment of the larger community and context in the prevention of disease to target key risk factors.

  • ■ Integrative preventive medicine changes the patient encounter in family and community medicine to recreate “routine” physical exams as opportunities for primary prevention and patient health education.

  • ■ Integrative preventive medicine empowers physicians to go beyond simply following up on prediabetic patients to proactively engaging them on an evidence-based lifestyle regimen to prevent the onset of diabetes.

  • ■ Integrative preventive medicine redefines the USPSTF standard for primary prevention guidelines to include proactive engagement and evidence-based integrative prevention of disease beyond routine screening recommendations.

  • ■ Integrative preventive medicine fosters the development of innovation in primary care where the patient is the focus and a relationship over time exists to initiate and follow up on lifestyle interventions to prevent disease and maintain optimal health.

Introduction

Seventy-five cents of every dollar spent on healthcare in the United States is spent on chronic diseases. In fact, cardiovascular disease, cancer, and diabetes are now responsible for 7 out of every 10 deaths among Americans each year and account for up to 75% of the nation’s health expenditures.1 These well-known chronic diseases have modifiable risk factors and are therefore preventable. Integrative preventive medicine (IPM) is the best approach to control and prevent the chronic diseases of our time that account for the vast majority of healthcare expenses and lives lost.

Integrative Preventive Medicine Recognizes the Changes in Epidemiology Toward Chronic Disease

Despite the epidemic of chronic disease, our healthcare system, or more accurately our “sick” care system, is based on an acute care approach that is over 100 years old. The current model is the result of fundamental changes in medical education, research, and practice that took place in the wake of the Flexner Report in 1910.2 At the time of the report in 1910, acute infectious diseases such as polio and tuberculosis were the major sources of morbidity and mortality.3 An acute care approach powerfully addressed these conditions through the development of a hospital-based system that successfully treated a nonambulatory acutely sick patient population. Philanthropic contributions and scientific breakthroughs fueled rapid expansion of this model into the industrial medical complex that now permeates our healthcare system.4 Despite our success in eradicating and controlling many acute infectious diseases, we now struggle with the changes in disease epidemiology that mandate a new focus on chronic disease management and prevention.

Integrative preventive medicine is based on these changes in disease epidemiology and therefore shifts the focus of our system appropriately from acute to chronic conditions. A shift in focus requires a fundamental understanding of the differences between acute and chronic care as shown in Table 6.1.

Table 6.1 Differences in Acute Versus Chronic Care

Disease Category

Acute

Chronic

Onset

Rapid onset, runs its course, self-limited, usually affects one body system

Gradual slow onset, affects multiple systems, is not responsive to “curing” treatments, not self-limited but progressive over time

Examples

Influenza, cold virus, strep throat, sprains, fractures, abscess

Diabetes, cardiovascular disease, asthma, obesity, cancer

Treatment

Supportive measures, targeted specific therapies with goal of cure (incision and drainage for abscess, removal of infected appendix or gallbladder)

Symptom management, to prevent but not to cure; multiple complex treatment plans aimed at control and prevention of progression (multiple medications for diabetes and dietary changes and exercise for weight loss)

While acute conditions usually have a rapid onset and are self-limited in their disease course, chronic diseases have a gradual onset and are progressive over time. One does not “catch” a heart attack like a cold virus; rather a myocardial infarction is the acute exacerbation of the chronic process of atherosclerosis. Evidence of this comes from many sources including atherosclerotic streaks found in Vietnam War veterans in their early to mid-20s.5 As the pathogeneses of acute and chronic diseases differ, so do their treatments. While acute disease usually involves supportive measures, as in the case of the common cold, or targeted therapies, for clear bacterial infections such as streptococcus pharyngitis, chronic conditions such as type II diabetes (the majority of diabetes cases, accounting for 90%–95% of all diabetes) require more complex multifactorial treatment plans. Integrative preventive medicine recognizes the distinction between chronic and acute conditions and focuses on the chronic diseases of our time. In sync with the pathogenesis of chronic disease, IPM focuses on risk factor modification over time. Integrative preventive medicine therefore emphasizes prevention instead of episodic treatment and risk factor modification instead of simply disease treatment once it is in its later stages.

