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Severe COVID-19 infection requiring oxygen support is reported to have high mortality. Chest Severity Score evaluated through CT scan has a predictive value about future outcomes in such cases. Score value ∼18 is predicted to have poor outcomes. We are presenting here a case of severe COVID-19 with all predictors suggestive of a bad prognosis including IL-6, D-Dimer, Ferritin and CRP in addition to 18/25 Chest Severity Score. Initially treated under ICU care at a tertiary care COVID hospital for about 14 days, the patient was intervened with Ayurveda on his own insistence seeing the unsatisfactory improvements. Ayurveda intervention for 19 days along with standard ICU care resulted in complete clinical recovery of the patient besides the correction of biomarker levels. Rapid clinical and biochemical correction in this severe COVID-19 case against all odds is highly significant and warrants an urgent search for possibility of instituting the integrative management strategies for all those treated in an allopathic facility. This case also advocates an early institution of Ayurveda interventions in COVID-19 in order to prevent deterioration leading to complications.

Graphical Plain Language Summary Multiple sclerosis (MS) is a chronic disease in which the immune system attacks the central nervous system, causing inflammation and neurodegeneration. People living with MS may experience a variety of symptoms as a consequence of this process, including many “invisible” symptoms that are internally manifested and not seen by others. Of the invisible symptoms of MS, which we have reviewed in a companion article, mood and mental health disorders are of particular concern due to their high prevalence and significant impact on patient quality of life. In this review, we showcase the experiences of patient authors alongside perspectives from healthcare provider authors as we promote awareness of the common mental health conditions faced by those living with MS, such as depression, anxiety, adjustment disorder, bipolar disorder, psychosis, and suicidal ideation. Many of these conditions stem in part from the increased stress levels and the many uncertainties that come with managing life with MS, which have been exacerbated by the environment created by the coronavirus disease 2019 (COVID-19) pandemic. A patient-centered interdisciplinary approach, routine screening for mental health changes, and referral to specialists when needed can normalize discussions of mental health and increase the likelihood that people living with MS will receive the support and care they need. Management techniques such as robust social support, cognitive behavioral therapy, mindfulness-based interventions, and/or pharmacotherapy may be implemented to build resilience and promote healthy coping strategies. Increasingly, patients have access to telehealth options as well as digital apps for mental health management. Taken together, these approaches form an integrative care model in which people living with MS benefit from the care of medical professionals, a variety of support networks/resources, and self-management techniques for optimal mental health care.

Background: Distributive leadership has been proposed as an effective means towards achieving integrated health services. This study draws from the case of Foundry, a network of integrated youth health centres in British Columbia, Canada, and explores the function and impact of distributive leadership in the context of a large-scale effort towards integrated service delivery for youth experiencing mental health and substance use challenges. Methods: Qualitative data was obtained from a developmental evaluation of Foundry using a longitudinal, ethnographic approach. Over 150 participants involved in the development of six Foundry centres were interviewed individually or in focus groups. Purposive and theoretical sampling strategies were used to maximize the diversity of perspectives represented in the data set. Results and Discussion: Distributive leadership was observed to be a facilitator for achieving service and system-level integration. Distributive leadership was effective in promoting streamlined service provision, and coordinating efforts towards optimized access to care. A new culture of leadership emerged through collaboration and relationship-building based on a common value system to prioritize youth needs. Conclusion: As Foundry, and other integrated youth services, continues to expand, distributive leadership shows promise in assuring diverse and coordinated input for integrating services.

Background Flexible and integrative treatment (FIT) models are rather novel in German mental health care. This study aimed at identifying and evaluating empirically based, practicable, and quantifiable program components that describe the specific treatment structures and processes of German FIT models. Methods A multi-step, iterative research process, based on Grounded Theory Methodology (GTM), was used to identify and operationalise components. A complex algorithm and expert-interviews were applied to quantify the relative weight of each component and to develop a sum score. Face and content validity were examined and internal consistency was tested by Cronbach’s α coefficient. Results Ten of eleven FIT components could be operationalised, quantified and united in the total score. All operationalised components showed sufficient face and content validity and eight components had a good reliability. Conclusions The components are a first step in the process of operationally defining German FIT models. They considerably overlap with various critical ingredients of international FIT models and may serve as a theoretical basis for constructing fidelity tools and research guides to enable process and outcome evaluation of German FIT models.

