The 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) identified patient-centered care as one of the six pillars of quality care. The emphasis on patient-centered care shifts the approach from health care as a traditional disease-focused model to one that focuses more on patient values and priorities. In 2009 the IOM summary of the Summit on Integrative Medicine and the Health of the Public noted the importance of integrating the best conventional care, fully engaging informed people so they achieve better health, and including the full range of approaches to enhancing health and wellness as well as to preventing and addressing chronic disease (IOM, 2009). Since then the concept of patient-centered care has evolved to person-centered care, an approach that focuses more broadly on interrelationships over time and the life course of an individual in the context of their families and communities (NASEM, 2021; Starfield, 2011). The World Health Organization (WHO) expanded the concept even further to people-centered care, which is more of a public health approach that further considers the life-course needs of people, families, and communities (WHO, 2016, 2020).
The whole health approach to care includes the concept of people-centeredness but goes beyond it. As described in greater detail in Chapter 2, the committee identified five foundational elements on which whole health systems are based: (1) people-centered, (2) holistic and comprehensive, (3) upstream-focused, (4) equitable and accountable, and grounded in (5) team well-being. The approach aims to shift from a reactive disease-oriented medical care system to one that emphasizes health promotion and disease
prevention and enables people and communities to achieve whole health. This approach is intended to understand people’s life meanings, aspirations, and purposes—what matters most to them in the context of their families and communities—to form the foundation of health care delivery. The whole health approach changes the conversation with individuals from identifying what is the matter with them to identifying what matters to them, and it puts the individual, not their symptoms, at the center of all care decisions (Gaudet and Kligler, 2019).
The Department of Veterans Affairs (VA) Whole Health System (WHS) emphasizes that focus on what matters to people. Its people-centered, integrative, and transformative approach to health care is intended to create and enable health and well-being by incorporating individuals’ goals and priorities into their health care decisions. The VA WHS care model includes peer-led support, personalized health planning, coaching, wellbeing courses, and integrated evidence-based conventional, complementary, behavioral, and integrative practices with the goal of addressing the social determinants of health. Other systems—in the United States and internationally—have adopted similar whole health approaches to care. If this transformational approach to care produces the hypothesized improvement in patient outcomes and satisfaction in a cost-effective manner, it could become a model for higher-value care across the country.
When implemented, a whole health approach ensures equitable access to care that addresses each of the above foundational elements. However, individual care preferences and goals will vary greatly, and many people may opt out of using some aspects of the approach. For example, individuals may only want care that meets their immediate medical needs, such as managing a chronic health condition, and not be interested in the broader approach to overall well-being. For people without complex needs, simply knowing that they can access care when needed may be all that they want at that point in their lives. One important aspect of the whole health approach is that it ensures each person knows about and can access all components of the full approach and that the health care system respects and honors an individual’s choice whether or not they take advantage of specific offerings.
A systems-level transition to a whole health approach, however, will require a seismic shift from the current state of U.S. medical care. Today, most health systems operate under a disease- and problem-based fee-for service model that treats medical care services as commodities in the competitive marketplace (NASEM, 2021). This is simply incompatible with a whole-person approach to care that promotes holistic and comprehensive health, well-being, and prevention. The dominant fee-for-service model has fostered a fragmented, siloed system that provides fertile ground for inequitable and unnecessarily costly care, dominated by professional tribalism, hyper-specialization, and business interests. More foundationally,
the current U.S. health, community, social, environmental, and education systems are not integrated or coordinated in their efforts, with each system having separate, competing, and unequal funding mechanisms. A systems-level transformation toward a whole health approach will have to address this status quo which is deeply ingrained in much of U.S. health and social care today.