The Role of Family and Community Medicine in Integrative Preventive Medicine

A new emphasis on preventing the chronic diseases of our time requires a new focus on primary care or family and community medicine (these will be used interchangeably throughout this chapter). Primary care has been underused, underfunded, and underappreciated by both the public and medical professionals. These cultural and professional biases against primary care have contributed in large part to the current shortage of primary care physicians, which has reached crisis levels.6 Despite these realities, family and community medicine or primary care and public health are critical to the care and prevention of chronic diseases. One main reason for this is the fact primary care occurs over time and is relationship based. It also includes “well” visits from childhood and “wellness” physicals for adults. These non-sick or healthy visits serve as great opportunities for prevention and risk factor modification. Integrative preventive medicine shifts the focus from acute to the chronic care and therefore empowers family and community medicine as the foundation for a new model of care that is based on prevention and health promotion over time. The value of this approach cannot be understated as a means to stem the tide of our current epidemic of chronic disease.

In addition to the implications for the practice of primary care outlined below, IPM also requires a new emphasis on family and community in medical education. Integrative preventive medicine is evidence based and recognizes that 80% of medical education is focused on biology and biological factors in the development of disease. Yet, 60% of premature deaths are actually due to “nonbiologic” factors.7 These “nonbiologic” factors form the basis for the risk factors of chronic disease and include behavioral choices, lifestyle, and social determinants. Therefore, IPM recognizes the broader social context and community as critical components to the success of any prevention or therapeutic intervention. For example, a diabetic patient may be advised to change her diet but may not be able to afford the healthy food choices that are necessary to control and prevent progression of diabetes through lifestyle changes. Ignoring these economic and social realities will result in ineffective healthcare interventions. Integrative preventive medicine enlists the support and engagement of the larger community to prevent disease by empowering peers and patients to take an active role in their health. For example, community health educators can serve as catalysts for groups of patients with diabetes or even prediabetes and metabolic syndrome to make lifestyle changes. Integrative preventive medicine further empowers family and community medicine by recognizing the need to shift our medical education to reflect the changes in disease epidemiology from acute diseases that require hospital-based care to chronic conditions that are best addressed in ambulatory settings. The need for this shift is well supported by the fact that 80% of clinical education still occurs in inpatient settings, while 80%–90% of medicine is now practiced in outpatient settings.7 Therefore, IPM recognizes the community and social context as a focal point of care and shifts medical practice to where it is needed most.

Integrative Preventive Medicine Creates a New Model of Family and Community Medicine

To stem the tide of our current epidemic of chronic disease, IPM creates a new model of primary care that is based on prevention and health promotion across the lifespan. Central to this new model is the definition of prevention and its purported goals. The concept of prevention (from the Latin root, praeventus, to anticipate) has been articulated since ancient times.8,9 Disease prevention therefore includes any and all efforts to anticipate the genesis of disease and forestall its progression to clinical manifestations. This definition of disease prevention does not presume to cure disease. Rather than focusing on acute treatment and cure, IPM seeks to compress morbidity and increase the period of disease-free life for as long as possible. The new model of family and community medicine is therefore based on this concept of morbidity compression that was first articulated by James Fries.10

In contrast to the goal of morbidity compression that is afforded by IPM, our current primary care system parallels other specialty fields in medicine that are reactive in their approach to treat acute morbidity as efficiently as possible. While optimal acute care is central even to acute exacerbations of chronic diseases such as myocardial infarctions, the chronic care IPM approach seeks to forestall and delay the development of this acute episode that is both potentially fatal and costly. The impact of IPM for family and community is best understood through an understanding of functional capacity and how it changes over time. Functional capacity is defined here as the ability to perform daily activities at a high level with an exceptional quality of life. Most estimates of functional capacity show a significant and steady decline in a number of physiological systems as early as age 45.11 This decline is accelerated resulting in increased healthcare usage as gleaned by various outcomes such as the percentage of people with prescription medications taken within the last 30 days which jumps from 38% to 67% when comparing individuals aged 18 to 44 with those who are between 45 and 64.12 This steady decline and persistent morbidity results in decades of hospitalizations and recurrent admissions to rehabilitation centers and ultimately assisted living care facilities that all together account for exorbitant costs and poor quality of life.12 As bleak as this picture appears, aging experts at the MacArthur Foundation have asserted that only 30% of the characteristics of aging are genetically based and that environmental factors play a more critical role in the process.13,14 This finding supports the goals of IPM to compress morbidity and lengthen the period of disease-free healthy life by modifying preventable risk factors for the chronic diseases of our time. Therefore, the goal becomes successful aging through the application of IPM in family and community medicine.

