3

Evidence Supporting Whole Health’s Foundational Elements

In Chapter 2 the committee defined whole health as “physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities.” This definition departs from more traditional and limiting conceptualizations that conflate health care with medical care—services determined and delivered by clinicians trained in medical sciences. When considered across the lifespan, inadequate medical care is a relatively small contributor to premature deaths compared with health behaviors, social factors, and genetic predisposition (Figure 3-1) (McGinnis et al., 2002). In the same way, addressing these determinants of health is essential to achieving whole health.

The committee also defined whole health care as “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.” The committee further identified five foundational elements of a whole health approach, which includes being (1) people-centered, (2) comprehensive and holistic, (3) upstream-focused, (4) equitable and accountable, and grounded in (5) team well-being. These foundational elements are not distinct services, but rather are characteristics embedded in the care delivery process. The elements overlap and are interwoven and synergistic. Every whole health system must address all five foundational elements in some manner, but the degree and manner may differ depending on local needs of the system and the people, families, and communities they serve.

In the United States, high-quality primary care most resembles elements of a whole health system. The National Academies of Sciences, Engineering,

and Medicine (National Academies) report Implementing High-Quality Primary Care noted that primary care is the only part of the health care system in which an increased presence is associated with longer lifespans and improved health equity, attributes often associated with well-being (NASEM, 2021). High-quality primary care, as the recent National Academies report defined, includes several elements consistent with a whole health approach, including longitudinal, team-based care focused on individuals, their families, and their communities. A high-functioning whole health system would also likely rely upon the attributes of high-quality primary care that explain its salutary effects: being a point of first contact, comprehensiveness, coordination, and continuity for people (Starfield et al., 2005).

Nonetheless, achieving whole health cannot be accomplished just by expanding or strengthening primary care alone. Rather, it must begin with the self-identified needs of the person,¹ family, and community for wellbeing. Whole health systems must be able to organize actions and resources to respond to those needs across physical, behavioral, spiritual, and socioeconomic domains. Since this exceeds the reach of primary care or even all

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¹ The committee is using person and people rather than patient, as whole health starts before a person becomes a patient.

of medical care, the committee speaks of reclaiming the notion of health from the medical sciences by focusing on the five foundational elements of whole health systems. As such, achieving the committee’s definition of whole health depends upon interprofessional teams working in whole health systems including but not solely comprising health care clinicians. Whole health systems must be built on a foundation larger than a health care chassis. Social services, public health, community programs, education, environmental planning, judicial, and employer sectors likely need to be involved to some degree in an effective whole health approach. Interprofessional teams working with people, families, and communities produce whole health within systems, where a system is “an interconnected set of elements that is coherently organized in a way that achieves something” (Meadows, 2008). Not all systems need be within single organizations, such as the Department of Veterans Affairs (VA), but to be effective they must possess a considerable degree of organizational cohesion built around relationships and connections among the people in the system. They must also possess or develop and sustain a shared sense of values as well as defined inputs, interactions, and outputs (in this case, whole health). As Chapter 6 will discuss in further detail, for a system to have coherency and organization, it must have boundedness—a means for building and maintaining the system, including resources for design, assemblage, integration, oversight, and accountability.

In this chapter the committee reviews the evidence supporting the foundational elements of a whole health approach. To identify the evidence supporting each of the five elements, the chapter focuses on each separately, but the committee recognizes that all elements are interdependent and that there is significant overlap across the elements. As mentioned above, a whole health system is more than the sum of its parts. The committee examines the separate parts to provide an evidential foundation for building a whole system, while Chapter 5 addresses the evidence of whole health systems that integrate the elements into practice.

ELEMENT ONE: PEOPLE-CENTERED CARE

More than four decades of research have demonstrated the value of people-centered care, which is sometimes referred to as person-centered care, person-centeredness, and patient-centered care (Coulter, 2006). For the purposes of this report, the committee will refer to people-centered care throughout, but the committee is drawing from the evidence and experiences across each of these movements and their respective literature.

The term “patient-centered” was first used in the 1960s to describe care that understood “the patient as a unique human being” (Balint, 1969) and that went beyond the traditional diagnosis to a “deeper more holistic

diagnosis” (Balint, 1955). This language grew out of the context of British general practitioners working with psychiatrists in the psychotherapeutic tradition. In 1972 researchers described the need to identify the patient’s real reason for their visit. This view highlighted the need for the clinician to look beyond the presenting problem and its traditional diagnosis to look deeper and discern to what extent the presenting problem was a sign of the patient’s limited tolerance for the discomfort or the anxiety regarding the presenting problem or even a signal of another problem altogether (McWhinney, 1972). Subsequent research on the broad range of issues that people experience demonstrated better patient-reported outcomes associated with a “holistic” approach—one in which clinicians respond not only to the presenting complaint but also to a broad range of problems including physical, emotional, functional, and life problems (Stewart et al., 1979). Early definitions of patient-centered care emphasized this broader way of thinking about clinical encounters, shifting from a clinician- or disease-centered approach (Levenstein et al., 1986) which later coalesced into a comprehensive definition in the 1995 book Patient-Centered Medicine—Transforming the Clinical Method which was updated in the book’s second and third editions (Stewart, 2014).