The shift from this current state of medical care to a whole health approach will require a far-reaching transformation that refocuses the current medical care system by addressing all domains that affect health, including the root causes of poor health such as health behaviors, mental health, social determinants of health, and structural determinants of health, while incorporating patients’ goals and priorities into their health care decisions. It also must be both accessible and accountable to people, families, and diverse communities (across all racial, ethnic, religious, socioeconomic, and other historically disadvantaged groups) and be built upon a healthy, high-performing interprofessional workforce. To achieve this, it must break down conceptual, administrative, and financial barriers that isolate clinical care from the assessment and coordinated management of these domains.
The VA operates in a mostly prospective financial environment, with salaried clinicians and other staff insulated from most of the pressures of a fee-for-service environment in which clinicians are reliant on providing billable, reimbursable services. This makes VA well positioned to lead the charge in shifting away from the predominant reactive, problem-based approach to care to one that is holistic, equitable, and focused on the needs, desires, and well-being of the whole person. Within this context, the VA has made various efforts to advance the concept of people-centered care and whole-person health care by adding features to standard medical care, such as comprehensive mental health care integrated into primary care, patient-centered primary care homes, complementary and integrative health,1 and efforts to address social determinants of health. VA WHS, which the VA first implemented in 2018 at 18 pilot sites and is now promoting at all 171 of its medical centers, is perhaps the most advanced example of an effort to implement a new paradigm of care based on the premise of system transformation to support veterans’ health, recovery, and well-being. According to the VA, preliminary data on the effectiveness of its WHS are promising, but there are many research needs that must be addressed to further evaluate these efforts (Bokhour et al., 2020) (see Chapter 5 for more detail).
1 Within the context of VA’s WHS, complementary and integrative health “reaffirms the importance of the relationship between practitioner and patient; focuses on the whole person; is informed by evidence; and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals, and disciplines to achieve optimal health and healing” (Tick and Nielsen, 2019, p. 1), and it includes acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qi Gong, and yoga.
The efforts required to shift from medical care to a whole health approach may be significant for the VA and seismic for the United States as a whole, but the committee wishes to underscore the urgency of the problem that the whole health approach is attempting to address. If the measure of the performance of a country’s health system is the ability to ensure all inhabitants have a fair and just opportunity to be as healthy as possible, then there is abundant evidence that the United States is failing. The United States spends more and achieves lower outcomes than other developed countries. In an analysis of dozens of performance measures across 5 domains among 11 high-income countries, the United States ranked last in equity, access to care, administrative efficiency, and health outcomes—and last overall in aggregate—despite spending far more of its gross domestic product on health care (Schneider et al., 2021). Life expectancy at birth in the United States has consistently trailed most other countries in the Organisation for Economic Co-operation and Development, and the gap is widening. Moreover, in 2021 life expectancy at birth in the United States declined for the second year in a row (CDC, 2022). Only about half of this decline was attributable to the COVID-19 pandemic. The same analysis showed differences of up to 18 years in life expectancy at birth among groups of different races and ethnicities.
Most of the widening gap in life expectancy between the United States and other countries is due to an increase in mid-life mortality caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases (Woolf and Schoomaker, 2019). The country’s current medical care infrastructure has demonstrated that, with its current orientation toward disease- and problem-based treatment, it is incapable of treating people with these conditions in a fair and systematic way, let alone preventing the conditions.
Accompanying these decrements in life expectancy has been an erosion of trust in U.S. health care (Cope et al., 2022). Trusting relationships between patients, clinicians, and health care organizations affect health behaviors and outcomes and are key for system effectiveness. Yet before and during the COVID-19 pandemic, trust declined as frustration about racial injustice and polarization around issues of health, policy, science, and information increased (Hostetter and Klein, 2021; Kennedy et al., 2022).
Fundamentally, these issues demonstrate a misalignment in how the United States is investing limited resources and the services provided versus what people, families, and communities need to achieve whole health. Health care systems cannot do this alone—public health, community care, social services, environmental services, work environments, and educational systems are all needed. This report will explore the evidence assessing whether whole health systems—ones that are people-centered, comprehensive and holistic, upstream-focused, equitable and accountable, and grounded in team well-being—can address these challenges and promote
whole health and, if so, what is required to create, scale, and spread them in the VA and throughout the United States.