This review article proposes a model of integrative care for cardiovascular patients in institutional settings. We review relevant historic and contemporary examples of medical–chiropractic cooperation and a brief review of the literature illustrating the clinical benefits of chiropractic care for patients with cardiovascular disease. The groundwork proposes a distinct research and clinical practice model incorporating the doctor of chiropractic (D.C.) as a synergistic partner with the medical cardiologist coined the Kaleidoscope Model of Integrative Care (KM). While a traditional kaleidoscope does not alter the nature of light itself, the observer does see the ‘raw data’ of colors and shapes, wavelengths, etc. contained within the “potential” of the light itself; left unrecognized, even subtle re-orientations of the instrument changes the perspective. Similarly, the KM is intended as a conduit for slight reorientations to traditional medical–chiropractic–patient hierarchies, thus creating new treatment options and generating robust changes in inter-professional perception of the patient's condition(s) and treatment options. It is hoped that this model will not only serve future patients within hospitals, but that institutions will serve as incubators for better collaboration and research among the majority of free-standing medical and chiropractic practices ultimately benefitting the patient with cardiovascular disease. Keywords: Cardiology, Chiropractic, Heart failure, Integrative care, Translational medicine

Background Health policy in many countries directs treatment to the lowest effective care level and encourages collaboration between primary and specialist mental health care. A number of models for collaborative care have been developed, and patient benefits are being reported. Less is known about what enables and prevents implementation and sustainability of such models regarding the actions and attitudes of stakeholders on the ground. This article reports from a qualitative sub-study of a cluster-RCT testing a model for collaborative care in Oslo, Norway. The model involved the placement of psychologists and psychiatrists from a community mental health centre in each intervention GP practice. GPs could seek their input or advice when needed and refer patients to them for assessment (including assessment of the need for external services) or treatment. Methods We conducted in-depth qualitative interviews with GPs (n = 7), CMHC specialists (n = 6) and patients (n = 11) in the intervention arm. Sample specific topic guides were used to investigate the experience of enablers and barriers to the collaborative care model. Data were subject to stepwise deductive-inductive thematic analysis. Results Participants reported positive experiences of how the model improved accessibility. First, co-location made GPs and CMHC specialists accessible to each other and facilitated detailed, patient-centred case collaboration and learning through complementary skills. The threshold for patients’ access to specialist care was lowered, treatment could commence early, and throughput increased. Treatment episodes were brief (usually 5–10 sessions) and this was too brief according to some patients. Second, having experienced mental health specialists in the team and on the front line enabled early assessment of symptoms and of the type of treatment and service that patients required and were entitled to, and who could be treated at the GP practice. This improved both care pathways and referral practices. Barriers revolved around the organisation of care. Logistical issues could be tricky but were worked out. The biggest obstacle was the funding of health care at a structural level, which led to economic losses for both the GP practices and the CMHC, making the model unsustainable. Conclusions Participants identified a range of benefits of collaborative care for both patients and services. However, the funding system in effect penalises collaborative work. It is difficult to see how policy aiming for successful, sustainable collaboration can be achieved without governments changing funding structures. Trial registration ClinicalTrials.gov identifier: NCT03624829.

