8

Conclusions and Recommendations

Whole health is physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities. Having whole health is fundamentally different from being healthy in a biomedical model, which misses much of what matters most to people about their health. Whole health is a resource for everyday life to enable people and communities to achieve their life aspirations and cope with change. Achieving whole health starts with care systems understanding what matters to people and then building the environment, resources, and support to help people and communities achieve their life goals. All people and all communities have a right to whole health—it is a common good and it should be the desired goal and outcome of any effective health care system.

While rethinking the biomedical definition of health is not new, there has been a recent surge of health systems that are trying to implement whole health models of care. The Department of Veterans Affairs (VA) is among the leaders of this movement, initially implementing its Whole Health System (WHS) in 18 flagship and design sites with a primary focus on people with chronic pain, mental health needs, and disabilities. VA has since extended elements of this program across all VA medical centers, with plans to scale and spread its WHS system widely and expand the scope of services it offers and conditions that it addresses. VA’s unique financing and organization make it a logical setting to field and test a whole health approach to care because

• It serves as both an insurer and care provider.
• It delivers both health and social care through the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA).
• It has data, resources, a supportive payment system, and policy mandates to innovate and study what it means for people to have whole health and how systems can best deliver whole health care.
• It provides care for the many veterans who have health impacts from their service and who demand and deserve whole health support and care.

In addition to VA’s WHS, the committee found many examples of whole health care in the United States and internationally. These approaches were built around health systems, people with specific health conditions, and defined regions and communities. The whole health systems that the committee identified had many commonalities, such as being built on a foundation of high-quality primary care and prevention; identifying how people, families, and communities define health and well-being; incorporating cross-sectoral approaches and interprofessional teams; and spanning clinical and community settings where people receive care, work, play, learn, grow, and live. Most importantly, the examples the committee highlighted aligned well with the five foundational elements that the committee identified as being necessary to deliver whole health care. These are being (1) people-centered, (2) comprehensive and holistic, (3) upstream-focused, (4) accountable and equitable, and (5) grounded in team well-being. Each of these foundational elements has a rich body of evidence supporting its value in whole health care delivery and improving whole health outcomes for people and communities. The committee was not able to verify that any of the individual examples of a whole health approach that were identified fully and robustly implements every foundational element, but all foundational elements were represented when the examples were considered in total.

As this report has described, a whole health approach requires integration across sectors, some of which, especially those that address upstream factors, typically operate outside of health care systems today. Although this report is primarily focused on how VA health care and other U.S. health care systems can scale and spread whole health, similar reports could be written from the perspective of social services, community programs, public health, or education systems and how they can better integrate and scale and spread whole health themselves.

Published evaluations of the identified approaches used a range of methods to evaluate the outcomes of implementing whole health care. In general, many people and communities wanted access to and felt they could benefit from whole health care, and many clinicians and health system

leaders supported implementing a whole health approach. While different studies measured different outcomes, and while no single whole health approach demonstrated—or even measured—all the following benefits, there is evidence that whole health approaches

• Improved patient care experience and patient reported outcomes;
• Increased access to care, reduced emergency room use, and had fewer hospitalizations;
• Improved clinical quality metrics;
• Improved outcomes for specific conditions such as management of chronic pain, mental health, traumatic brain injury, and healthy aging;
• Reduced maternal and infant mortality;
• Improved health equity;
• Promoted team well-being; and
• Showed some reductions in health care expenditures.

Despite the interest, need, and positive findings, a systems-level transition to a whole health approach will require seismic cultural, structural, and processual shifts. Both top-down (e.g., systems leaders and policy leaders) and bottom-up (e.g., people engaged with whole health care, stakeholders, clinicians) changes will be needed to address the requisite team, organization, community, and system-level structural and process transformations. Health care systems should implement these changes in ways that ensure whole health care services are integrated across systems (including systems that address upstream factors that often operate separately from health care systems), services, and time. In addition, these changes will need to be supported by a healthy and adequately trained workforce, meaningful measurement, information technology, and payment and policy reforms. A global, cross-sector, learning health system’s approach should evaluate, learn, adapt, and refine whole health approaches continually, and systems will need to learn from each other to scale and spread best practices.