PROJECT ORIGIN AND STATEMENT OF TASK
In January 2019 the Creating Options for Veterans’ Expedited Recovery (COVER) Commission,2 a federally established advisory committee, recommended that VA commission the National Academies of Sciences, Engineering, and Medicine (National Academies) to provide input on how to accelerate whole person care transformation by building on current efforts in mental health, primary care, and whole health care across the VA. In response to that recommendation, the VA commissioned the National Academies to provide guidance on how to fill gaps and create processes to accelerate this transformation for veterans who receive care both inside and outside the VA system.
With the support of the VA, the Samueli Foundation, and the Whole Health Institute, the National Academies launched this study in July 2021 and formed the Committee on Transforming Health Care to Create Whole Health: Strategies to Assess, Scale, and Spread the Whole Person Approach to Health. The committee’s charge was to examine the potential for improving health outcomes through a whole health care model; identify best practices and lessons learned from the flagship and design sites of the VA’s Whole Health Initiative as well as from health systems in the private sector; and consider ways to transform health care by scaling and disseminating whole person care to the entire U.S. population. The committee was asked to consider the foundational elements of an integrated whole health model, but it was not charged with identifying specific interventions that should be included in whole health models of care or defining specific evidentiary standards for making those decisions (see Box 1-1).
The Committee on Transforming Health Care to Create Whole Health: Strategies to Assess, Scale, and Spread the Whole Person Approach to Health comprised 18 members with a broad range of expertise, including people-centered clinical care, nursing, primary care, health care systems in general, the VA health care system in particular, health care disparities, health care policy, health services research, integrative medicine, behavioral health, social work, community wellness, psychiatry, pharmacy, and the social determinants of health. Appendix A presents brief biographies of the committee members, fellows, and staff.
The committee deliberated during six 2-day meetings and many conference calls between October 2021 and September 2022. At two of the meetings, the committee invited outside speakers to inform the committee’s deliberations, and members of the public had the opportunity to offer questions, comments, and suggestions. The speakers provided valuable input on a broad range of topics, including integrative approaches for women veterans, spiritual care, health coaching, people-centered system design, the COVER report, the VA Whole Health Initiative, and the work of the Whole Health Institute. To further inform its work, the committee commissioned three papers on the following topics: evidence on patient-centeredness, patient-centered systems, and implementation and scaling of whole person health; whole health in VA health care, including insights on implementation, research, and future evaluations; and lessons for whole health from other health systems.3
With the help of National Academies staff, the committee also completed an extensive search of the peer-reviewed literature, ultimately considering more than 5,000 articles and targeting English-language articles published since 2001 on topics including where whole health is currently being implemented; what whole health accomplishes; what factors affect the performance of whole health; the VA Whole Health Initiative; and health system transformation. In addition, the committee reviewed the gray literature, including publications by private organizations, government, and international organizations, with a focus on outcomes and implementation strategies.
This study takes place at a time when most people residing in the United States in need of care interact with what can best be described as a medical care system that largely provides reactionary, transactional, and disease- and problem-based treatment of medical problems as they arise. There are few resources in the current medical care system devoted to proactive prevention (Gmeinder et al., 2017), and in most settings the system is optimized around billable services rather than the creation of health among people, families, and communities.
As described in the recent National Academies report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021), primary care is the bedrock of any well-functioning health system but has been systematically neglected for decades. Chapter 2 describes the important role of high-quality primary care in any whole health system. In the United States, however, primary care is currently
strained and under-resourced, accounting for 35 percent of all health care visits but only about 5 percent of health care expenditures. Nevertheless, it is an essential element to achieving the quadruple aim (enhancing the patient experience, improving population health, reducing costs, and improving the health care team experience) as well as reducing inequities that are commonplace in U.S. health care today (Bodenheimer and Sinsky, 2014; Christian et al., 2018; Macinko et al., 2003; Park et al., 2018; Phillips and Bazemore, 2010). In fact, primary care is the only part of the U.S. health care system that improves community health and promotes equity (NASEM, 2021).