Figure 6.1 shows how the application of IPM to healthcare and the development of a prevention model can change the curve of decline in functional capacity with age. Optimizing prevention through the application of evidence-based primary prevention strategies in family and community medicine settings can shift this curve to the right and thereby increase the period of disease-free, high-quality life. Not only does the IPM approach result in increased functional capacity and quality of life but also it prevents hundreds of millions of dollars that are currently being spent on care for the long period of morbidity that affects most of our population. By shifting the graph to the right through the delay of disease progression and morbidity onset, billions of dollars now spent on geriatric care can be saved. Thus, the IPM prevention model increases individual quality of life and reduces costs to our healthcare system.

Figure 6.1 Functional Decline with Age in Acute Care Versus Precention Models. Developed by Randall S. Stafford and Farshad Fani Marvasti

Figure 6.1 Functional Decline with Age in Acute Care Versus Precention Models. Developed by Randall S. Stafford and Farshad Fani Marvasti

Integrative Preventive Medicine Leverages Primary Care to Disseminate Prevention Strategies

Integrative preventive medicine deployed early in the lifespan through evidence-based application of primary prevention to clinical practice seeks to compress morbidity and extend the period of disease-free, high-functioning life. It uses an integrative and admittedly holistic approach to medical care that is absent in our current family and community settings. Therefore IPM is more proactive than reactive in how it approaches health and disease: going upstream to change the course of these conditions by focusing on prevention.

In established models, prevention has been categorized as primary, secondary, and tertiary.15 As shown in Table 6.2, prevention efforts need not be limited to patentable medications or a fixed clinical site with episodic visits and diagnostic testing. Prevention involves the entire range of services from modifying behavior for healthy lifestyle changes to community health education interventions to address the “built environment” including underlying social, political, or economic conditions that predispose population members to disease. As noted, our current system emphasizes the optimization of acute care and thereby focuses almost exclusively on secondary and tertiary prevention. The new model of IPM in primary care expands the dissemination of prevention strategies to shift the focus toward primary prevention as an upstream approach to the chronic diseases of our time.

Table 6.2 A Range of Prevention Efforts

Level

Definition

Examples

Primary Prevention

Activities intended to forestall the development of a disease prior to its clinical diagnosis

Eating a healthy diet and regular exercise to maintain optimal weight, cholesterol, blood pressure, and glucose control in patients with family history of diabetes mellitus type II; population-based health-screening activities such as health promotion activities to address SES, cultural and built environment where disease develops prior to clinical diagnosis.

Secondary Prevention

Activities intended to forestall further developments of existing disease while in its early stages before it results in significant morbidity

Implementing diabetes prevention program with lifestyle changes or low-dose metformin in newly diagnosed diabetic prior to onset of end organ disease. Controlling hypertension through aerobic exercise, the DASH diet, and antihypertensive medications.

Tertiary Prevention

Activities intended to forestall end-stage sequelae of symptomatic clinical disease including significant morbidity leading to functional impairment or death

Treating a diabetic patient with neuropathy and chronic kidney disease with optimal medical management to prevent renal failure and dialysis. Anticoagulants in patients with coronary disease

Integrative Preventive Medicine Changes the Patient Encounter in Primary Care to Recreate “Routine” Physicals