COMMITTEE GOALS AND RECOMMENDATIONS

This report and its recommendations apply both to VA systems of care and, more broadly, to systems of care throughout the United States and internationally. Based on the committee’s statement of work and the evidence the committee found, the committee assumed that many in the medical community and outside of it desire to transform conventional medical care to whole health care. Common sense suggests that each person, family, and community would want to achieve whole health as it is defined. (For a list of committee definitions of terms like whole health, see Box 8-1.) Yet

while evidence supports the benefit of whole health care, the committee also recognizes that not all people and systems will want to receive, deliver, or fund whole health care.

To ensure that every veteran and every person in the United States has access to and can receive the support needed to attain whole health, the committee’s recommendations, detailed below, fall under six critical implementation goals. These goals describe a transformational journey in which health systems iterate goals as they learn from one to the next in order to develop the capacity for whole health care.

1. COMMIT to the shared purpose of helping people achieve whole health.
   • Engagement, support, buy-in, and prioritization from the bottom up and top down are needed to enable the cultural and structural transformations necessary to scale and spread a system of whole health care.
2. PREPARE for a whole health approach to care.
   • Interprofessional teams, organizations, and systems need to understand where they are developmentally on the trajectory to delivering whole health care and what they need to change to deliver whole health care.
3. INTEGRATE across systems, services, and time to support whole health care throughout the lifespan.
   • Achieving whole health will require support in all settings throughout peoples’ lifespan, and within and across the communities to ensure holistic and comprehensive care.
4. DELIVER all foundational elements of whole health care across the lifespan.
   • Each foundational element of whole health care is essential and interdependent, and successful whole health systems need to attend to all five elements.
5. EVALUATE to iteratively refine whole health care systems and create generalizable knowledge.
   • The understanding of how to best deliver whole health care is evolving rapidly, so evaluating, adapting approaches efficiently, and sharing learnings will be essential for national success.
6. DESIGN public- and private-sector policies and payment to support whole health as a common good and whole health care as a way of achieving whole health.
   • Scaling and spreading whole health care throughout the United States will not be possible without realigning infrastructure, policies, and payment to support, promote, and fund the provision of the foundational elements of whole health care.

GOAL ONE: COMMIT TO THE SHARED PURPOSE OF HELPING PEOPLE ACHIEVE WHOLE HEALTH

Recommendation 1.1: To scale and spread whole health, the Department of Veterans Affairs, the Department of Health and Human Services, other federal agencies addressing health and social services, state and local governments, health systems, social services, community programs, and external environment actors (payers, corporations, educators, and others) should make whole health a core value.

Making whole health a core value means committing to the cultural, structural, and process changes needed to achieve whole health. This commitment starts with leadership across public and private sectors, including health care, community programs, social services, and public health organization, payers, educators, and informatics-oriented organizations or vendors, and it requires meaningful actions:

• Securing prioritization and buy-in at all levels of leadership.
• Naming the care delivery approach as a “whole health approach.”
• Making a whole health approach part of the organization’s core mission statement.
• Creating a vision and roadmap for delivering whole health.
• Including the people, families, and communities that will be served in the design of the whole health care system.
• Financially investing in the development of whole health approaches.
• Identifying champions at the local level and supporting their efforts to lead needed transformations.
• Incorporating whole health approaches in day-to-day culture for patients and care team members.

GOAL TWO: PREPARE FOR A WHOLE HEALTH APPROACH TO CARE

Recommendation 2.1: National, regional, and facility VA leaders should ensure that all sites are ready to offer the Whole Health System of Care to all veterans by ensuring that each site understands and adopts the whole health mission and vision and has the resources and services it needs to transform its care delivery approach.

While VA has made tremendous advances in developing, implementing, and spreading its WHS, not all VA sites have fully implemented it. All veterans should have easy access to whole health care in their community, which will require scaling and spreading the WHS more fully to all VA facilities. Additionally, not all VA sites will have the resources and interprofessional team members to fully implement the WHS. To address this expected limitation, WHS services should be more accessible either on site or through virtual platforms, as well as through non-VA health care and community-based systems by taking advantage of community programs through the MISSION Act (see Recommendation 6.1).

