Hospital Partnership: Q & A

Welcome to our bimonthly question-and-answer column, designed to address your questions and share our consulting experience. (We will continue to update you about events related to acupuncture and public health in our regular column.). As questions continue to come in, we'll address common concerns voiced by acupuncturists throughout the country. Please e-mail any questions related to starting an enterprise, the nonprofit sector, public health settings, hospital integration, and clinical issues to our electronic addresses listed at the end of this month's article.

Question: If I have only a limited number of hours available to devote to hospital practice, is it worth my time to pursue offering clinical services? Realistically, I don't have more than one morning a week to work in a hospital environment, but I'd like to consider practicing there. Any ideas?

Our response: As acupuncturists, we have a variety of options to consider when we offer treatment. The versatility of Asian medicine definitely favors creative approaches!

Although one standard of practice is the clinical setting, in which one acupuncturist treats one or more clients in separate treatment rooms, there are other alternatives. Depending on the type of health condition(s) being addressed, acupuncturists might want to consider offering treatment to individuals in a small group context. This type of approach would lend itself to auricular treatment focused on particular issues such as stress, pain or sobriety maintenance.

Intakes or other private conversations can be arranged in a nearby office to protect client confidentiality. Intakes can be scheduled for a particular day or time when other treatments do not compete for the acupuncturist's attention. Treatment could be offered on a weekly basis provided that this schedule would appropriately address the health issues presented by the clients.

As in a private practice, intake materials can and should provide optimal information for the acupuncturist; baseline indicators such as pulse or tongue diagnosis can easily be included in the intake documents.

Having a quiet room is important; the space should have comfortable chairs arranged so that sufficient space exists for the acupuncturist to move around each client freely. Cups of herbal tea can be dispensed to promote relaxation. Despite the fact that conversation is not encouraged, a bonding between clients can occur that is therapeutic for all.

This type of clinical milieu is particularly conducive for stress reduction settings or for pain clinics, but may work well in other settings. Our agency has just begun a new collaboration with the oncology department at Massachusetts General Hospital. Up to 60 patients may be in the infusion ward receiving chemotherapy, which is done in a group setting with patients reclining in large chairs. With limited funding, we sought to find a cost- and time-effective solution to provide acupuncture care. Patients will receive auricular treatment that can focus on pain, anxiety or discomfort, as well as on minimizing nausea or other side-effects related to chemotherapy. This service will provide a large number of clients with free auricular treatment during their infusions and help to substantiate the need for additional funding to expand the program to include full body treatment.

We don't recommend this type of treatment if you're working with individuals who are struggling with detoxification from drug or alcohol use or with sobriety maintenance; in both of these contexts, the most appropriate treatment milieu includes counseling and daily treatment as described by the National Acupuncture Detoxification Association.

Question: How formal should the planning and negotiation process with a hospital be? Do you suggest a written contract or other agreement?

Our response: Having a written agreement that is acceptable to both the institution and to yourself will help to clarify mutual responsibilities and roles of the practitioner and the host agency. As institutional personnel change, verbal agreements can be re-interpreted. Working relationships can change or evolve over time, obscuring some of the original intent and planning. Most institutions require their legal team to design or review all contracts. You can expedite the process by submitting a draft agreement as a starting point.

The key elements of a written agreement include:

• Liability issues - Who provides malpractice insurance? What types of procedures related to acupuncture will be acceptable (e.g. moxibustion or cupping)?
• Supplies and waste disposal - Who will provide the supplies, and who will accept responsibility for biohazard waste disposal and documentation?
• Record-keeping - How will the acupuncturist record and access treatment notes? What level of detail is required? Will records be integrated into the hospital's system?
• Confidentiality - How will HIPAA regulations be monitored and enforced?
• Client referral - Who is responsible for promoting the program? What referral networks does the institution already have in place?
• Appointment-making - Who does this? Are reminder calls routinely made before treatment?
• Level of participation in institutional activities - Will the acupuncturist be included in grand rounds, staff meetings, and other internal gatherings? Will information about the acupuncture service be routinely included in the hospital's newsletter and Web site?
• Fees - What fee structure and payment mechanisms are planned for the service and acupuncturist? Who will collect payment for treatment? Will the acupuncturist be paid on a percentage basis or be on salary at the hospital?

We recommend having written agreements securely in place before starting work in the institutional environment; it's definitely preferable to have working arrangements clearly defined before beginning a new service. Taking the time to fully explore the realities of what the program entails will benefit everyone concerned; the realities of starting a program and then having to discontinue it will negatively impact patients and reflect poorly on our profession.

This is analogous to the adage about taking the pulse; the superior acupuncturist will spend time "listening" and interpreting the pulse and, after the pulse is fully understood and appreciated, proceed to the treatment. Taking the pulse may actually require more time than providing the acupuncture. The opposite approach of quickly taking the pulse and precipitously moving on to the treatment, without fully comprehending the message the pulse is giving, can lead to suboptimal results and should be avoided.

By moving methodically through the discussions and negotiations with institutional partners, acupuncturists can gain valuable expertise in forging agreements that work. These agreements can further serve to promote acupuncture practice and become templates for additional expansion into the hospital setting. Cultivating and developing institutional partnerships is crucial for acupuncturists. At this time in the U.S., we're at a point in our professional development where health care that includes acupuncture can become a right, not a privilege.