As primary care is relationship based and occurs over time, it is the best-suited field for the deployment of an integrative prevention model to address chronic disease. Although our current model focuses on acute treatment and tertiary prevention, IPM shifts the focus to primary and secondary prevention. This shift results in the recreation of “routine” physicals as opportunities for primary prevention and health education. Instead of merely asking a comprehensive review of systems to find evidence of a latent condition or performing physical exam maneuvers to find an abnormal murmur, IPM transforms these visits to true “wellness” focused encounters. Rather than focusing exclusively on finding latent disease, these visits ought to focus on assessing the patient for risk factors and behaviors that could lead to the development of chronic disease. For example, metabolic syndrome, or syndrome x, has been implicated as a common pathway toward the development of both diabetes and cardiovascular disease.16 Currently we have little to offer these patients and usually wait until an actual diagnosis is made to address these risk factors. Integrative preventive medicine empowers primary care physicians and their extended team of ancillary healthcare providers to prevent the inevitable progression of metabolic syndrome to disease. For example, motivational interviewing has been identified as a potentially powerful tool for effecting behavioral change.17 Behavioral change is critical to addressing metabolic syndrome to prevent disease. Its importance is recognized based on the fact that social determinants of disease and not predetermined unchangeable genetics affect our ability to age successfully.13 These nonbiological factors such as lifestyle choices can be modified. In the IPM model, the social history becomes more extended as a means to find these social determinants and adjust them early on in the process. Therefore, primary prevention and individuals with precursors of disease such as metabolic syndrome become key targets for early intervention to prevent disease diagnosis and progression.

To address metabolic syndrome and early stage chronic disease, IPM expands the use of motivational interviewing and health education. It incorporates well-studied tools such as action planning as part of routine visits to recreate these encounters and initiate a dialogue between the patient and the provider to effect behavioral change. Action planning has been studied in various contexts and has been shown to be particularly effective in healthy behavioral change.18 Most patients reported making a behavior change based on an action plan, suggesting that action plans may be a useful strategy to encourage behavior change for patients seen in primary care.19 The Chronic Disease Self-Management Program (CDSMP) developed by Kate Lorig at Stanford uses this model for behavioral change to address chronic disease. The model involves using a systematic approach of setting health goals with patients using a standard template, SLAM,20 as shown in Table 6.3. Even in 15-minute patient encounters that are characteristic of our acute care model, the SLAM template can initiate an IPM lifestyle change through brief action planning. Subsequent email or phone contact can be made with the patient to assess their progress either by the physician or health coach in a team-based model of care. Success here depends on gaining momentum with small steps toward successful lifestyle changes. Integrative preventive medicine recognizes the critical role that this science of behavior change plays in perpetuating our chronic disease epidemic and favors research and education in this area as part of the new prevention model of care.

Table 6.3 SLAM Template Used in the CDSMP Approach to Setting Health Goals

SLAM

Specific

Walking

Limited

For 45 minutes

Achievable

Must be 7 out of 10 on confidence scale

Measurable

Walk on Mon/Wed/Fri by next week

In addition to action planning and motivational interviewing, providing accurate, evidence-based health education is central to the role of family and community in IPM. The word “doctor” comes from the Latin root docēre, which means to teach.21 In our acute care model, doctors primarily focus on medications and procedural interventions rather than education. The IPM model of care identifies education as a critical tool that is largely untapped by physicians and healthcare providers in our current system. The new prevention model makes education paramount as the primary means for preventing chronic disease through primary care visits and community health education programs. With the preventive model that is proactive rather than reactive, health education materials tailored to each individual patient in the form of an after visit summary and plan of care is emphasized as a key part of the clinical encounter. Using this format of summarizing key insights and patient health goals as a take-home message for patients is a relatively simple way to support individual efforts to make healthy lifestyle changes.