Recommendation 2.2: Health care systems, community programs, social services, and public health organizations committed to helping people achieve whole health should ensure that all sites are ready to

offer whole health care to the people, families, and communities they serve.

VA and many other health systems in both the public and private sectors have made significant advances in implementing whole health approaches, while other systems are just beginning their whole health journeys. In the United States, whole health implementations are primarily health system based, although in other countries there are examples that are more community based and even regionally or nationally based. Whether just starting to implement a whole health approach or scaling and spreading an existing approach to new sites, health systems need to take multiple actions to prepare for transforming care, including

• Assessing organizational and interprofessional team member readiness.
• Identifying potential facilitators, barriers, and strategies for overcoming barriers.
• Defining the elements of the current care system that will need to change to transition from conventional to whole health care.
• Determining what resources are available and what resources are needed, and pursuing those that are lacking.
• Identifying sites to serve as early adopters and designating champions to lead the redesign, innovation, and implementation.
• Creating a sense of urgency.
• Organizing interprofessional teams around the whole health needs of the people, families, and communities served.
• Developing processes for interprofessional teams to collaborate, share information, and coordinate resources.
• Establishing ongoing dynamic mechanisms for meaningful input from the people, families, and communities who will be co-creating whole health care.
• Developing the clinical, social services, and community cross-sector partnerships needed to fully address all five foundational elements of whole health.
• Ensuring that the whole health needs of the interprofessional workforce are also met.

GOAL THREE: INTEGRATE ACROSS SYSTEMS, SERVICES, AND TIME TO SUPPORT WHOLE HEALTH THROUGHOUT THE LIFESPAN

Recommendation 3.1: The Department of Veterans Affairs should integrate the delivery of whole health services between the Veterans Benefits Administration and the Veterans Health Administration.

Many of the benefits VBA offers to eligible veterans address the issues that are relevant to upstream factors foundational to whole health. However, VBA and VHA are separate administrations under the Department of Veterans Affairs, with separate leadership, budgets, and reporting structures. As currently structured, their efforts are siloed and do not fulfill the characteristic of being holistic with components and team members seamlessly integrated and coordinated. Integrating key VHA and VBA efforts and team members has the potential to maximize the effectiveness and efficiency of VA’s whole health efforts while also reducing health inequities among veterans.

Recommendation 3.2: Health care systems should create and strengthen the infrastructure needed to partner with community programs, social care, and public health systems.

This recommendation applies to both VA and non-VA systems committed to helping people achieve whole health. Even if VHA and VBA fully integrate their whole health services (Recommendation 3.1), achieving whole health will require contributions from community programs, social services, and public health. Whole health systems will need infrastructure to support partnerships at the federal, state, and local levels, and they will need to include both the public and private sectors. Examples of agencies for health systems to consider building whole health partnerships with include

• Public and private payers (e.g., Centers for Medicare & Medicaid Services, state Medicaid agencies, commercial insurers, employers).
• Local and state mental health and substance use departments.
• Health behavior change organizations (e.g., diabetes prevention programs, child guidance centers).
• Public health departments.
• Social service agencies (e.g., Social Security Administration, Department of Housing and Urban Development, local housing administrations, homeless shelters, food pantries, community service boards).
• Workforce development agencies (e.g., Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration).
• Education systems and training programs (e.g., Department of Education, universities, local school boards, vocational training programs).
• Health informatics actors (e.g., Office of the National Coordinator for Health Information Technology, health informatics vendors and developers).
• Private businesses and corporations.

To determine the specific partnerships necessary to build a whole health approach, health systems will need to identify the resource, service, and provider gaps in their current approach to whole health care. Functionally, the infrastructure needed to create partnerships should either physically or virtually co-locate care team members. Interprofessional teams should feel integrated and de-siloed and have coordinated leadership pursuing a common whole health vision. Infrastructure should support easy, seamless, and frequent information sharing and communication across team members. There should be sufficiently shared goals, purpose, mental models, and structural stability such that changes within partnering organizations do not undermine the whole health interprofessional team approach. Health systems will need workforce training efforts to support working across sectors, with a new focus and new goals to define success.