Defining People-Centered Care

To inform its work, the committee commissioned a scoping review on people-centeredness and the related constructs noted above.² The review identifies seven approaches to people-centeredness described in five publications (IOM, 2001; Langberg et al., 2019; Mead and Bower, 2000; Morgan and Yoder, 2012; Sturgiss et al., 2022). Four interconnected components are present in all seven described approaches: (1) the person’s experience, including illness, thoughts, and feelings; (2) appreciating the person in context, especially in the context of family; (3) mutual discussion of goals and preferences and having this discussion inform decisions; and (4) the relationship between the patient and clinician, including empathy, emotion, and sharing power. Three of the approaches also highlight the importance of the clinician as a person and how this influences care (Langberg et al., 2019; Mead and Bower, 2000; Sturgiss et al., 2022). Three others highlight the importance of coordinated and integrated care when it is necessary to engage the expertise of multiple professionals in a person’s care. Using these findings, the committee sets forth six components that the delivery of people-centered care must emphasize:

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² Moira Stewart’s commissioned paper is available at https://doi.org/10.17226/26854.

1. Person’s experience (strengths, illness, thoughts, and feelings)
2. Person in context (social support, work, community, especially family)
3. Discussion of goals and preferences and using these to inform shared decisions
4. Relationships, including empathy, emotion, and sharing power
5. Clinician as a person (cues to affective relationship, professionalism, advocacy)
6. Coordination (accessibility, coordination, care pathways)

There is significant direct overlap with at least four of the above components of people-centered care and how the VA’s Whole Health System (WHS) uses the people-centered concept, as shown in Table 3-1 (Krejci et al., 2014; Stewart, 2014). The “clinician as a person” and “coordination” domains of people-centered care are important elements of ensuring team well-being in the VA WHS.

Outcomes of People-Centered Care

To understand the effectiveness of people-centered care in a contemporary context, the commissioned scoping review identified all pragmatic, randomized controlled trials of people-centered care that had been conducted since 2010. The review included studies if the intervention addressed the patient–clinician clinical encounter or coordination of the health care system. Sixteen studies were identified from two systematic reviews (McMillan et al., 2013; Smith et al., 2021), and two papers published after these reviews were further identified for inclusion (Fortin et al., 2022; Stewart et al., 2021). All 16 studies focused on the patient level, 2 focused on the person’s experience, 15 on discussion of goals, 1 on relationship, 7 on the organizational level, and 7 on training. Table 3-2 shows the types of outcome measures, number of different measures, and number of measures that showed statistically significant improvements as a result of the patient-centered intervention.

Patient-reported outcome measures, such as activities of daily living and quality of life, were more frequently measured than clinical measures; clinical status outcome measures (i.e., HbA1c, hypertension management) were used in only 2 of 16 studies (Ford et al., 2019; Lynch et al., 2014). Of four measures used, only one showed a significant improvement with the patient-centered intervention. Researchers who study patient-centered interventions prefer patient-reported outcomes, measuring what matters to patients, which aligns philosophically with a commitment to testing patient-centered innovations. Furthermore, a robust literature that directly connects

TABLE 3-1 Complementarity of the People-Centered Clinical Method and the VA Whole Health System

TABLE 3-2 Outcome Measures: Type, Number of Measures, and Percent of Measures Significant

self-rated health and mortality supports the importance of patient-reported outcomes (Idler and Benyamini, 1997).

Fourteen of the 16 trials used 49 patient-reported outcome measurements, of which 21 (43 percent) showed significant improvements from the patient-centered intervention. Similarly, patient-reported experience measures, such as rating of continuity, rating of care coordination, and patient perception of patient-centeredness, were reported frequently. Five of the 16 trials measured 13 patient-reported experience measures, of which 10 (77 percent) showed significant improvements from interventions. Collectively, these findings demonstrate a mechanism whereby patient-centered interventions affect outcomes. First, patients notice that care delivery is better (more patient-centered). Second, some patients may feel better as a result. And finally, for a few patients, feeling better translates into physiologic improvements.

The positive outcomes reported here may be understated. Across the 16 studies included in the commissioned scoping review, implementation failures resulted in some participating practices not implementing some crucial intervention components, reducing the potential benefit of the interventions (Stewart et al., 2021). Implementation failures can occur because of inadequate time for training the team (Fortin and Stewart, 2021; Ngangue et al., 2021), a stressful practice context (Mann et al., 2019; Salisbury et al., 2018), and inadequate staff support (Mann et al., 2019). The degree to which clinicians co-created and valued the intervention also seemed to affect implementation (Stewart et al., 2021). The study with the strongest

associations with positive outcomes co-created the intervention together with clinicians, with a goal of strengthening the aspects of practice that the clinicians valued highly, including clinician time spent with the patient and increased continuity of care (Mercer et al., 2016).

