Achieving Whole Health: A New Approach for Veterans and the Nation (2023)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Achieving Whole Health A New Approach for Veterans and the Nation Alex H. Krist, Jeannette South-Paul, and Marc Meisnere, Editors Committee on Transforming Health Care to Create Whole Health: Strategies to Assess, Scale, and Spread the Whole Person Approach to Health Board on Health Care Services Health and Medicine Division Consensus Study Report PREPUBLICATION COPY—Uncorrected Proofs 

NATIONAL ACADEMIES PRESS 500 Fifth Street, NW, Washington, DC 20001 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-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26854 This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334- 3313; http://www.nap.edu. Copyright 2023 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved. Printed in the United States of America. 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. PREPUBLICATION COPY—Uncorrected Proofs 

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs 

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process, and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs 

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 Value and Professionalism in Health Care, American Board of Family Medicine TAMMY CHANG, Associate Professor, Department of Family Medicine, University of Michigan MARGARET 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. v PREPUBLICATION COPY—Uncorrected Proofs 

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 vi PREPUBLICATION COPY—Uncorrected Proofs 

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 manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: AMANDA BREWSTER, University of California, Berkeley PASCALE CARAYON, University of Wisconsin-Madison DAVE A. CHOKSHI, NYU School of Medicine HEIDI GULLET, Case Western Reserve University School of Medicine PINAR KESKINOCAK, Georgia Institute of Technology KAMERON MATTHEWS, CityBlock Health BENJAMIN MILLER, Well Being Trust BEN OLMEDO, Dignity Health STEVE SHORTELL, University of California, Berkeley School of Public Health BETH ANN SWAN, Emory University School of Nursing vii PREPUBLICATION COPY—Uncorrected Proofs 

viii REVIEWERS Although the reviewers listed above provided many constructive com- ments 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 Wash- ington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the stan- dards of the National Academies and that all review comments were care- fully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs 

Contents PREFACE xi ACKNOWLEDGMENTS xv ACRONYMS AND ABREVIATIONS xvii DEFINITIONS xix SUMMARY 1 1 INTRODUCTION 17 2 DEFINING WHOLE HEALTH 33 3 EVIDENCE SUPPORTING WHOLE HEALTH’S FOUNDATIONAL ELEMENTS 59 4 WHOLE HEALTH IN PRACTICE 115 5 WHOLE HEALTH SYSTEMS’ EVIDENCE 157 6 SCALING AND SPREADING WHOLE HEALTH 219 ix PREPUBLICATION COPY—Uncorrected Proofs 

x CONTENTS 7 INFRASTRUCTURE FOR SCALING AND SPREADING WHOLE HEALTH 297 8 CONCLUSIONS AND RECOMMENDATIONS 353 APPENDIXES A BIOGRAPHIC SKETCHES 371 B DISCLOSURE OF UNAVOIDABLE CONFLICT OF INTEREST 385 PREPUBLICATION COPY—Uncorrected Proofs 

Preface Health care in the United States is at a critical crossroads. Life expec- tancy 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 out- comes 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 incentiv- ized 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. xi PREPUBLICATION COPY—Uncorrected Proofs 

xii PREFACE Service members exposed to multiple combat deployments have been left with a variety of physical and behavioral consequences of these experi- ences. Throughout history, those who served our nation have experienced wartime injuries, exceptional emotional stressors, and environmental tox- ins 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, homeless- ness, post-traumatic stress, and substance use disorders compared with the general population. Given their service to our nation, the United States has a moral obliga- tion to ensure that our veterans receive the best care possible. The health care needs of veterans are the responsibility of the largest comprehen- sive health care system in the nation, the Veterans Health Administration (VHA). Over the past several decades the VHA has transformed itself, serv- ing 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 coor- dinated 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, PREPUBLICATION COPY—Uncorrected Proofs 

PREFACE xiii 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 Com- mittee 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 sys- tems 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 sup- port 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 incor- porates 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 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 PREPUBLICATION COPY—Uncorrected Proofs 

xiv PREFACE 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 direc- tor Marc Meisnere, senior board director Sharyl Nass, research associ- ate 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 PREPUBLICATION COPY—Uncorrected Proofs 

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. GRETCHEN EVANS, No Barriers ROBERT EVANS, Western North Carolina VA Health Care System WAYNE JONAS, Samueli Foundation URSULA KELLY, Emory University BEN KLIGLER, Department of Veterans Affairs APRIL KYLE, Southcentral Foundation JAMES MARZOLF, Whole Health Institute LAURA ANN MCMAHON, Department of Veterans Affairs We extend thanks to the following individuals who provided com- missioned 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. xv PREPUBLICATION COPY—Uncorrected Proofs 

xvi ACKNOWLEDGMENTS 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 Gon- zales, 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 Acad- emies Research Center, including Anne Marie Houppert, Ellen Kimmel, and Rebecca Morgan as well as graphic designer Casey Weeks. PREPUBLICATION COPY—Uncorrected Proofs 

Acronyms and Abbreviations ACO accountable care organization AHRQ Agency for Healthcare Research and Quality CMS Centers for Medicare & Medicaid Services COVER Creating Options for Veterans’ Expedited Recovery CPT current procedural terminology EHR electronic health record FQHC federally qualified health center GRACE Geriatric Resources for Assessment and Care of Elders HiAP Health in All Policies HIT health information technology HRSA Health Resources and Services Administration HSA hospital or health service area LHS learning health system MISSION Act Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 xvii PREPUBLICATION COPY—Uncorrected Proofs 

xviii ACRONYMS AND ABBREVIATIONS NASSS Nonadoption, Abandonment, Scale-up, Spread, and Sustainability NCA National Cemetery Administration NCGWG North Carolina Governor’s Working Group on Service Members, Veterans, and their Families NICoE National Intrepid Center of Excellence PACE Program for All-Inclusive Care for the Elderly PACT patient-aligned care team PCBH primary care behavioral health PCED Primary Care Equity Dashboard PCMH patient-centered medical home PRAPARE Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences PTSD post-traumatic stress disorder SCF Southcentral Foundation TBI traumatic brain injury THRIVE Transforming Health and Resilience through Integration of Values-Based Experience VA U.S. Department of Veteran Affairs VBA Veterans Benefits Administration VHA Veterans Health Administration WH whole health WHO World Health Organization WHS Whole Health System (VA) PREPUBLICATION COPY—Uncorrected Proofs 

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 encom- passes 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. 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. xix PREPUBLICATION COPY—Uncorrected Proofs 

xx DEFINITIONS 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 acu- puncture, massage, yoga, wellness coaching, and meditation. Also com- monly known as complementary and integrative medicine 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 organiza- tion, 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 behav- iors, social, economic, and education needs, and the natural and built envi- ronments in which people and communities reside. PREPUBLICATION COPY—Uncorrected Proofs