GOAL FOUR: DELIVER ALL FOUNDATIONAL ELEMENTS OF WHOLE HEALTH CARE ACROSS THE LIFESPAN

Recommendation 4.1: The Department of Veterans Affairs should fully incorporate all whole health foundational elements into its Whole Health System.

VA has made tremendous efforts to develop and implement its WHS. It has focused appropriately on the issues most directly related to service-related issues for veterans—chronic pain, mental health, and traumatic brain injury. Implementation has also focused more on the people-centered (“what matters to you”), complementary and integrative health, health coaching and peer navigation, and individual well-being components of the approach. Future efforts should continue and should advance these activities and more fully develop all foundational elements of whole health care with particular attention to ensuring that the care offered is comprehensive and holistic, addresses upstream factors (e.g., health behaviors, mental health, social needs) and team well-being, and is accountable to all veterans with particular attention to equity for disabled, socially vulnerable, racial and ethnic minority, women veterans, and others who may have difficulty accessing services due to geography or other factors. Additionally, VA will need to extend the whole health approach to older veterans, women’s health, maternal health, family health, LGBTQ+ health, chronic disease management, and healthy aging.

Recommendation 4.2: Health care systems, community programs, social services, and public health organizations should model whole health approaches after the Department of Veterans Affairs and other early adopters.

VA and other early adopter health systems have learned and shared a significant amount of knowledge about implementing a whole health approach to care. Systems that are committed to helping people achieve whole health should begin by building on what others have done successfully. Local tailoring will be necessary to address the specific needs of the people served, available resources of the local care systems, the local environment, and opportunities for collaboration. Whole health implementations among early adopters have addressed a wide range of populations and conditions, but in any one system whole health implementations have generally been developed for select populations or conditions. Whole health care should be the default way that health care is practiced and should be available for all people in every community across the lifespan, including both caring for people of all ages at any one time and a longitudinal approach to whole health care across each person’s life and health trajectories. Health systems should tailor whole health care to the populations they serve, and systems will need to assess and address their gaps in care as these align with specific communities needs and conditions.

Recommendation 4.3: Building on its existing health center program, the Health Resources and Services Administration should lead the scale and spread of whole health care in the community.

Through its experience in starting up national networks of federally qualified health centers and area health education centers and coordinating more than 3,000 grantees and 90-plus programs designed to provide equitable health care to people who are geographically isolated and economically or medically vulnerable, the Health Resources and Services Administration (HRSA) is well positioned to serve as a federal leader in promoting whole health care adoption and implementation in non-VA settings among its current and future grantees (see Recommendation 4.2). HRSA has established systems of accountability and addresses upstream factors as well as conventional health care. Particularly important has been HRSA’s ability to scale and spread initiatives across the nation, including in some of its most vulnerable communities, in collaboration with state and community partners. Strategies to support scale and spread can include linking health center certification and funding to the center implementing a whole health care approach; requiring grantees to measure, learn from, and report on whole health processes and outcomes; and providing health centers with technical assistance to achieve the whole health goals outlined in this report. HRSA’s approach to promote uptake and delivery of whole health care services can serve as a model for commercial and federal payers as well as state and local health departments. These roles would be an expansion of HRSA’s current

mandate and would likely require congressional support and funding, a necessary investment to promote access to whole health care, particularly among underserved populations.

GOAL FIVE: EVALUATE TO ITERATIVELY REFINE WHOLE HEALTH SYSTEMS AND CREATE GENERALIZABLE KNOWLEDGE

Recommendation 5.1: Systems fielding a whole health approach should systematically and continuously evaluate and participate in external evaluations of the implementation and adaptations of the approach and disseminate lessons learned.