Person Experience and Sense of Purpose

Having a sense of purpose refers to the extent to which a person views his or her life as having goals, direction, and meaning. It is recognized as a major component of well-being and for the committee’s purposes can be considered part of the person’s experience (George and Park, 2017; Heintzelman and King, 2014; Ryff, 2014). Purpose or meaning in life is thought to be shaped by social structural factors and life experiences. Having a higher sense of purpose is associated with lower all-cause mortality (Alimujiang et al., 2019), reduced risk of specific diseases (e.g., cardiovascular disease, cognitive impairment) (Cohen et al., 2016; Lewis et al., 2017), better health behaviors (e.g., increased physical activity, better sleep) (Kim et al., 2020; Turner et al., 2017), greater use of preventive health care services, and fewer nights spent in the hospital (Kim et al., 2014). Research has shown that the associations between a lower sense of purpose and adverse outcomes are independent of medical conditions or other experiential or psychological factors (Alimujiang et al., 2019; Boyle et al., 2012). A recent study examining the association between purpose in life and socioeconomic status found that people with the highest level of life purpose consistently had lower mortality risk across levels of socioeconomic status than those with the lowest level of life purpose (Shiba et al., 2021).

The positive health effects associated with a sense of purpose have increased interest in interventions that might enhance this protective characteristic. Indeed, the evidence of a robust relationship between life purpose and all-cause mortality from the Health and Retirement Study led to a call for research on life purpose interventions (Weston et al., 2021), and, as a result, there are now reviews of interventions focused on increasing sense of purpose or “meaning in life.” One review of these therapies noted that some were beneficial, though the review also pointed to the low quality of the small number of existing studies, most of which were focused on specific populations such as those facing serious physical illness (Vos et al., 2014). This review also noted that these interventions can be conducted in groups. A meta-analysis of 33 randomized controlled trials of interventions designed to increase “meaning in life” among people who had experienced adversity or disease reported moderate evidence for improved measures related to meaning in life or purpose in these populations. This review also noted that some of the interventions were relatively brief and did not require licensed professional leaders (Manco and Hamby, 2021). The

interventions showing the best evidence of effects compared with active controls were narrative programs, where individuals reviewed and wrote about their lives with the goal of achieving empowerment or a sense of peace. Mindfulness interventions, followed by psychotherapy and psycho-educational interventions, showed positive effects compared with waitlist or passive controls.

Longitudinal Relationship-Based Care

People-centered care must be grounded in longitudinal or continuous relationships that build a shared understanding and trust over time, for which there is strong supporting evidence of benefit. One investigator suggested that these relationships frame the personal nature of medical care and contrasted this with the dehumanizing nature of disjointed care (Peabody, 1927); more recently another researcher demonstrated that longitudinal relationships are one of the fundamental features of primary care and showed how this feature was essential to primary care’s positive impact on health equity, cost, and quality of care (Starfield, 2011). The Institute of Medicine labeled continuity of care a defining characteristic of effective health systems and a foundational component of effective primary health care (IOM, 1996). Forty years of evidence reveals the value of long-term, interpersonal caring relationships on critical outcomes including patient satisfaction, costs, and care quality and also how these relationships are associated with the avoidance of undesirable health care utilization (Saultz, 2003; Saultz and Lochner, 2005).

ELEMENT TWO: COMPREHENSIVE AND HOLISTIC CARE

The committee determined that the achievement of whole health requires delivery systems that offer both comprehensive and holistic care. Comprehensive describes what care is being provided, and holistic describes how care is provided. Comprehensive care means that care addresses all domains of conventional medical care as well as addressing upstream factors influencing health (see below). Holistic means that care is provided to address the person, family, and community as a whole by a coordinated, integrated interprofessional team.

Comprehensive Care

Whole health needs to be comprehensive to address all the needs of a person, family, and community. Comprehensive care includes all of the individual components of conventional medical care—acute, chronic, preventive, reproductive, and mental health care, dental, hearing, and vision

care—plus the components of complementary and integrative health, spiritual care, and upstream factors such as health behaviors, social needs and education.

Acute Care and Chronic Care

Ample evidence demonstrates the benefits to health and well-being of making each of these domains of care available as components of comprehensive care delivery. Acute care, the active treatment of short-term health issues, has long been the central model of delivering care, and it is something the U.S. health care system does well. However, 60 percent of the U.S. population has at least one chronic health condition, and over 40 percent has more than one (Buttorff et al., 2017). As a result, some health systems over the past two decades have implemented a chronic care model, an integrated, team-based framework that transforms care for patients from being reactive to an immediate health issue to one that is proactive and planned. Evidence from multiple studies shows that team-based chronic care improves outcomes for multiple chronic conditions (Coleman et al., 2009).