Metastatic cancer, especially in the growing population of geriatric patients, presents a big challenge to these patients, as well as to treatment teams and the entire health care system. This article describes some common medical problems faced by patients with metastases to liver and bone, and presents a diagnostic approach, and therapeutic management of various symptoms, relevant to advanced stages of the malignant disease. The article highlights the importance of patient education on various aspects of metastatic cancer, and underscores the unique position of pharmacists practicing pharmaceutical care, which is particularly beneficial in this group of patients with advanced malignancy. Also, this paper emphasizes that achieving a proper balance between managing the malignant disease and maintaining the patients’ quality of life, especially in the elderly population, should involve coordinated efforts of the oncology treatment team, primary care physicians, pharmacists, therapists and nurses, as well as patients, their families and caregivers.

Purpose For some years now, a programme for the use of integrative care in paediatric oncology has been established in a German university hospital and offers patients and parents complementary treatment options. According to their medical condition and wishes. A variety of external applications such as medical wraps, warm oil compresses and rhythmic embrocations are offered. This article analyses how patients and parents perceived and experienced the integrative care program. Methods In this qualitative study, data consists of field notes conducted through participant observation, informal conversations and interviews with parents (n = 25) during the implementation phase of the program. Data was analysed on basis of thematic analysis and organized with the analysis software MAXQDA. Results Parents and families intuitively developed strategies for dealing with crisis situations such as childhood cancer. In addition, many of the families brought with them a wealth of experience in complementary medicine. Parents perceived the integrative care treatments as soothing, relaxing and pain-relieving for their child. Patients could relax and side effects of chemotherapy were alleviated. However, children, who undergoing chemotherapy were not always open for physical touch and thus sometimes also rejected the treatments sometimes. Conclusion The analysed integrative care programme is perceived as a strong patient and family-centred approach of support during the oncological paediatric treatment. From a salutogenetic viewpoint, this program aims to strengthen the dimension of manageability within the concept of sense of coherence. Parents are given supportive means to manage side effects and ease their child’s suffering, through touch and attention that can be very beneficial.

Introduction : The project arises from the need to make healthcare systems more efficient, at the same time respond to the population suffering from complex wounds, through a new integrative care model in complex wounds of interdisciplinary clinical care delivery units. After analysing the existing models to address this kind of problem, of a designed structure that seeks to define an optimized model characterized by patient centralization, integrated care, efficient management practices, multidisciplinary competence team and; the resulting model would be designed with the active involvement of stakeholders and policy makers with the objective of guaranteeing the widest possible applicability. Complex wounds are a relevant problem within the existing population in the different levels of care. It is important to note, that it is a multifactorial problem. The approach of these wounds is a great challenge for healthcare teams. Main Objective : Define an innovative integrative care model in complex wounds by interdisciplinary units and management models. Secondary Objectives : Analyse the efficiency of this model, the approach and management of patients with hard-to-heal wounds. Method : The differential diagnosis is the first key in this process. Complex wound units perform accurate filtering of each case, and can make referrals to the indicated specialist, but controlling patients, from its entry into the system until the resolution of the problem. In this way the possible drawbacks or jamming that could arise in the circuit may be detected. The established care plan is agreed and adapted to the individual needs of each patient, always supported by a skilled professional. The empowerment of patients in their health care is the second key to not abandon the plan of care. The team of specialists includes different disciplines, such as: Plastic and Reconstructive Surgery, Vascular Surgery and Angiology, Internal and Infectious Medicine, Dermatology, Nutritionist and Expert Nursing Team. Results : This Project began in February 2013 closing the year with 325 patient visits (n: 44) data that was exceeded in 2014 with 738 visits (n: 81). In September of the current year, we’ve already reached 900 visits. The average time of evolution of the lesions on arrival to the system (retiring three cases that broke the norm with 15, 9 and 8) were around 12 months, while the average problem resolution time ranged from 2 months. In 2013 we managed to resolve 68% of cases, while 2014 ended with 81% of cases resolved. There were several correlated variables that could be of interest in this part of the study very motivating for future studies DISCUSSION : It's important to have a clinically effective and cost-effective allocation of health resources, decisions on treatment and prevention of wounds as a result. Reduce length of patient hospital stays. Promote preventive measures that allow reducing the prevalence. The scope of the parameters to be considered, favours the development of an archetype with a high transfer potential to other unit types. Streamline demand improving hospital and primary healthcare. Offer support to care centres so that they can become self-sufficient. Reduce queries of specialized patients derived incorrectly. Nursing plays a new role (in Spain): "Advanced Nursing" may require changes in legislation and regulations to eliminate barriers in the practice. This model of integrated care, works in several fields. A horizontal integration between health services, social services and other providers and a vertical integration model, which includes primary care, community, hospital and geriatrics. This experience has been through some obstacles. Economic: It has been implemented in a time of crisis and budget cuts, which has fought with an internal restructuring of the team that has led to a professional and human effort. Resistance to change: The lack of predisposition to the collaboration of other medical equipment has been a problem that has been waning as was demonstrating the efficiency and professionalism. Professional barrier: A nursing coordinator has the need to interact with other leaderships of higher professional range (mostly medical). Has been created close relations between different disciplines. Distrust to a new management model: Has been increased the effort and steady work, which has generated well results and a special interest in its diffusion. Conclusion : There is the need to develop basic lines of work in different fields. It’s necessary to carry out more studies to prove that interdisciplinary wounds units are suitable and a need required by society and expected from the health care system: a low cost, the best possible management and excellent quality of care.