While primary care’s importance to any whole health system should not be understated and the definition of high-quality primary care is closely aligned (NASEM, 2021) with how this committee defines whole health (see Chapter 2), it would be misguided to view whole health simply as high-quality primary care with some additional features. Rather, the chassis upon which whole health must be built is fundamentally different from our current system. Whole health begins with the self-identified needs of an individual for well-being—often before the individual is a patient—and those practicing whole health must be able to organize actions and resources to respond to those needs across physical, behavioral, spiritual, and socioeconomic domains. While high-quality primary care plays a critical role in achieving this, adequately building new systems around a whole health approach will require redefining the very notion of health from a reactive, treatment-based approach, which is the norm today, to one that is more proactive and focused on the five foundational elements of whole-person health systems.
About the VA
The VA comprises three organizations: the Veterans Health Administration (VHA), which is the largest health care system in the United States; the Veterans Benefits Administration (VBA), which provides a variety of benefits to veterans, service members, and their families; and the National Cemetery Administration (NCA), which oversees burial services for veterans and eligible family members (VA, 2018). Of the three, VBA had the largest fiscal year (FY) 2022 budget, at $159 billion. VHA had a FY 2022 budget of $98 billion, and NCA’s FY 2022 budget was $394 million (CRS, 2021). An undersecretary oversees each of the three organizations and reports directly to the Secretary of Veterans Affairs. In general, the three administrations within the VA operate separately, with their own leadership and reporting structures.
While VHA4 is a primary focus of this report, many of the upstream factors that this committee identified as foundational elements of whole health fall within the purview of the VBA. For example, VBA manages veterans’ compensation benefits, employment training programs, and education benefits and provides home loans and mortgage delinquency assistance, financial management assistance, an independent living program, and other benefits (VA, 2022b). As subsequent chapters of this report describe in greater detail, addressing these upstream, social determinants of health adequately through an integrated, whole health approach to health care has the potential to improve the nation’s health overall and reduce health inequity (NASEM, 2019). Because these benefits and services are already present under the large VA umbrella, the organization overall is well positioned in theory to incorporate them into a single, whole health approach to care that spans the services already offered by VHA and VBA.
VA Health Care
Through VHA, the VA health care system is the largest integrated health care system in the United States, providing care for veterans of the U.S. armed forces discharged under other than dishonorable conditions through 18 veterans integrated service networks, which are regional systems of care working together to better meet local health care needs and provide greater access to care (VA News, 2022). In 1946, Gen. Omar Bradley and the VA’s first medical director, Maj. General Paul Hawley, laid the groundwork for VA health care by creating the Department of Medicine and Surgery (VA, 2021) and instituting a number of changes and initiatives to accommodate the nearly 16 million new veterans who served during World War II and the changing nature of their health care needs. For the first time in its history, the U.S. military saw more casualties resulting from combat injuries than diseases, and improved battlefield medical care meant more service members returned home with wounds that were not previously survivable (VA, 2021).
Today, VA provides care at 171 VA medical centers, 1,287 community-based outpatient clinics, and 300 vet centers, of which more than 80 are mobile Vet Centers. As of July 2021 there were 19,542,000 living U.S. veterans, 10.4 percent of whom identified as female, with a demographic breakdown by race and ethnicity shown in Table 1-1.
Of the total veteran population, more than 9 million are enrolled in VA health care (VA, 2022b), with nearly 400,000 full-time VA employees, including some 450 VA suicide prevention coordinators, providing care (GAO, 2021). In addition, the VA has approximately 1,100 veteran peer specialists who provide culturally competent outreach, engagement, and
4 This report will generally refer to VA (rather than VHA) unless it is discussing the distinction between VHA and VBA as it is in this section.