Specialty Care

Specialty care refers to care for a patient who has a health problem or illness that requires special knowledge in one particular medical area. Specialty care can be ongoing or preventive for a specific system of the body. Specialists—such as, for example, cardiologists, surgeons, and physical therapists—have knowledge or skill related to a specific disease or organ system of the body. In the United States the balance of primary care (generalist) and specialist physicians has changed dramatically over the past 80 years. In 1940 approximately three-quarters of U.S. physicians were generalists (Jauhar, 2014). Today, approximately 65 percent of all physicians in the U.S. provide specialty care, compared with 30 percent in other high-income countries (Lazris et al., 2018). This is important because a growing body of evidence shows that health care systems with robust primary care have better outcomes and lower costs than those that rely more on specialists (NASEM, 2021; Phillips and Bazemore, 2010; Shi, 2012; Starfield, 1998). Whole health systems need to coordinate and integrate generalist and specialist care in a way that minimizes fragmentation and reduces harm from overuse (Morgan et al., 2018).

Preventive Care

Evidence shows that preventive care, which focuses on preventing or detecting problems before they cause major health issues, reduces the risk for multiple diseases, disabilities, and death; improves health care quality; and reduces use and expenditures (Musich et al., 2016; Truman et al., 2000). All people across all phases of life benefit from preventive care, which includes primary preventive services, which are aimed at preventing conditions from developing; secondary preventive services, which find conditions early before they cause problems and are manageable; and tertiary preventive services, which are designed to prevent complications arising from existing conditions. Preventive services generally include screening tests, health behavior counseling, preventive medications, and immunizations (CDC, 2013). Despite having hundreds of recommended preventive services (USPSTF, 2022), each with ample evidence to demonstrate that their delivery results in improved length and quality of life, Americans receive only about half of recommended preventive care services (McGlynn et al., 2003).

Reproductive Care

For many individuals reproductive care is an entry point into the health care system, and for some it is their usual source of medical care and health information (HHS, 2022). Reproductive care includes contraceptive services, pregnancy testing and counseling, fertility and preconception care, and screening and care for sexually transmitted infections, breast cancer, and cervical cancer. Reproductive care services are an essential component of comprehensive care. Access to family planning services, especially effective contraception, is essential for preventing undesired pregnancies (Harper et al., 2015; Secura et al., 2014). In 2011, 45 percent of all pregnancies were unintended, with higher rates among socioeconomically disadvantaged, Black, and Hispanic women (Finer and Zolna, 2016). Undesired pregnancies are associated with negative economic, psychosocial, and clinical outcomes for mothers, infants, and families (IOM, 1995). The negative impact of undesired pregnancies on the whole health of children and families is likely to increase following the United States Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization (Hajdu and Hajdu, 2021; Lin and Pantano, 2015).

Mental Health Care

The need to provide mental health care in any systematic approach to achieving whole health is well supported by years of research showing that

mental illnesses and psychosocial distresses reduce quality of life and contribute to uncontrolled chronic conditions (Conversano and Di Giuseppe, 2021). In addition, people who feel depressed, anxious, and stressed are less likely to seek medical care, adhere to care plans, or maintain healthy behaviors (DiMatteo et al., 2000) and are more likely to report lower physical and social functional status, less favorable mental well-being and health perceptions, and greater pain (IsHak et al., 2018). Screening for, counseling on, and treating mental health conditions improves health (Coulehan et al., 1997). In addition, there is growing evidence that current systems of care do not adequately address co-occurring chronic mental disorders and substance use disorders (NASEM, 2020).

Oral, Vision, and Hearing Care

The importance of addressing oral health in a whole health approach is supported by a growing body of evidence linking oral health, particularly periodontal disease, to an increased risk and progression of chronic diseases, including diabetes, heart disease, and stroke, as well as low birth weight and premature birth in pregnant women (Bensley et al., 2011; Elani et al., 2018). Regular eye exams can reveal serious health problems, such as diabetes, high blood pressure, high cholesterol, and heart disease, as well as eye diseases such as cataracts and glaucoma. Vision loss can affect an individual’s quality of life, independence, and mobility, and it is linked to falls, injury, and adverse effects on mental health, cognition, and social function (NASEM, 2016). Similarly, research has linked even mild hearing loss to declines in cognitive function, depression, memory problems, dementia, and social isolation (Irace et al., 2022; Shukla et al., 2020).

Complementary and Integrative Health

Research has shown that complementary and integrative health (CIH), which includes acupuncture, massage, yoga, wellness coaching, and meditation, can improve health outcomes for a number of health conditions (Armstrong et al., 2018; Gannotta et al., 2018; Scherwitz et al., 2003). CIH is particularly effective in treating chronic pain, one of the most common reasons for medical visits in the United States (Clarke et al., 2016). CIH approaches are increasingly used as part of cancer care (Armstrong et al., 2018), as reflected in the new field of integrative oncology (Greenlee et al., 2014). Similarly, research has shown that spiritual care is effective in helping individuals deal with pain (Brady et al., 1999), speeding recovery from illness and surgery (Casar Harris et al., 1995), improving end-of-life care (Lo et al., 1999), increasing patient satisfaction (Astrow et al., 2018; Williams et al., 2011), improving mental health (Dein et al., 2010; Koenig,

2015; Koenig et al., 2012; Pour Ashouri et al., 2016), and providing better overall health (Hall et al., 2019; Koenig, 2012).

