Consensus Study Report

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This activity was supported by contracts between the National Academy of Sciences and U.S. Department of Veterans Affairs, Samueli Foundation, and the Whole Health Institute. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-69927-3
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. Achieving whole health: A new approach for veterans and the nation. Washington, DC: The National Academies Press. https://doi.org/10.17226/26854.

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COMMITTEE ON TRANSFORMING HEALTH CARE TO CREATE WHOLE HEALTH: STRATEGIES TO ASSESS, SCALE, AND SPREAD THE WHOLE PERSON APPROACH TO HEALTH¹

ALEX H. KRIST (Co-Chair), Professor, Family Medicine and Population Health, Virginia Commonwealth University

JEANNETTE SOUTH-PAUL (Co-Chair), Senior Vice President and Chief Academic Officer, Meharry Medical College

ANDREW BAZEMORE, Senior Vice President, Research and Policy, Co-Director, Center for Professionalism and Value in Health Care, American Board of Family Medicine

TAMMY CHANG, Associate Professor, Department of Family Medicine, University of Michigan

MARGARET A. CHESNEY, Professor of Medicine, University of California, San Francisco

DEBORAH J. COHEN, Professor and Research Vice Chair, Department of Family Medicine, Oregon Health & Science University

A. SEIJI HAYASHI, Lead Medical Director for Government Programs, CareFirst BlueCross BlueShield

FELICIA HILL-BRIGGS, Vice President of Prevention, Simons Distinguished Chair for Clinical Research, Feinstein Institutes for Medical Research; Professor of Medicine, Zucker School of Medicine, Northwell Health

SHAWNA HUDSON, Professor, Department of Family Medicine and Community Health, Robert Wood Johnson Medical School

CARLOS ROBERTO JAÉN, Holly Distinguished Chair, Patient-Centered Medical Home, Professor and Chair, Department of Family and Community Medicine, Professor of Population Health Sciences, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio

CHRISTOPHER KOLLER, President, Milbank Memorial Fund

HAROLD KUDLER, Associate Consulting Professor, Department of Psychiatry and Behavioral Sciences, Duke University; Adjunct Professor of Psychiatry, Uniformed Services University of the Health Sciences

SANDY LEAKE, Senior Vice President and Chief Nursing Officer, The University of Tennessee Health System (Knoxville)

PATRICIA LILLIS, Radiation Oncologist, Marshfield Medical Center

AJUS NINAN, Behavioral Science Officer, United States Army

___________________

¹ NOTE: See Appendix B, Disclosure of Unavoidable Conflict of Interest.

PAMELA SCHWEITZER, Former Assistant Surgeon General and 10th Chief Pharmacist Officer, Retired, United States Public Health Service (USPHS) Commissioned Corps; Volunteer Assistant Clinical Professor, Department of Clinical Pharmacy, University of California, San Francisco

SARA J. SINGER, Professor of Medicine, Stanford University School of Medicine

ZIRUI SONG, Associate Professor of Health Care Policy and Medicine, Harvard Medical School and Massachusetts General Hospital

Study Staff

MARC MEISNERE, Study Director

MARJANI CEPHUS, Research Associate

TOCHI OGBU-MBADIUGHA, Senior Program Assistant (through November 2022)

ARZOO TAYYEB, Finance Business Partner

SHARYL NASS, Senior Director, Board on Health Care Services; Co-Director, National Cancer Policy Forum

National Academy of Medicine Fellow

ALEXANDER MELAMED, Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School

Consultants

JOSEPH ALPER, Science Writer

ASAF BITTON, Ariadne Labs

DENISE M. HYNES, Portland VA Research Foundation

MOIRA STEWART, Western University

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by PATRICK H. DELEON, Uniformed Services University, and ERIC B. LARSON, University of Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Contents

PREFACE

ACKNOWLEDGMENTS

ACRONYMS AND ABBREVIATIONS

DEFINITIONS

SUMMARY

1 INTRODUCTION

2 DEFINING WHOLE HEALTH

3 EVIDENCE SUPPORTING WHOLE HEALTH’S FOUNDATIONAL ELEMENTS

4 WHOLE HEALTH IN PRACTICE

5 WHOLE HEALTH SYSTEMS’ EVIDENCE

6 SCALING AND SPREADING WHOLE HEALTH

7 INFRASTRUCTURE FOR SCALING AND SPREADING WHOLE HEALTH

8 CONCLUSIONS AND RECOMMENDATIONS

APPENDIXES

A BIOGRAPHIC SKETCHES

B DISCLOSURE OF UNAVOIDABLE CONFLICT OF INTEREST

Preface

Health care in the United States is at a critical crossroads. Life expectancy has been decreasing for nearly a decade. Complications from multiple chronic conditions continue to rise. Mental health needs are at an all-time high. Unhealthy behaviors are prevalent. Despite remarkable breakthroughs and innovations in treating disease, the United States has worse health outcomes than most other developed countries and at a substantially higher cost. Adding fuel to the fire, the COVID-19 pandemic has killed millions of people worldwide; caused physical, mental, and social suffering; and exacerbated health and economic inequities.