Introduction: In its annual report for 2008, the World Health Organization (WHO) states fragmentation is one of the five most common shortcomings experienced by health systems in health care provision, while an integrated healthcare model can significantly improve efficacy/efficiency, reduce visits to doctors, improve patient satisfaction, and ensure safe and quality healthcare. Aim: The aim of our study is to point out importance of the cooperation between healthcare professionals from different sectors, institutions and levels of care involved in patient treatment and care and to propose measures for integration including criteria for clinical review and audit. Methods: In this paper, feedback and results from three workshops held in Tuzla on October 16th, 2007, Bihac on December 9th, 2013, and Sarajevo on November 24th, 2018, were analyzed. All three workshops used the same methodology: first they have had a lecture on the topic of “Interface theory and protection blocks in the health system” and the second part took the form of six working groups in accordance with participants’ affinities and places of employment. Results: The measures proposed to improve the interface are included: Development and adoption existing of clinical practice guidelines and pathways; Maintain joint working group meetings; Eliminate conflicts between PHC and hospital care and seek consensus through formal cooperation. Criteria for clinical audit of the PHC-hospital interface are: annual analysis of unnecessary or inadequate referrals as well as of any duplication of tests and prescriptions (failure to control costs); joint planning of preventive treatments (including the ministry and public health authorities); and clear responsibilities related to screening programs and patient path analysis. Discussion: Standardized communication protocols should be used to improve communication between health professionals at different levels and to moderate integration processes and protect data. Conclusion: Regular communication between healthcare professionals across the various institutions and levels of health care is a prerequisite for organizational, functional, service and clinical integration.

Camphill Medical Practice NHS(CMP) and Camphill Wellbeing Trust (CWT), a Scottish medical charity, have developed an integrative medical-therapeutic approach for patients with complex needs in a primary care setting. This multi-modal approach is both integrative in its nature and integrated in its delivery. The anthrohealth approach [also known as anthroposophic medicine1] is based on the conventional medical system of diagnoses and treatment, but extends this with a specific holistic understanding of the patient in illness and in health. The prescribing spectrum is extended with medicines derived from minerals, plants and animals, and the therapeutic options with specific nursing techniques and therapies. These include therapeutic speech and art, eurythmy therapy, rhythmical massage, riding therapy and counselling /psychotherapy. A shared anthrohealth philosophy and knowledge base amongst doctors, nurses and therapists facilitates effective integration of the therapeutic modalities within patient-centred individualised therapeutic programmes. These aim to help the patient address illness, build resilience and maintain wellbeing. The approach has high patient satisfaction, particularly where conventional treatment has plateaued or has little to offer. Anthrohealth is also integrated in delivery through the joint working of an NHS practice and a third sector organisation. CMP’s core primary care services are extended with CWT’s anthrohealth services, through collaborative planning and sharing of resources, including premises and personnel.