Religion, Spirituality, and Health

There is ample evidence to demonstrate the value of attending to religious and spiritual needs on mental health and well-being (Dein et al., 2010; Koenig, 2015; Koening et al., 2012; Pour Ashouri et al., 2016). Studies have shown, for example, that persons with higher levels of religiosity and spirituality have lower levels or faster remission of depression and fewer suicide attempts and completed suicides. Interventions that attend to an individual’s religious or spiritual needs produce better treatment outcomes for depression than standard interventions to reduce anxiety, substance abuse, and cigarette smoking. Studies have also observed better physical health outcomes associated with higher levels of spirituality and religiosity. One study, for example, found a correlation between higher levels of spirituality and religiosity and lower odds of developing high blood pressure, while another study found similar associations between higher levels of spirituality and religiosity and lower levels of disability (Idler and Kasl, 1997). Individuals with higher levels of spirituality and religiosity also engage in healthier behaviors and practices (Bożek et al., 2020) and are better able to cope with chronic pain (Dedeli and Kaptan, 2013) and cancer (Lee, 2019). A review of 91 prospective observational cohort studies examining the relationship between religiosity and spirituality and physical health revealed an association with reduced mortality for 69 of the studies (Chida et al., 2009). The protective effect in the studies with initially health populations was independent of social support, negative mood, socioeconomic status, and health behaviors such as alcohol consumption, exercise, and smoking. This review also indicated that “organizational activity,” such as attending church, was associated with greater survival in the prospective studies among healthy populations. A recent study extended the relationship between spiritual coping and survival to persons infected with HIV/AIDS (Ironson et al., 2016). This 17-year prospective observational cohort study tested the use of spiritual practices, positive spiritual reframing, and empowerment as a coping strategy for living with HIV and showed a two-to fourfold survival advantage.

Holistic Care

Holistic care refers to the way in which the components of care are delivered as well as considering the person, family, and community as a whole. This means not caring for a person’s heart to the neglect of the kidneys or in a way that is contrary to the person’s personal values,

preferences, and goals. Holistic also refers to the interprofessional team being coordinated and integrated so that the whole care experience is more than the sum of its parts.

One recent National Academies report noted that Americans live shorter lives and experience poorer health than people in other high-income countries, which it attributed, in part, to an extensive fragmentation of service delivery which creates “inefficiencies and coordination problems that may be less prevalent” in peer nations (IOM/NRC, 2013, p. 107). Experts have also commented on the barriers that U.S. citizens face in receiving desired health services, with one study noting that most Americans receive only half of all recommended health care services (McGlynn et al., 2003) and another finding that only 8 percent of U.S. adults over age 35 received all recommended high-priority clinical preventive services (Borsky et al., 2018).

Delivery design that promotes comprehensive integration at the population and personal levels is one proposed solution to fragmentation and insufficiencies in accessing needed care. A comparison of health systems at the national and regional levels found that systems with higher degrees of “comprehensiveness of primary care”—the extent to which primary care practitioners provided a broader range of services rather than making referrals to specialists for those services—and with a family orientation in which services all family members received care from the same practitioner produced better outcomes across a range of population health indicators, including mortality, mental health, and low birthweight (Starfield, 1998; Starfield et al., 2005). Additional demonstrated benefits from a comprehensive approach to care delivery include higher patient satisfaction, lower health system costs, fewer hospitalizations, and lower rates of clinician burnout (Bazemore et al., 2015; Weidner et al., 2018). Research has also shown that comprehensiveness at the individual clinician level leads to higher scores on outcome measures in a manner that could transition to the health system level (Bazemore et al., 2015; O’Malley and Rich, 2015; O’Malley et al., 2019b).

Two conceptual approaches provide evidence on the value of delivering holistic care: (1) the biopsychosocial model (Borrell-Carrió et al., 2004; Engel, 1977; Kusnanto et al., 2018) and (2) the model of integrated behavioral health in primary care (Cubillos et al., 2021; Hunter et al., 2018).