The current systems of health care are failing us, largely due to four factors. The country has designed a health system to cure disease and not to promote health. The for-profit economics of health care have incentivized an environment of “haves” and “have nots” with inequities in access to care and inequities in the quality of care delivered to people and entire communities. The country has failed to adequately invest in addressing upstream factors that drive well-being; these known social determinants of health shape our daily lives and influence health more than health care delivery itself. The nation has focused on developing new cures to disease but has neglected to advance the science and systems of how we deliver care, which is essential to ensuring that the right people get the right care at the right time.

Veterans represent a particularly vulnerable group that is at greater risk for poor health outcomes. Recent U.S. military conflicts in Iraq and Afghanistan have spotlighted the trauma and stressors affecting the millions of U.S. service members who have been in active war zones since 2001.

Service members exposed to multiple combat deployments have been left with a variety of physical and behavioral consequences of these experiences. Throughout history, those who served our nation have experienced wartime injuries, exceptional emotional stressors, and environmental toxins during their military service. As a result, veterans have higher rates of chronic disease, cancer, and chronic pain. For many reasons, the transition to peacetime civilian life following separation from military service can be difficult, and veterans experience higher rates of unemployment, homelessness, post-traumatic stress, and substance use disorders compared with the general population.

Given their service to our nation, the United States has a moral obligation to ensure that our veterans receive the best care possible. The health care needs of veterans are the responsibility of the largest comprehensive health care system in the nation, the Veterans Health Administration (VHA). Over the past several decades the VHA has transformed itself, serving as a health system leader for numerous health care delivery innovations that span patient safety, informatics, care and payment design, learning, and research. Recognizing the breadth of veteran needs, VHA has developed a novel Whole Health System (WHS) to redefine what health means and how we help people achieve health and improve overall well-being. The whole health approach is an outgrowth of multiple other movements in health care, both in the United States and internationally. It recognizes that the health of people, families, and communities depends not only on the absence of disease, but also on all the factors that affect physical, emotional, social, and spiritual well-being. It views health not as a desired biomedical state of being, but as a resource that allows people to achieve their life goals and aspirations.

We believe that every health system’s primary purpose should be to help the people that it serves achieve whole health. We recognize that this will take fundamental changes, starting with expanding the provision of care beyond just traditional health systems to include a holistic and coordinated approach from health care, public health, education, community programs, and social services to address the full spectrum of health and social needs that people have. For most people in the United States today, both veterans and civilians, any effort to comprehensively address all the factors that affect whole health is uncoordinated, siloed, complex, and generally inefficient. A whole health approach will add order and structure to this chaos and help to better meet the needs and priorities of people, families, and communities. The Department of Veterans Affairs (VA), which includes both the VHA and the Veterans Benefits Administration (VBA), is well positioned to start and test a whole health care transformation. The VHA provides health care, and the VBA addresses social needs. The VHA has a strong primary care workforce, adopted a people-centered approach,

invested in informatics and telehealth, and has a safety, quality, and research mission and focus—all essential structures and processes to scale and spread whole health care. Additionally, the VA cares for a demographically diverse population that can benefit from whole health care.

The National Academies of Sciences, Engineering, and Medicine Committee on Transforming Health Care to Create Whole Health: Strategies to Assess, Scale, and Spread the Whole Person Approach to Health was tasked with examining the potential for improving health outcomes through whole health care and recommending future directions and priorities for the VA and other health systems interested in implementing a system of whole person care. The widespread implementation of this approach beyond the VA is critical because a substantial percentage of veterans receive some or all of their care outside of the VHA and because all people can benefit from whole health care. We acknowledge the complexity of creating a uniform approach to care as well as coordinating and harmonizing different systems of care, but a system of care that addresses what is most important to people rather than what is most convenient for those providing care is desirable for all citizens.

Movement toward whole health will require a radically different mindset and significant systems change in which stakeholders embrace the foundational elements, develop the structures and processes needed to support whole health, and achieve new levels of integration such that service delivery is coordinated across care settings and time. The shift from the current state to whole health care will require a transformation that incorporates individuals’ health values, goals, and priorities while maintaining high-quality disease management. The comprehensive degree to which the current systems of care must change to achieve whole health, both within VA and beyond, demands a new way of thinking, leadership nationally and locally who believe in and will drive these changes, and a commitment to a learning system approach of continuous evaluation, adaptation, and a process of refinement.