Background: Spiritual care has been shown to be beneficial for patient in the settings of oncology and intensive care [1-5]. We propose that the quality of care given to the aging or to individuals with chronic illness might also improve as a result of the inclusion of spiritual care interventions in the integrative care models which guide the management of such individuals. The research studies to date that point to a positive impact of spirituality on patient outcomes in this patient population, have been criticized for the lack of a strong theoretical framework [6- 11]. The need for spiritual care is recognized, but a theoretical model has not been developed, and testable spiritual interventions have not been defined. In addition, there are also key reasons that have to do with the conceptualization of integrative care itself — the focus on the integration of ‘services’ which have a direct economic component is reflected in the WHO definition of integrated care: “Integrated care is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency” to the individual [12, p.6]. The person in the WHO scheme is always to be seen as part of an entity and a system of beliefs, culture, religion and a community ecosystem and not to be seen as a "single" person. Similar reports from the IOM (Institute of Medicine) (13, p.20) focus on the essentials of a “systems engineering” approach to fixing an aliening health care system, defining essential and necessary steps best depicted by the following diagram. The individual, labeled as patient, is the white circle with no subscript. Although the word spiritual evokes fears in some people that esoteric concepts undermine the scientific rationality, we would argue that conceptually spiritual care is based on the rational concept of how we define a person in

Introduction: The Danish Multiple Sclerosis Society has conducted a research project where five conventional and five complementary practitioners as a team have treated people with Multiple Sclerosis (MS). As part of the treatment project’s interdisciplinary framework, the team has worked with negotiated treatment goals. The overall purpose of this paper is to explore how negotiated treatment goals can contribute to an interdisciplinary treatment effort for people with MS. Theory: The study explores 1) How a flexible framework for involving negotiated treatment goals has been handled by the practitioners, 2) What potentials and challenges have been involved in the practitioners’ work with negotiated treatment goals. The analyses are based on theories of epistemic cultures and learning theories, focusing on interdisciplinary development. Methods: The study was conducted as an exploratory case study. The data material consists of patient-owned records, referral schemes, questionnaires and completion reports. Results and conclusions: The flexible frame for the involvement of negotiated treatment goals has been handled in an incohesive way. Lack of time for coordination and trends for mono-professionalism as well as parallel treatment have posed challenges in the process, both for practitioners and patients. Despite these challenges, the team managed to implement successful treatment courses, not least due to a thorough pre-phase of collaboration. Discussions: The research results indicate that there is therapeutic potential in the use of negotiated treatment goals, but that a number of conditions must exist to obtain benefits from such negotiation.

Introduction: More than 50% of the People with Multiple Sclerosis (PwMS) in Denmark have used complementary and alternative medicine (CAM). The majority of these combine CAM and conventional treatment, and from 2004 to 2010 the Danish Multiple Sclerosis Society conducted a research project with the purpose of investigating and testing models for cooperation between conventional and complementary practitioners. Theory: Five health care providers and five CAM practitioners were set up to work together from 2004 to 2010 in developing and offering integrated treatment to 200 PwMS at a Danish MS Hospital. The investigation of the collaborative process between practitioners has been based on theories of epistemic cultures as well as learning theories, focusing on interdisciplinary development. Methods: Empirical material consists of individual interviews with practitioners, a group interview with practitioners, a group interview with professional staff at the Danish MS Hospital, interviews with patients as well as written responses from the practitioners. Results and conclusions: The six-year cooperation among the practitioners documented mutual inspiration and learning within the team, as well as numerous basic challenges involved in developing interdisciplinary treatment for PwMS. Cooperation between researchers and the treatment team resulted in the development of four interdisciplinary models, which describe the potentials and barriers in relation to various types of collaboration. Discussions: In many cases, integrating CAM and conventional treatment providers is seen as an ideal. This paper points out the importance of not overlooking the opportunities, values and the potential inherent in a pluralistic ideal in terms of the patients’ own active efforts and the dynamism that can arise when the patient becomes a co-informant, co-coordinator and/or co-integrator.