Scaling and spreading effective whole health approaches so that whole health is accessible to all will take fundamental and seismic changes to the structures, processes, and goals of how the nation thinks about and cares for people. Even systems, such as VA, that have implemented a whole health approach are in the early stages of their transformation. It is essential for public and private systems fielding a whole health approach to evaluate how they implement whole health care and its outcomes, which will require partnerships with health researchers and participation in external evaluations. Learning from this kind of evaluation will inform continual adaptation and improvement, and this learning should be disseminated so that it may inform others who are also implementing or considering implementing a whole health approach. Evaluations should be prospective, longitudinal, and multilevel; should use a mix of methods; should include information on how-to achieve whole health; and should not be overly burdensome on clinicians or people receiving care. Findings should be shared openly and transparently, using narratives and numbers, with details to assess the strengths, limitations, and potential biases so that all can learn and adapt approaches based on the results. These evaluations should focus on learning and should be separate and distinct from evaluations used to ensure accountability and the quality of whole health care.

Recommendation 5.2: Building on its overall mission to study the care of people and the allocation of Patient-Centered Outcomes Research (PCOR) Trust funding to disseminate evidence to practice, the Agency for Healthcare Research and Quality (AHRQ) should fund research to evaluate whole health care as well as research that disseminates evidence on whole health practices. Additional research support will be needed from other national and international organizations, foundations, and private payers.

To accomplish Recommendation 5.1, systems will need research support and funding. AHRQ is a logical lead for this type of research, given its mission to study the care of people and its Center for Evidence and Practice Improvement. In addition, AHRQ has designated funding from the PCOR Trust Fund to ensure the dissemination of evidence into practice. This could be used to fund studies on how to best scale and spread whole health transformations and to implement lessons learned to ensure that whole health care is as efficient and effective as possible. Periodically, AHRQ can fund evidence reviews and create a central information hub to make it easy for systems implementing whole health care to find and understand lessons learned.

Implementing new approaches to care is a complex, multilevel, and iterative process. It will be important to measure both processes and outcomes and capture both efficacy (outcomes in controlled settings) and effectiveness (outcomes in usual day-to-day circumstance). Doing this will require a range of flexible and iterative study designs, including randomized controlled trials that can prove causality, pragmatic designs that assess adaptations and implementation over time, and observational and comparative designs with higher risks of bias but more ability to capture real-world impacts and processes. Evaluations will need to use mixed methods that incorporate quantitative and qualitative data and economic evaluations to study how to achieve the greatest value in care delivery.

The National Institutes of Health’s dissemination and implementation portfolio and new Advanced Research Projects Agency for Health (ARPA-H) can be applied to whole health care. The World Health Organization’s leadership and support for people-centered care is in alignment with similar support for whole health care. The Patient-Centered Outcomes Research Institute’s mission to fund comparative effectiveness research could apply to comparing various approaches to delivering care. Other organizations that focus on measurement development, quality improvement, and the dissemination of best practices, such as the National Quality Forum and National Committee for Quality Assurance, could also play active roles in studying whole health. Federal leadership from organizations such as the Office of the National Coordinator for Health Information Technology can create incentives for informatics vendors to develop and support the systems needed to deliver whole health care, integrate collection and measurement tools into the electronic care delivery workflow, and make data more easily accessible to care systems and academic health services researchers. Public and private payers purchasing health care services should also fund whole health evaluations.

GOAL SIX: DESIGN PUBLIC- AND PRIVATE-SECTOR POLICIES AND PAYMENT TO SUPPORT WHOLE HEALTH AS A COMMON GOOD

Recommendation 6.1a: The Department of Veterans Affairs, Congress, and regional third-party administrators should determine how the MISSION Act applies to delivering whole health services.

Recommendation 6.1b: Regional third-party administrators of the MISSION Act should streamline the process for enrolling community providers in community care networks and define and enforce standards for health record transfer between community care systems and VA as a condition for reimbursement.

Delivering whole health care will require VA and Congress to clarify the services that the current MISSION Act legislation and policy covers and to hold regional third-party administrators accountable for establishing the clinical capacity needed to ensure timely, high-quality care. VHA and VBA programs should engage with non-VA health systems and social support programs to promote the routine identification of patients/participants with past military service and create coordinated care systems across VA and community settings to promote whole health.

