The HOPE Note: Transforming Primary Care with Integrative Health

Introduction: The Need for a Paradigm Shift

The US healthcare system is currently facing a crisis characterized by high costs and poor results. The fundamental issue is that the current healthcare model was built on an “acute care” framework designed to treat illness, usually at late stages. While effective for acute injuries, this approach no longer works for healing the chronic diseases that plague modern society.

Today, 45 percent of Americans suffer from at least one chronic disease, and these conditions account for 81 percent of hospital admissions and 91 percent of prescriptions. Economically, the disparity is stark: the top 5 percent of patients are responsible for nearly 50 percent of all healthcare spending in the United States. To address this unsustainable trajectory, healthcare must shift from a physician-oriented, hierarchical system to a comprehensive approach involving the patients themselves. The HOPE Note is presented as a roadmap and tool to facilitate this shift toward integrative health.

Understanding the Determinants of Health

A core premise of the HOPE Note is acknowledging that medical intervention plays a surprisingly small role in overall health outcomes. Only 15 to 20 percent of health-related outcomes are attributable to medical interventions. The remaining determinants of health are related to behaviors (such as diet and smoking), and the physical, social, and economic environments that affect a person’s ability to make healthy choices.

Despite the fact that lifestyle factors cause seven out of 10 deaths, medical training and financial incentives encourage physicians to look only at conventional approaches like drugs and procedures. Conditions such as hypertension, diabetes, anxiety, and chronic back pain can often be managed with lifestyle and alternative approaches rather than medication alone. To be effective, physicians must integrate self-care and evidence-based complementary healing methods into their overall approach.

Defining Integrative Health

To clarify the landscape of modern care, the document defines several key terms:

Integrative Health: The pursuit of personal health and well-being that addresses disease as needed, supported by a team dedicated to conventional, complementary, and self-care approaches. It focuses on the whole person and the whole community.
Conventional Medicine: The delivery of evidence-based approaches for disease prevention and treatment as currently taught and paid for by the mainstream system.
Integrative Medicine: The coordinated delivery of conventional medicine combined with evidence-based complementary and alternative medicine (CAM).
Lifestyle Medicine: The incorporation of healthy, evidence-based self-care and behavioral approaches into conventional practice.

The HOPE Note vs. The SOAP Note

Medical students are trained to use the SOAP note (Subjective, Objective, Assessment, and Plan). While SOAP is effective for diagnosing and managing acute diseases, it is insufficient for chronic, multifactorial conditions. It often fails to address social and emotional factors, lifestyle issues, or the patient’s values and life goals.

The HOPE Note (Healing Oriented Practices and Environments) is designed to complement the SOAP note. It is a patient-guided process intended to identify the patient’s values and goals for healing, rather than just disease treatment. The objective is to identify behaviors that stimulate inherent healing capacity and engage the patient in shared decision-making.

The HOPE Note Template

The HOPE Note consists of a set of questions across four specific domains. These questions guide the conversation to reveal what truly matters to the patient.

1. Mind and Spirit

These questions assess the patient’s intrinsic motivations and beliefs. The core distinction here is asking “What matters?” instead of “What’s the matter?”.

Key Questions: “Why do you seek healing?” “What are your plans and aspirations in life?” and “What do you find to be your most meaningful daily activities?” .

2. Social and Emotional

Because social support is “salutogenic” (health-creating), understanding a patient’s relationships is vital.

Key Questions: “How is your social support?” “Do you have family and friends with whom you can discuss your life events and feelings?” and questions regarding past social or physical traumas.

3. Behavior and Lifestyle

Behavior and lifestyle impact up to 70 percent of chronic illnesses. This section provides a snapshot of the patient’s daily habits.

Key Questions: “What do you do for stress management?” “How’s your diet?” “Do you exercise?” “How is your sleep?” and “Do you use complementary and alternative medicine?” .

4. Environment

The physical environment (home, work, neighborhood) plays a larger role in health than many realize.

Key Questions: “What is your home and work environment like?” “What is your exposure to light, noise, clutter…?” and “What is your exposure to toxins?” .

At the conclusion of these questions, the physician summarizes the top three items the patient wants to work on to verify alignment.

Putting the Patient Front and Center

The HOPE Note facilitates patient engagement, which has been described as “the blockbuster drug of the century”. Engaged patients are more motivated, make better decisions, experience fewer complications, and have lower healthcare costs. One study indicated that knowledgeable and confident patients had costs 21 percent lower than less engaged patients with similar conditions.