TABLE 1-1 Race and Ethnicity of the U.S. Veteran Population
|White, alone||Black or African American, alone||American Indian and Alaska Native, alone||Asian, alone||Native Hawaiian and other Pacific Islander, alone||Some other race, alone||Two or more races||Hispanic or Latino (of any race)||White alone, not Hispanic or Latino|
SOURCE: VA, 2022a.
service to veterans enrolled in mental health and primary care VA sites across the nation. In FY 2019, women accounted for 62.2 percent of the VHA workforce, an increase from 60.8 percent in 2015, while minority representation increased from 40.8 to 43.0 percent over the same time period. Among VA health care employees in FY 2019 the average age was 47.8 years, 30.2 percent were veterans, and 13.2 percent reported having one or more disabilities. The VA health care workforce is projected to grow at 3.0 percent per year through FY 2024. To maintain and grow its health care workforce, VA typically hires anywhere from 35,000 to 40,000 new employees each year, with a total loss rate of 9.4 percent in FY 2019 (VA, 2020).
Today’s VA continues to meet veterans’ changing medical, surgical, and quality-of-life needs. New programs provide treatment for traumatic brain injuries, post-traumatic stress disorder, suicide prevention, issues unique to women veterans, and more. While historically the quality of VA-delivered health care has been variable, VA enacted a series of reforms starting in 1995 which have significantly improved care delivery, quality of care, and outcomes (Kizer, 1995). For example, a 2004 study comparing a sample of VA patients to non-VA patients across 26 health conditions, inpatient services, and outpatient services found that VA patients received significantly better overall care, chronic care, and preventive care than non-VA patients (Asch et al., 2004). Another study published in 2003 found that VA’s performance improved substantially between 1994—before the reforms—and 2000 and that by 2000 VA performed significantly better than Medicare on 12 of 13 quality indicators (Jha et al., 2003).
How COVID-19 Further Shaped the Whole Health Initiative
As was true for the entire U.S. health care system, the COVID-19 pandemic had a marked effect on the care delivered to veterans. It also highlighted the strengths of the VA: While members of the veteran population did have a greater likelihood of risk factors that could lead to severe
COVID-19 infection, they have fared slightly better than the general population during the pandemic. The overall excess mortality for veterans was 16.7 percent versus 20.8 percent among the general population (Feyman et al., 2022). This outcome highlights the importance of the VA system as a relatively reliable and accessible source of care in much of the country.
The isolation and stress that the pandemic caused demonstrates the need for a whole health approach now. Many people and families lost loved ones. Mental health and social needs grew alongside the pandemic (Panchal et al., 2021). Like many health systems nationally, VA was able to grow its telehealth capabilities rapidly, enabling its members to access many of its services when it was not possible to do so in person. The WHS was also able to pivot and deliver whole health care virtually during the pandemic—even expanding the number of services provided and the number of veterans it served. A series of qualitative interviews with 61 WHS leaders at 18 VA medical centers found that these centers intentionally embraced a whole health approach to providing care to both veterans and employees during the pandemic. According to the study investigators, who are conducting a multiyear study of the WHS transformation, efforts to support veterans and employees included patient wellness calls and promoting complementary and integrative health therapies, self-care, and whole health concepts to combat stress and support well-being (Dryden et al., 2021).
Rapid deployment of virtual technology enabled VA to continue delivering complementary and integrative therapies and to promote whole health activities. For example, the San Francisco VA adapted an in-person workshop series to a drop-in virtual series facilitated by a veteran peer-support specialist and clinicians (Seidel et al., 2021). Based on limited positive results, the San Francisco VA will use the virtual platform to expand and to serve veterans across Northern California.