Background: Massage therapy has grown in popularity, yet little is known globally or in New Zealand about massage therapists and their practices. Purpose and Setting: The aims of this study were to describe the practice patterns of trained Massage New Zealand massage therapists in New Zealand private practice, with regard to therapist characteristics; practice modes and settings, and therapy characteristics; referral patterns; and massage therapy as an occupation. Research Design and Participants: A survey questionnaire was mailed to 66 trained massage therapist members of Massage New Zealand who were recruiting massage clients for a concurrent study of massage therapy culture. Results: Most massage therapists were women (83%), NZ European (76%), and holders of a massage diploma qualification (89%). Massage therapy was both a full- (58%) and part-time (42%) occupation, with the practice of massage therapy being the only source of employment for 70% of therapists. Nearly all therapists (94%) practiced massage for more than 40 weeks in the year, providing a median of 16 – 20 hours of direct client care per week. Most massage therapists worked in a “solo practice” (58%) and used a wide and active referral network. Almost all therapists treated musculoskeletal symptoms: the most common client issues or conditions treated were back pain/problem (99%), neck/shoulder pain/problem (99%), headache or migraine (99%), relaxation and stress reduction (96%), and regular recovery or maintenance massage (89%). The most frequent client fee per treatment was NZ$60 per hour in a clinic and NZ$1 per minute at a sports event or in the workplace. Therapeutic massage, relaxation massage, sports massage, and trigger-point therapy were the most common styles of massage therapy offered. Nearly all massage therapists (99%) undertook client assessment; 95% typically provided self-care recommendations; and 32% combined other complementary and alternative medicine therapies with their massage consultations. Conclusions: This study provides new information about the practice of massage therapy by trained massage therapists. It will help to inform the massage industry and other health care providers, potential funders, and policymakers about the provision of massage therapy in the NZ health care system.

Introduction: Translational education takes up the notion of integrating basic research and practice out of a cross-disciplinary perspective given that disciplinary knowledge will no longer be sufficient to account for the complexity of the encountered problem fields. Persons trained in translational education will thus be able to integrate several disciplinary knowledge domains and translate new developments in basic research to their application. Description of care or policy practice: The concept of translational education has become prominent in medical training and it clearly has implications for the training of care givers given the complexity of the diverse problems associated with care. Care and care giving always imply theory and research from different scientific disciplines; there are medical, legal, sociological, and psychological components of care giving, and care giving also increasingly relies on new developments in the domains of technology. In order to keep an integrative view of all these developments and to finally obtain an integrative approach in care, translational education represents an imperative task for training carers in the domains of ageing and disabilities. Conclusion and discussion: Caring for a person—be it formal or informal—always has to rely on a sound basis of knowledge in order to prevent failures as well as feelings of stress and strain. Given that the knowledge base for carers becomes increasingly complex as it is fed by several disciplines as well as societal developments, training and education programmes should realise both a translational approach as well as a lifelong learning perspective. Although much is in favour of such an approach, limits of translational education do exist as well and these comprise mainly the production of a common knowledge across multiple domains for the cost of neglecting in-depth understanding of specific knowledge domains.

The burden of cancer continues to increase globally, with substantial personal, societal, and economic consequences. Population growth and aging underlie this increase&mdash, a reflection of the effect of population health interventions in the last two centuries. Much of this gain has come through observation, derivation of evidence, and rigorous application of valid science to the public, both healthy and affected by diseases such as cancer. Increasingly, molecular medicine will affect the knowledge of cause and the personalization of therapy. However, science informs the decision-making process and places evidence within the beliefs of individuals and society as they relate to innovation, judgment, and values&mdash, the &ldquo, logic&rdquo, underlying alignment of conventional and complementary (holistic) care as a basis for compelling, consistent, and confident decisions.