While the MISSION Act was well intentioned, the current implementation of the act is fraught with problems and as currently put into practice has significant limitations in access to care through community (non-VA) clinicians. These limitations would likely be magnified if the act’s requirements were applied to broader whole health care. There are numerous reasons for this, including the language of the legislation, inadequate community provider networks, ineffective policy and procedures regarding care standards and information exchange between community and VA systems, and financial overruns that threaten VA’s ability to sustain clinical capacity at its own sites of care. If VA wants to scale and spread whole health for veterans receiving care through MISSION Act eligibility, it will first have to clarify whether whole health services, particularly those that address upstream factors (e.g., homelessness, housing, education, and vocational services), can be delivered by community providers under current MISSION Act rules. Paying for care from community providers and adding whole health care should not undercut access to services at VA sites. For the MISSION Act to succeed, VA will also have to ensure that it detects and thwarts financial abuse and fraud promptly and that there are sufficient networks of community providers and services in areas with unmet veteran needs. However, building larger networks of community providers will be challenging, as many communities are themselves facing significant provider and service

shortages. Even so, regional third-party administrators can make the process of becoming an eligible community care provider more efficient in order to attract more participants. They can also ensure that both VA and community systems have a complete picture of each veteran’s whole health status, needs, and preferences by facilitating reliable and consistent health record exchange between systems.

Recommendation 6.2: The Department of Veterans Affairs, in partnership with the Department of Health and Human Services (HHS), should create a national Center for Whole Health Innovation to design and advance the policies and payments for whole health care.

Accomplishing the five goals discussed above will require a complex set of multilevel changes across many sectors and systems. The magnitude of change needed to accomplish whole health care implementation is great, even among systems like VA that are already on this path. New partnerships will need to be forged, policy and payment changes will be needed, and an unprecedented level of coordination will be needed at the local, state, and national levels. This will be a decades-long process and is not a change that the nation can accomplish in the next few years. Moreover, no one organization currently has the authority or responsibility for envisioning and leading the implementation of an effective whole health approach that spans health care, public health, community programs, education, and social services sectors. Given the magnitude of change needed, the current early stage of whole health implementation, the need for a longer trajectory of iterative system design, and the need for research and adaptation to implement and refine the whole health approach, the committee recommends creating and funding a national Center for Whole Health Innovation. The center would be charged with developing the needed policies, practices, and tools required to support scaling and spread of whole health both within VA and, more broadly, across health, community, and social systems nationally.

While the committee considered various entities to lead this effort, it concluded that, given the complexity and needs across sectors, only the federal government has the authority and resources to oversee the required changes. The committee is not aware of a single other public or private organization that could address whole health. While a coalition of organizations (either a private or a public–private coalition) might be able to address whole health care, responsibility would be diluted, and the coordination of efforts would be overly complex and cumbersome. There is a critical role for nongovernmental stakeholders (health system leaders, researchers, technology vendors, and others) to provide needed input and collaboration into designing the policies and payments for whole health care, and

the committee concluded this could best be achieved by including these stakeholders as partners in the Center for Whole Health Innovation. The committee considered different ways in which the center could be organized within the federal government. Because VA has begun the implementation of its Whole Health System, it makes sense for it to be among the leaders of the national effort. However, because successful scale and spread of whole health across non-VA health, community, and social systems will depend on coordination across so many sectors, the committee felt that it was critical that HHS and VA partner in the effort. The committee did consider assigning this task to an agency within HHS, but rather ultimately determined that secretary-level leadership was needed to coordinate and assign agency-level participation. While pockets of success and innovation would likely continue throughout the country without a nationally coordinated effort, these successes would be scattered and not live up to their full potential.

VA and HHS should jointly lead the creation and design of the Center for Whole Health Innovation. Collectively VA and HHS can represent the spectrum of where people will receive care, the coordination of care, and the federal and national leaders in implementing whole health care. The center could be modeled after other national centers, such as the Center for Medicare & Medicaid Innovation. The Center for Whole Health Innovation will need investments in the range of what the CMS innovation center or the Cancer Moonshot initiative receive, which will likely require congressional support. The Center for Whole Health Innovation will need multisector support from other whole health stakeholder agencies and organizations such as CMS, HRSA, Department of Defense, Indian Health Service, Substance Abuse and Mental Health Services Administration, National Institutes of Health, AHRQ, Patient-Centered Outcomes Research Institute, ARPA-H, Social Security Administration, Department of Housing and Urban Development, Department of Education, Department of Agriculture, Department of Labor, Department of Transportation, veterans service organizations, and other representatives of people and communities being served by whole health systems.