This is particularly relevant for diabetes management. The Diabetes Prevention Program study showed that modest weight loss through dietary changes and physical activity sharply reduced the risk of developing diabetes—more dramatically than the drug metformin . This evidence supports the shift toward lifestyle interventions as a primary medical strategy.

Case Study: Sally’s Chronic Pain

The document illustrates the efficacy of this approach through the story of “Sally,” a former corporate vice president with chronic low back pain.

The Conventional Failure: Sally had been treated with NSAIDs, physical therapy, and opioids. She eventually developed an opioid addiction and depression, yet her pain persisted .
The HOPE Approach: Using the HOPE note, Dr. Jonas identified that her unhappiness and loss of identity after leaving her executive job were contributing to her pain.
The Plan: The intervention involved a team: a pharmacologist for medication optimization, a behavioral therapy expert for sleep, and a yoga professional for pain.
The Result: Sally learned to forgive herself for the change in her life direction, resulting in long-term pain relief and improved function.

This case highlights that the opioid crisis cannot be solved simply by removing access to opioids; physicians must integrate non-pharmacological approaches to pain management.

Benefits of Integrative Health in Practice

Adopting the HOPE model offers three distinct benefits to the medical practice:

1. Preventing Burnout

Physician burnout is rising, often caused by excessive workload, loss of meaning, and clerical burdens. Fundamentally, burnout stems from the inability to develop relationships with patients. The HOPE Note restores this relationship and can inspire the physician to live a healthier lifestyle themselves.

2. Improving Outcomes

Holistic approaches improve outcomes. For example, the Cornell Program for Healthy Living demonstrated that when primary care includes referrals to resources like smoking cessation or fitness centers, overall cost growth is lower (23 percent vs 37 percent for standard plans).

3. Reducing Costs

In a value-based reimbursement system, value is defined as “quality + outcomes / cost”. Providing integrated care to people with chronic conditions is cost-effective. Care coordination prevents unnecessary hospital admissions, limits excessive specialist use, and reduces unnecessary lab studies.

Creating a HOPE List and Setting Goals

After the consultation, the physician and patient create a “HOPE List.” These are evidence-based items meaningful to the patient, organized into actionable areas. The list generally falls into five categories:

Stress Management and Resilience: Utilizing mind-body techniques like meditation to reduce the stress response.
Physical Activity and Sleep: Essential for immune function, pain reduction, and weight maintenance.
Nutrition and Substance Use: Focusing on proper nutrition and reducing exposure to toxins like nicotine and alcohol.
Social Support: Leveraging social cohesion, which is essential for sustainable behavior change.
Environment: Attending to both the inner environment (spiritual/purpose) and the outer environment (architecture, nature, light) .

To ensure these goals are met, the document suggests strategies such as health coaching, group visits (which allow for peer support), technology assists (apps/trackers), and providing educational resources .

Financial Viability: Paying for HOPE

A common barrier to integrative care is the volume-driven, fee-for-service model. However, the document outlines specific ways the HOPE approach can be reimbursed under current structures:

Annual Wellness Visits (AWV): Medicare and many commercial insurers cover AWVs. These visits can include advance care planning, referrals for nutrition or tobacco cessation, and screenings for depression .
Care Coordinators: Practices can hire care managers (often nurses or social workers) to address barriers like lack of safe housing or food access. These services can often be billed under AWV codes or other specific codes.
Chronic Care Management: Medicare provides separate reimbursement codes for chronic care management services for patients with two or more chronic conditions.
Incentives: As systems move toward value-based care, reimbursements will increasingly depend on patient outcomes and lowering overall costs, particularly regarding chronic health issues like diabetes.

Conclusion

The document concludes by asserting that medicine is entering a new world where attention is paid to all determinants of health, not just physical disease. Primary care physicians are on the front lines of this shift. To succeed in this “new normal,” providers must listen to patients holistically and practice in an interdisciplinary manner. The HOPE Note is the practical tool offered to facilitate this necessary transition from disease treatment to health promotion.

Disclaimer:

The information provided in this summary is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider with any questions you may have regarding a medical condition.

SourceSource Document:

“The HOPE Note: Bringing an Integrative Approach to Primary Care” (January 2018) by Dr. Wayne Jonas.

Healthcare News & Policy, Senior Education