Unique Health and Well-Being Challenges for Veterans and Their Families
A recent Pew Research Center survey of veterans found that many who served in combat reported that their experiences strengthened them personally but also made the transition to civilian life difficult (Parker et al., 2019). About one in five veterans have served on active duty since the terrorist attacks of September 11, 2001. These post-9/11 veterans are more likely to have been deployed and to have served in combat, subjecting them to a set of experiences, stressors, and exposures distinct from those of other veterans. Approximately half (47 percent) of post-9/11 veterans describe emotionally traumatic or distressing experiences related to their military service, compared with one-quarter of pre-9/11 veterans. About a third (35 percent) of post-9/11 veterans say they sought professional help to deal
with those experiences, and a similar proportion—regardless of whether they have sought help—say that they think they have suffered from symptoms of post-traumatic stress disorder (PTSD) (Parker et al., 2019).
Families face serious challenges even while their service members are still in the military. A recent report presented findings from the 2021 Military Family Support Programming Survey with responses from 8,638 participants (L’Esperance et al., 2021). The largest group of respondents were spouses of active-duty members, at 44 percent, followed by active-duty members, at 14 percent. The survey indicated that military families are having a hard time making ends meet, which is affecting their overall well-being, loneliness, and both housing and food security (L’Esperance et al., 2021).
Service members and their families often struggle across multiple dimensions while still receiving military pay, housing supplements, and other benefits, and they are likely to face even more significant challenges following separation from service. More than one-third of veterans (35 percent) report financial distress after leaving the military, and roughly 3 in 10 (28 percent) have received unemployment compensation (Parker et al., 2019). In addition, 20 percent say they have struggled with alcohol or substance abuse. Veterans who report PTSD symptoms are more likely to report such problems (Parker et al., 2019). For many veterans, such problems combine with undereducation, underemployment, job instability, financial and food insecurity, marital stress, and difficulty parenting to result in family breakup, homelessness, and incarceration. At each stage of this in this steady downward social drift there are opportunities to stabilize and then regain ground if the right combination of clinical, benefits, and social services can be identified and engaged. This is the promise of whole health.
VA’s national leadership in whole health is a natural outgrowth of its unique history, mission, and capabilities. However, VA’s innovative campaign to transform itself into a fully integrated whole health system of care will not be easy, and the recent passage of the MISSION Act, which enables eligible VA-enrolled veterans to receive care in non-VA settings, creates new challenges (VHA, 2021). Nonetheless, it will be even more challenging to implement whole health transformation across the rest of U.S. health care because few existing systems have grappled with the realization that individuals, families, and communities cannot achieve and maintain health without a realignment of forces to assess and address upstream factors of health, including social determinants, as an integral feature of all health care. Similarly, fragmented payment systems, health information technology systems, workforce shortages, and unequal access to services further complicate the scale and spread of a national whole health system. The U.S. health care systems will have to overcome cultural inertia in order to establish new structures and processes capable of meeting the needs
of individuals, families and communities in concert with their values and aspirations.
ORGANIZATION OF THE REPORT
The committee divided the report into eight chapters. The remainder of this report lays out the committee’s analysis of VA’s WHS as well as of similar efforts conducted by other health systems in the United States and internationally. Chapter 2 provides the committee’s definition of a whole health approach, one that starts with VA’s definition and describes in detail the five foundational elements that are essential to any whole health system. Chapter 3 reviews the evidence supporting the committee’s five foundational elements. Chapter 4 describes VA’s WHS design and philosophical approach as well as four other systems that have implemented a whole health system of their own. Chapter 5 further explores the evidence supporting these and other promising whole health models from around the world. Chapter 6 focuses on the theoretical basis of scaling and spreading whole health systems. Chapter 7 discusses necessary infrastructural changes, as well as some of the major barriers and facilitators for implementing a system of whole health within and outside of VA. Chapter 8 presents the committee’s conclusions and recommendations to advance the scale and spread of whole health both within and outside of VA.
In addition to the core content, there are two appendixes. Appendix A presents the biographies of the committee members, fellows, and staff. Appendix B describes an unavoidable conflict of interest with one of the committee members.
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