Another tool that has been studied with some success is the use of exercise prescriptions.22 These prescriptions for physical activity have been found to be effective but are limited when simply given out of context. With IPM, the focus is on prevention and physical activity becomes a central pillar to treatment in addition to medication or other conventional therapies. When given in the context of the after visit summary as part of the patient’s health plan and goals set during the visit, exercise prescriptions can be powerful tools for patients to recognize the value of such healthy lifestyle practices. Integrative preventive medicine also expands and tailors exercise prescriptions to include physical therapy routines that are amenable to self-care. For example, the prevalence of low-back pain cause by low-back strain is known to be a common primary care diagnosis. Other sprains and strains also present to the primary care provider. In addition to standard medical therapy such as NSAIDs, exercise regimens have a key role in treating acute injuries to the low back or other joints. These persistent injuries such as low-back strain can be prevented through the use of daily low-back exercises. The expanded routine physical exam that focuses on a needs assessment for patients as part of the IPM model would identify a sedentary lifestyle as a key target for intervention. As most people are now employed in office jobs that require long hours of sitting, low-back injuries are more common. Therefore, exercise prescriptions that include specific low-back exercises to anyone with this sedentary lifestyle can be a powerful tool when widely used in “routine” physical settings to prevent back injury.

Hippocrates is considered to be the founder of Western medicine. He is quoted as advocating for the use of food as medicine and medicine as food. Recognizing the linkages between diet and chronic disease that are currently building similar to the evidence that clearly linked smoking with lung cancer, food prescriptions can also be used as part of the new IPM model for integrative prevention of chronic disease. For example, there has been well-established evidence for the Mediterranean diet in the prevention of cardiovascular disease.23 A food prescription for this type of diet with specific examples and food choices such as the use of extra virgin olive oil in healthy portions as part of our diet can be prescribed along side statins or blood pressure medications used to treat risk factors for cardiovascular disease. Integrative preventive medicine providers could also include simple recipes as part of their food prescriptions for easy-to-make foods such as homemade salad dressing to accompany fresh leafy greens. For example, a salad dressing of extra virgin olive oil, sea salt, cayenne pepper and fresh lime or apple cider vinegar can be made in minutes. The benefit of teaching patients how to make delicious foods that are healthy for them cannot be overstated, as this contributes to healthy habits that pay long-term dividends in preventing disease and maintaining health.

Integrative Preventive Medicine Empowers Primary Care Providers

Integrative preventive medicine empowers physicians to go beyond simply monitoring patients with metabolic syndrome or prediabetes to proactively engaging them with the evidence-based lifestyle changes outlined earlier to prevent the onset of diabetes. Evidence-based nutritional advice and exercise counseling can be systematically incorporated into patient encounters over time. Integrative preventive medicine is more strategic and evidence based rather than simply limited to conventional approaches that are confined to the acute care model that continues to be misapplied to the chronic disease burden. Interventions that are more in sync with the IPM approach toward diseases such as obesity include stealth interventions that focus on overall well-being and physical activity instead of simply weight loss as the explicit endpoint.24 A primary care provider who practices IPM may identify hypertension and obesity as part of a typical patient visit, but will focus on the overall holistic picture of health as the goal of therapy instead of narrowing it down to numerical changes in these measurements. For example, developing a pattern of healthy daily physical activity and following dietary guidelines to ensure at least 5–7 servings of vegetables and fruits every day would be the goal of care. A healthy side effect of behavioral change to achieve this goal would be lowered blood pressure and weight loss to optimal levels. Therefore, IPM shifts the focus from disease-oriented outcomes toward patient-oriented outcomes as a means to achieve chronic disease control and prevention. This shift empowers primary care providers to succeed in behavioral change therapies for their patients.

Integrative Preventive Medicine Redefines Standards to Focus on Primary Prevention