The recommendation to form the center has many similarities to the recommendation to form the Secretary’s Council on Primary Care in the National Academies’ Implementing High-Quality Primary Care report. The proposed center and the proposed council have some overlap in terms of mission, charge, and design of whole health and primary care, respectively. However, whole health is more than high-quality primary care, and primary care has unique needs outside of whole health. The center and council will need to collaborate and build synergy with their efforts, but they should be independent parallel entities with unique charges.

The Center for Whole Health Innovation will need to address five specific tasks (as well as others not called out in the following list):

1. Disseminate and advance the vision of whole health for the nation and how to deliver whole health care effectively and efficiently. This report is a first step in developing a shared understanding of whole health and a framework for how to deliver whole health care. As whole health care scales and spreads further, the Center for Whole Health Innovation can aggregate, share, and disseminate lessons learned and best practices to help systems commit, prepare, implement, measure, and adapt their whole health approach.
2. Define how to measure and hold systems accountable for whole health success. Measures are needed to assess the effectiveness of the delivery of whole health care and the attainment of whole health by people, families, and communities. These measures need to be distinctly different from current biomedical measures and should instead measure whether systems deliver whole health care’s foundational elements. Short-term measures could assess the process and delivery of care while long-term measures could focus on health outcomes.
3. Ensure structures, processes, and infrastructure development to support whole health. Structures and processes that support whole health care will require experimentation with expanded interprofessional teams, new forms of inter- and intra-organizational relationships, and mechanisms for promoting their integration. The necessary infrastructure will include health information technology, workforce training and education, engagement of people and communities on whole health care, and measurement for learning to scale and spread and for accountability purposes.
4. Adapt value-based payment models aligned with delivering whole health care. These payment models should include the entire interprofessional team and scope of whole health care services. They should also reinforce the delivery of all five foundational elements of whole health care. Payers, public and private, need to be united in their support of payment reforms.
5. Consider equitable allocation of resources to deliver whole health care. Because much of whole health occurs outside of conventional medical care, there is a need to meaningfully invest in developing community programs and social services, especially in historically under-resourced settings with the most unmet need. National policies are needed to better allocate payment and resources across the broad spectrum of whole health services such as increased funding to address upstream factors affecting health, allocating more health and social care resources to the people and places in need, training the workforce needed to deliver whole health care, and improved education for all.

CONCLUSIONS

Whole health is a common good that benefits people, families, and communities. Scaling and spreading whole health care so that all can have access to needed services is a tall task and will take seismic cultural, structural, and process transformations. These include how to think about what it means to be healthy, how to deliver health care, who is accountable for delivering health care, and even how to measure success. Throughout the transformation process, the people, families, and communities who receive whole health care should be engaged as equal partners in defining health goals and the preferred strategies to reach them. Multisector collaboration and investment on a national and local level are needed, as is a significant reallocation of resources to ensure effective, efficient, and equitable care.

The United States has made significant national investments to address diseases and conditions, which have produced tremendous medical advances and innovations. However, the nation has not made similar commitments to improving the delivery of care and ensuring that it is delivered effectively and efficiently. As a result, many people and communities fail to receive effective care, and care is often not aligned with what is needed and wanted. The whole health care approach is a promising model to guide the investments that health systems need to make to study and improve how they deliver care. The recommendations and approaches outlined in this report provide a roadmap for improving health, social, and community systems of care.

While there are challenges, there will be substantial benefits to transforming how the nation defines health and delivers health care. Recent innovations in VA and in other early adopter systems of whole health care have advanced the field significantly and demonstrated the value of a whole health systems approach. Building on these advancements will ensure future success leading to better health and well-being for veterans and the nation.

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