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J Altern Complement Med. 2019 Mar;25(S1):S52-S60. doi: 10.1089/acm.2018.0445.

What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.

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1 Center for the Study of Healthcare Innovation, Implementation and Policy CSHIIP, Greater Los Angeles VA Medical Center, Los Angeles, CA.
2 Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, CA.
3 Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA.
4 Brandeis University Heller School for Social Policy and Management, Waltham, MA.
5 Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI.
6 Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA.
7 Integrative Health Coordinating Center, VA Office of Patient Centered Care and Cultural Transformation, Washington, DC.



Health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health (CIH) approaches. The nation's largest health care system, the Veterans Health Administration (VA), has been transforming to such a system. However, anecdotal evidence suggested that many VA medical centers have faced challenges in implementing CIH approaches, whereas others have flourished. We report on a large-scale, research-operations partnered effort to understand the challenges faced by VA sites and the strategies used to address these to better support VAs implementation of CIH nationally.


We conducted semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers, with content based on Greenhalgh's implementation framework. For analysis, we identified a priori categories of content aligned with Greenhalgh's framework and then generated additional categories developed inductively, capturing additional implementation experiences. These categories formed a template to aid in coding data.


VA sites commonly reported that nine key factors facilitated CIH implementation: (1) organizing individual CIH approaches into one program instead of spreading across several departments; (2) having CIH strategic plans and steering committees; (3) strong, professional, and enthusiastic CIH program leads and practitioners; (4) leadership support; (5) providers' positive attitudes toward CIH; (6) perceptions of patients' attitudes; (7) demonstrating evidence of CIH effectiveness; (8) champions; and (9) effectively marketing. Common challenges included are: (1) difficulties in hiring; (2) insufficient/inconsistent CIH funding; (3) appropriate patient access to CIH approaches; (4) difficulties in coding/documenting CIH use; (5) insufficient/inappropriate space; (6) insufficient staff's and provider's time; and (7) the health care cultural and geographic environments. Sites also reported several successful strategies supporting CIH implementation.


VA sites experience both success and challenges with implementing CIH approaches and have developed a wide range of strategies to support their implementation efforts. This information is potentially useful to other health care organizations considering how best to support CIH provision.


acupuncture; implementation research; integrative medicine; mindfulness; veterans; yoga

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