As co-chairs, we are grateful for the expertise, commitment, and hard work of the committee members who shaped this report. The volunteer committee included 17 members with the breadth of backgrounds needed to understand the needs of veterans and the VA, the science of scale and spread of health system transformation, and the structures and processes needed to help people achieve whole health. The committee brought a broad perspective, informed by their experiences as medical, nursing, social work, and complementary and integrative health practitioners as well as economists, educators, researchers, and scholars. We are also indebted to Asaf Bitton, Denise Hynes, and Moira Stewart who provided the committee with comprehensive technical reports as well as to the VA and other early

adopter health systems which shared their whole health journeys with the committee.

The committee wishes to acknowledge the leadership, guidance, and support that it received from the National Academies staff. Study director Marc Meisnere, senior board director Sharyl Nass, research associate Marjani Cephus, senior program assistant Tochi Ogbu-Mbadiugha, National Academy of Medicine fellow Alexander Melamed, and science writer Joe Alper were essential to defining our complex statement of task, assembling key stakeholders and thought leaders, understanding the current state of whole health care, developing our recommendations, and writing this report.

Alex H. Krist and Jeannette South-Paul, Co-Chairs
Committee of Transforming Health Care to Create Whole Health:
Strategies to Assess, Scale, and Spread the Whole Person Approach to Health

Acknowledgments

The study committee and the Health and Medicine Division wish to express our sincere gratitude to the many individuals and organizations who contributed to this report.

We would like to thank the study sponsors: the Department of Veterans Affairs, the Samueli Foundation, and the Whole Health Institute. Our work would not have been possible without their generosity and support. The committee gratefully acknowledges all of the speakers and participants who played a role in the public meetings conducted for this study.

We extend thanks to the following individuals who provided commissioned papers: Asaf Bitton from Ariadne Labs for his paper on other health systems for Whole Health, Denise Hynes from Portland VA Research Foundation and the Center to Improve Veteran Involvement in Care for her paper on insights on Whole Health in VA, and Moira Stewart from Western University for her paper on evidence on patient-centeredness and patient-centered systems.

Finally, profound appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process, especially to Samantha Chao, Julie Eubank, Annalee Gonzales, Mimi Koumanelis, Stephanie Miceli, Maryjo Oster, Devona Overton, Rebekah Hanover Pettit, Marguerite Romatelli, Lauren Shern, Leslie Sim, and Lauren Tobias. Thanks also goes to the staff of the National Academies Research Center, including Anne Marie Houppert, Ellen Kimmel, and Rebecca Morgan as well as graphic designer Casey Weeks.

Acronyms and Abbreviations

Definitions

WHOLE HEALTH DEFINITIONS¹

whole health—physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities.

whole health care—an interprofessional, team-based approach anchored in trusted longitudinal relationships to promote resilience, prevent disease, and restore health. It aligns with a person’s life mission, aspiration, and purpose.

whole health system—a collaborative health delivery system that encompasses conventional medical care, comprehensive and integrative health, community programs, social services, and public health. It addresses the five foundational elements of whole health (people-centered, holistic and comprehensive, upstream-focused, equitable and accountable, and team well-being). Whole Health System (WHS) (capitalized) refers to VA’s WHS.

SYSTEMS INVOLVED IN WHOLE HEALTH

community programs—programs and services designed to address the needs and wants of a local population. Examples of community programs include spiritual and religious programs and health behavioral change programs.

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¹ These definitions are a combination of committee conceptualizations and definitions cited from the literature. Citations are included in the report body where definitions first appear.

health system—an organization or practice engaged in the delivery of health care services, including innovative models.

public health system—a broad range of federal, state, and local health agencies, laboratories, and hospitals as well as nongovernmental public and private agencies, voluntary organizations, and individuals working together or in parallel to promote and protect the health of given community.

social services—programs and services provided by government or local organizations that help individuals, families, and communities address unmet needs related to health, housing, employment, nutrition, and other social needs.

WHOLE HEALTH CONCEPTS

complementary and integrative health—practices and modalities that are not currently part of conventional medical care and often include acupuncture, massage, yoga, wellness coaching, and meditation. Also commonly known as complementary and integrative medicine.

conventional medical care—care that includes acute, chronic, preventive, reproductive, and mental health care, dental care, hearing care, vision care, and health behavior counseling.

scale—to expand, adapt, and sustain successful models within an organization, locality, or health system.

spread—to replicate a successful model elsewhere in other organizations, localities, or health systems.

people-centered care—an approach to care that focuses on values, priorities, and life-course needs of people, families, and communities.

upstream factors—the root causes of poor health, including health behaviors; social, economic, and education needs; and the natural and built environments in which people and communities reside.