Integrative preventive medicine redefines the US Preventive Services Taskforce (USPSTF) standard for primary prevention guidelines to include proactive engagement and evidence-based integrative prevention of disease beyond routine screening recommendations. Instead of focusing simply on screening for a disease as a means of secondary prevention, IPM seeks to use the best evidence to prevent the disease and extend the period of disease-free high-functioning life for as long as possible. As shown in Table 6.4, a number of conditions with conservative screening recommendations by the USPSTF25 can be expanded based on known evidence to include proactive primary prevention. According to the CDC, “of cancers that affect both men and women, colorectal cancer is the second leading cause of cancer-related deaths in the United States and the third most common cancer in men and in women.”26 In the case of colorectal cancer screening, the guidelines suggest that nothing is done until age 50 to find occult cancer or precancerous lesions such as polyps via colonoscopy. As early as the 1970s, epidemiological research discovered a direct correlation with red meat consumption and the incidence of colon cancer.27 Additional evidence has accumulated over the last 40 years to support several basic interventions that are efficacious, safe, cost-effective, and amenable to self-care. Strong evidence exists for decreasing colorectal cancer by increased physical activity of all types and foods containing dietary fiber such as plant foods. Equally strong evidence exists to show an increased risk for colorectal cancer with consumption of red meat, processed meat, alcoholic drinks especially in men, and abdominal fat.28 Therefore, expanding our approach to address this deadly disease through an IPM framework empowers individuals of all ages to engage in these lifestyle changes to prevent colorectal cancer. Such lifestyle changes based on existing evidence as shown in Table 6.4 have little to no harm associated with them. For these and other conditions IPM moves beyond relying on surveillance to find early stage disease and instead focuses on primary prevention that every patient can engage in at any time.

Table 6.4 USPSTF Grades of Evidence: Grade A: Strongly Recommended Grade B Recommended, Grade C No Recommendation (service can improve health outcomes but balance of harm and evidence too close to justify recommendation) Grade D Not Recommended Grade I Insufficient Evidence18

Condition

USPSTF Guideline

IPM Expansion

Colorectal Cancer

Adults, beginning at age 50 years and continuing until age 75 years (Grade A)

All ages to increase physical activity, fiber with plant-based foods, decrease red meat and alcohol intake, and smoking cessation

Healthful Diet and Physical Activity to Prevent Cardiovascular Disease (CVD)

  • Adults BMI>25 with additional CVD risk factors (Grade B)

  • General population (Grade C) Intensive behavioral counseling on lifestyle changes

All ages could benefit greatly from simple behavioral counseling and motivational interviewing with action plans and healthy lifestyle goals

Diabetes Mellitus

Adults, sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg (Grade B)

Screen adolescents and adults with risk factors even if asymptomatic, all ages prevent insulin resistance with diet and physical activity action plans for lifestyle change

Low-Back Pain

Insufficient to recommend for or against the routine use of interventions to prevent low-back pain in adults in primary care settings (Grade 1)

All ages, specific low-back exercises and ergonomic changes for desk -based jobs to strengthen low-back muscles and prevent injury

In support of the shift from limited screening for secondary prevention to proactive primary prevention, the USPSTF has initiated new recommendations for the prevention of cardiovascular disease through evidence-based physical activity and dietary changes such as the Mediterranean diet.23 As shown in Table 6.4, this is given a grade B recommendation for those who are overweight or obese and have specific cardiovascular risk factors. The recommendation is grade C for the same basic lifestyle health education for the general public, and there is a note in both cases on potential harms including “the lost opportunity to provide other services that have a greater health effect.” This statement suggests there is a time limit on what can be done with any given patient. Although our current practice of primary care is an episodic approach based on the acute care model of care, much can be done to expand health education and improve health literacy beyond these visits. Although little evidence exists to recommend this by the USPSTF, an IPM perspective questions the relevance of this approach to a basic health education issue. Given the easy accessibility and lack of side effects for these lifestyle changes to prevent cardiovascular disease, there is little to no conceivable harm in sharing this information with patients. In fact, health education of this type will help to thwart the misinformation and false claims of the food industry that continuously bombard the general public through many media outlets. Taking a broader perspective, IPM leverages media and community health education programs to disseminate prevention knowledge such as the Mediterranean diet to the general population. Innovative models of care can be developed to expand this beyond current practices. Therefore, IPM enables physicians and the healthcare team to intervene at multiple levels of patient engagement to promote health throughout the lifespan. Through IPM, primary care physicians attempt to not only detect early stage disease through screening but also discover risk factors in the form of behavioral practices that contribute to the development of chronic disease and thereby focus on primordial prevention beyond traditional primary care visits and restrictive guidelines.