The Biopsychosocial Model

The biopsychosocial model highlights the value of attending to the person–family–community as a whole. It proposes that illness and health result from interactions among biological, psychological, and social factors and that these interactions are nonlinear and so complex that one cannot know and control all of the contributions and influences that lead to illness and

health (Bolton and Gillett, 2019; Engel, 1977; Stacey, 2001). This model emphasizes that changes in lifestyle can prevent the leading causes of death, such as heart disease, stroke, and chronic obstructive pulmonary diseases (GBD 2015 Risk Factors Collaborators, 2016). The model has evolved to include seven pillars of care: self-awareness, active cultivation of trust, an emotional style characterized by empathic curiosity, self-calibration to reduce bias, educating the emotions to assist with diagnosis and forming therapeutic relationships, using informed intuition, and communicating clinical evidence to foster dialogue (Borrell-Carrió et al., 2004). The biopsychosocial model provides important elements concerning how to approach therapeutic relationships and decision making by recognizing that there are too many factors at play for rigid treatment protocols and that any two individuals with the same diagnosis will have very different physical, social, and psychological factors underlying their condition.

A variety of studies have shown that empirical applications of the biopsychosocial model that involve interdisciplinary teams that include clinical psychologists, dietitians, physiotherapists, and primary care physicians improve outcomes for a number of clinical conditions. These include chronic pain (George, 2008; van Erp et al., 2019), fibromyalgia (Turk and Adams, 2016), diabetes (Segal et al., 2013), chronic obstructive pulmonary disease (Kaptein et al., 2014), asthma (Stempel et al., 2019), irritable bowel syndrome (Tanaka et al., 2011), and post-concussion headaches (Register-Mihalik et al., 2020). Interdisciplinary team-based care focusing on common presenting problems, such as pain prevention and treatment, diabetes management, cardiovascular disease prevention and management, or cancer care and survivorship, are common at major health centers.

Primary Care Behavioral Health Model

Evidence also supports the seamless integration of behavioral health into primary care as important to whole health. Primary care behavioral health (PCBH) refers to a “team-based primary care approach to managing behavioral health problems and biopsychosocially influenced health conditions” (Reiter et al., 2018, p. 112). The evidence for the effectiveness of integrated behavioral health is growing, particularly for addressing depression, and anxiety (Archer et al., 2012; Balasubramanian et al., 2017; Bruce and Sirey, 2018), and for alcohol and substance use treatment (Cubillos et al., 2021; Hunter et al., 2018; NASEM, 2020). One study found that “brief behavioral health interventions delivered in integrated primary care target specific patient concerns (rather than provide only generic support) and improve patient functioning” even across a brief time period of only two to three sessions (Bridges et al., 2015, p. 19). Integrated behavioral health services have demonstrated effectiveness in improving outcomes among

racially and ethnically diverse populations, including Latinos (Bridges et al., 2014; Dwight-Johnson et al., 2010; Flynn et al., 2020) and African Americans (Berge et al., 2017).

Integrating behavioral health into primary care also improves the experience people have when receiving care. A randomized controlled trial demonstrated that compared with usual care, patients receiving PCBH services reported greater use of coping strategies, greater adherence to relapse prevention plans, and greater use of antidepressant medication, with retention and satisfaction highest among patients who received PCBH services (Robinson et al., 2020). One qualitative study, for example, found that individuals felt cared for when their care addressed the full spectrum of their needs, including physical, emotional, and social needs (Davis et al., 2018). In addition, this study found that individuals perceived personal, interpersonal, and organizational benefits from integrated care and that their interactions with members of the integrated care team helped them develop and improve their coping skills. Other benefits that the individuals in this study received included personal growth, improved quality care, and better access to care. Another study combining quantitative and qualitative methods demonstrated that integrating behavioral health into primary care reduced depression severity, enhanced individuals’ experiences of care and their interactions with behavioral health clinicians and helped them acquire new skills to cope with difficult situations at work and home (Balasubramanian et al., 2017).

Research has also demonstrated the benefits of co-locating behavioral health and primary care and of warm handoffs.³ One study on the use of integrated and co-located behavioral health in a pediatric setting, for example, found that integrated care that included warm handoffs increased the likelihood that the individual would receive a depression diagnosis. Co-located care, in which the individual received a scheduled behavioral health visit at the same clinic, was more likely to produce diagnoses of disruptive behavior, trauma/adjustment, and attention-deficit/hyperactivity disorder (Hoff et al., 2020). Warm handoffs in a pediatric setting have also been associated with improved pediatric patient engagement compared with “referral as usual processes” used in co-located service models (Young et al., 2020). Another study in a rural setting found that over 90 percent of individuals initially referred for behavioral health care via a warm handoff had a subsequent behavioral health visit, compared with 50 percent of

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³ A warm handoff is a transfer of care between two members of a health care team while the individual receiving care (and their family if applicable) is physically present. The process provides an opportunity for the individual seeking care to hear what is communicated between the health care team members, ask questions, and clarify details.

individuals without the in-person introduction by their primary care provider to the mental health professional (Mitchell et al., 2022).

Cost savings can also result from integrating behavioral health into primary care. A study of claims data from individuals with Blue Cross Blue Shield of Kansas City insurance found that “integrating behavioral health services into the practice was associated with $860.16 per member per year savings, or a 10.8 percent savings in costs” (Ross et al., 2019, p. 59).