Integrative Preventive Medicine Fosters the Development of Innovation in Primary Care

In redefining the approach to prevention beyond restrictive guidelines, IPM fosters the development of innovative models of primary care where the patient is the focus and the relationship over time is leveraged to optimize chronic disease prevention. Integrative preventive medicine goes beyond diagnosing and treating patients to include lifestyle interventions to prevent disease and promote health. The longitudinal nature of primary care enables it to facilitate behavioral change incrementally over time based on a therapeutic relationship between the provider and the patient. This relationship has come under significant duress in our current system, where providers are pressed for time and unable to delve deeper into the social and nonbiological elements that largely determine the chronic diseases of their patients.7 Changes in healthcare delivery such as the advent of managed care and the persistence of fee for service reimbursement based on the acute care model has resulted in a volume-based practice structure where primary care physicians move through patients like “hamsters on a treadmill.”29 This model is largely a result of the misapplication of the acute care approach to the current burden of chronic disease. Being overworked and dissatisfied, primary care physicians are powerless to provide adequate access for acute care visits and limited in their ability to provide state-of-the-art chronic care.30 A shift toward a preventive care model through implementation of IPM in family and community medicine aligns with the emerging shift from volume-based to value-based reimbursement.

By using family and community medicine to prevent disease and maintain health, IPM shifts the focus of care from “sick” to “healthy” visits. Given current models of reimbursement that are based on the acute care system of disease management, most patients do not go to their doctor unless they are sick and experiencing disease symptoms or illness. An integrative prevention-based model requires a shift in reimbursement patterns from fee for service in treating acute conditions to value-based reimbursement that pays primary care provider health systems to keep their patients healthy over time. The move toward value-based reimbursement is likely to accelerate in the coming years to stem the exorbitant costs of care. The shift has already resulted in the emergence of disruptive models of primary care innovation that are currently being studied and discussed in public forums.31 An initiative funded by the Robert Wood Johnson Foundation known as the LEAP program has identified a team-based approach as a key innovation to improving primary care in the management and prevention of chronic disease.32 Integrative preventive medicine fosters this type of innovation by recognizing the need for a preventive model of care that is best suited to the chronic diseases of our time. For example, the Diabetes Prevention Program (DPP) has been extensively studied as a community-based approach to preventing diabetes that is efficacious, safe, and cost-effective.33 Expanding this type of approach beyond traditional sick care visits to include the greater community and healthcare team is a key part of IPM in primary care. Similar to DPP, group visits and workshops can be powerful tools for IPM. Involving health education and the development of peer group dynamics, this format is well suited to chronic disease care and prevention. Such new models of care based on the IPM prevention model will align with value-based changes in healthcare to reinforce the therapeutic relationship as a means to stem the tide of chronic disease through effective dissemination of primary prevention strategies.

Conclusions

Our current system is over 100 years old. It is based on outdated epidemiology and therefore focused on acute care. Our current epidemic of chronic disease demands a new model that shifts the focus from acute treatment to chronic disease prevention. Integrative preventive medicine reinvents family and community medicine to create a new model of care. This model is based on prevention with the goals of morbidity compression and expansion of functional capacity throughout the lifespan. It does not presuppose cure but rather anticipates and forestalls the development of chronic disease through novel evidence-based preventive therapies. The focus of primary care is therefore expanded beyond disease diagnosis and treatment to include primary prevention through lifestyle changes over time. The implications of IPM for family and community medicine are reaching in scope requiring a reevaluation of existing visit structures, screening practices, and reimbursement models. Research in primary prevention strategies needs to be expanded and subsidized to develop evidence-based interventions at all ages that are amenable to self-care, cost-effective, and safe. The science of behavioral change will become critical to identify mechanisms to catalyze the move toward healthy lifestyles on a population level. To support these changes in primary care practice, policy must also be developed to address the social and economic determinants of disease. Such changes will legislate on environmental toxins, the built environment, and the food industry to be accountable for their respective impact on chronic disease and health. The refined IPM model of primary care should be taught as part of medical education to ensure a baseline of competency for providing preventive approaches to patients at risk for chronic disease diagnosis and progression. This will require the expansion of motivational interviewing and health education in the undergraduate medical school curriculum. With these and other changes, the role of family and community medicine will be redefined to serve as the chief means for implementing a new prevention model to stem the tide of lives lost from the chronic diseases of our time.

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