ELEMENT THREE: UPSTREAM-FOCUSED

Research has shown that the root causes of poor health extend well beyond health care and that individual behavior, social, structural, economic, and environmental factors are the primary determinants of health and well-being (McGinnis, 1993). Many of these factors influence an individual’s health and well-being long before a problem manifests or before they encounter the health system at all. The committee refers to these collectively as upstream factors since the effects of their neglect occur later, or “downstream,” in the health care system. Compared with other high-income countries, the United States has much higher rates of chronic disease, reduced quality of life, and greater rates of premature death directly caused by these upstream factors (IOM/NRC, 2013; Woolf and Schoomaker, 2019; Woolf et al., 2013). The United States also spends proportionally more on conventional medical care and less on these upstream factors than other developed countries. With multisector and community partnerships, health systems can address these upstream factors and improve health and well-being, making this capacity foundational for whole health systems.

Health Behaviors

A whole health approach should address unhealthy behaviors, which are a demonstrably significant contributor to poor health. Historically, four unhealthy behaviors—tobacco use, unhealthy diet, physical inactivity, and risky alcohol use—have accounted for nearly 40 percent of preventable deaths in the United States (Mokdad et al., 2004). Today, unhealthy drug use—and specifically opioid and fentanyl use—is also a major contributor of poor health and premature death (SAMHSA, 2019).

Tobacco Use

Despite several decades of reduced use, tobacco remains the leading cause of preventable disease, disability, and death in the United States, with an estimated 480,000 deaths annually (HHS, 2014). In 2019 an estimated 50.6 million U.S. adults, 20.8 percent of the adult population, used tobacco,

with 14 percent using combustable cigarettes and 4.5 percent using electronic cigarettes (Cornelius et al., 2020). Research has shown that clinical interventions that include screening, counseling, and pharmacotherapy help people quit smoking, which in turn prevents smoking-related disease (Fiore et al., 2008; Krist et al., 2021; Rigotti et al., 2022). Any team member can deliver these interventions in any setting. Effective interventions as brief as several minutes can increase the likelihood that a person will quit smoking, and more intensive interventions have greater impact (Fiore et al., 2008). Research has also shown that community-based and policy interventions help reduce tobacco use (Rosen and Ben Noach, 2010). These include smoke-free policies (Community Guide, 2012b), mass-reach health communications (Community Guide, 2013), restricting access to tobacco for adolescents (Community Guide, 2001), developing tobacco control programs (Community Guide, 2014), increasing the unit price for tobacco products (Community Guide, 2012a), and increasing access to treatment programs.

Unhealthy Diet and Physical Inactivity

In the United States more than 35 percent of men and 40 percent of women are obese, a number that has been rising for decades (Hales et al., 2020). Unhealthy diet and sedentary lifestyles are major drivers of obesity, which is a leading cause of premature death and can lead to chronic diseases such as coronary heart disease, type 2 diabetes, cancer, and disability. As described later in the chapter, however, scarce availability of affordable, healthy foods and limited access to safe recreation are major environmental contributors to these negative outcomes (Ferrer et al., 2016; Townshend and Lake, 2017). During the COVID-19 pandemic, obese people were more likely to be hospitalized and die from COVID-19 than non-obese people (Gardiner et al., 2021; Tartof et al., 2020). Obesity is also a major driver of health care costs, particularly as people age (Kim and Basu, 2016). Intensive, multicomponent behavioral interventions can improve diet and exercise and help people lose weight; improve intermediate outcomes such as blood pressure, cholesterol, and blood sugars, which in turn prevents chronic conditions such as diabetes and cardiovascular disease and improves the quality of life (Curry et al., 2018; USPSTF et al., 2017). These interventions are effective for children, adolescents, and adults. However, a major challenge is that changing these foundational elements of peoples’ lives requires intensive support over a prolonged period from a multidisciplinary team, often taking 30 or more hours over 6 or more months.

Ample evidence has also shown that community-based interventions improve diet and physical activity for people (Khan et al., 2009). Examples include offering diabetes prevention programs in local YMCAs (Adams et al., 2016; Rehm et al., 2017), multicomponent interventions to increase

healthier foods and beverages in schools (Community Guide, 2016), community-based digital and telephone interventions (Community Guide, 2020), and workplace programs to promote healthy diet, exercise, and weight loss (Community Guide, 2007).

Unhealthy Alcohol and Drug Use

Unhealthy alcohol use is the fourth leading cause of preventable death in the United States, with more than 87,000 yearly alcohol-attributable deaths from accidents and chronic disease (Stahre et al., 2014). Alcohol misuse not only has health consequences but also causes social and economic problems. Between 2001 and 2013 the prevalence of alcohol use disorder in the United States increased from 8.5 to 12.7 percent (Grant et al., 2017), and the COVID-19 pandemic may have made alcohol use and misuse more common (Clay and Parker, 2020). Similar to the situation with tobacco use, research has shown that brief screening and behavioral counseling interventions routinely delivered by clinicians can reduce risky drinking and support prolonged abstinence in those with alcohol use disorder, which in turn leads directly to moderately improved health as well as social and economic benefits (USPSTF et al., 2018).

According to one study, fully 12 percent of U.S. residents 18 years or older reported current unhealthy drug use, and 8 million persons annually meet criteria for drug dependence or abuse (SAMHSA, 2019). Between May 2020 and April 2021, drug overdose deaths exceeded 100,000 (National Center for Health Statistics, 2021). In addition to health effects, unhealthy drug use is associated with impaired school and work performance, interpersonal dysfunction, and other social and legal problems. Fortunately, counseling and treatment have been shown to reduce unhealthy drug use and increase the likelihood of abstinence, prevent relapse, and improve quality of life, well-being, and life satisfaction (USPSTF et al., 2020). Treatment includes counseling, pharmacotherapy, harm reduction interventions, testing for blood-borne pathogens, assessment of misuse or abuse of or dependence on alcohol or tobacco, assessment of potentially coexisting mental health disorders, and pain management for patients with pain who are abusing opioids (USPSTF et al., 2020).

Social Needs

Social needs—defined here as housing, food, transportation, finances, employment, education, and safety—constitute a key upstream factor that contributes to poor health and therefore must be addressed in any whole health approach. Having a social need causes health inequities, higher health care costs, overuse of health services, reduced quality of life,

morbidity, and mortality (Commission on Social Determinants of Health and World Health Organization, 2008; Hämmig and Bauer, 2013; Krieger et al., 2014; Marmot et al., 2008). Addressing social needs has the potential to save more lives than conventional medical advances (Woolf et al., 2007). For example, there is evidence of a strong association between years of educational attainment and decreased mortality (Hayward et al., 2015). To address social needs, the National Academies, the World Health Organization, and many others have called for integrating conventional medical care and social care (IOM, 2016; Landon et al., 2012; Marmot et al., 2008).

While social needs are a major driver of health and well-being, the role of health care systems in addressing social needs is evolving (Krist et al., 2019; Maani and Galea, 2020). Addressing social needs is complex, as a broad range of underlying factors that are difficult to address often influence individual social and economic conditions. Other sectors may be better equipped to handle social needs than health care, such as social services, community organizations, education, public health, and policy makers. Action is needed at the local, state, and national levels from public and private sectors, synergistically and over an extended period time.

While health care cannot address social needs alone, it does have a key role to play with other sectors. Understanding the needs of a person, family, and community is an important part of people-centered, comprehensive, holistic care. It is an essential step for understanding who a person is, what factors may shape his or her life, and what the person may want help in addressing. Even if the health care system cannot help to fulfill a person’s social need, knowing about the need may change how care is provided (Tong et al., 2018).

In theory, a trusted clinician in a relationship with a patient may be well positioned to screen for and identify social needs. Once these have been identified, the clinician and care team can help connect a patient with services to address those needs. As a result, many health care systems increasingly incorporate programs to address patients’ social needs, but evaluations of these programs to date have focused primarily on process and some social outcomes (Reyes et al., 2021). The National Academies’ 2019 report Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health (NASEM, 2019a) examined how health systems could integrate social care into health care and recommended eight steps (see Box 3-1). These eight recommendations align well with what is needed, in terms of social care, to develop and implement whole health systems of care.

The Role of Racism

The committee recognizes that systemic racism is a primary driver for many of the social determinants of health and thus a critical upstream factor that any whole health approach must address. Allostatic load, the cumulative burden of chronic stress when persistent life challenges become unmanageable or overwhelming over time, illustrates how systemic racism can negatively affect a variety of health outcomes. A recent systematic review showed that allostatic load was associated with racial and ethnic discrimination and poor health outcomes (Guidi et al., 2021). National quality measures demonstrate that compared with white people, Black people received worse care on 76 out of 190 (40 percent) measures and Hispanic people on 58 out of 167 (35 percent) measures (Doubeni et al., 2021). Black, Hispanic, and Asian people are less likely to receive recommended preventive care and more likely to suffer worse outcomes from preventable conditions (Doubeni et al., 2021). In response, many health care systems have issued statements commiting to addressing racism in health care.

To date, most health system interventions to address racism have focused on addressing implicit bias among health care providers, cultural tailoring of information and interventions, and achieving workforce race and ethnicity compositions that are reflective of the communities being served. Research has shown that these actions have some benefit with respect to access to care and the delivery of evidence-based care (Lin et al., 2021; Williams et al., 2019). However, these interventions fall short of addressing the systemic disparities in access to care, quality of care, and timeliness of care that health care systems must address to eliminate their contribution to racial disparities in health outcomes (IOM, 2003). Whole health systems need to commit to addressing these shortcomings head on and address the underlying structural causes contributing to inequities. Emerging methods, such as community-based system dynamics (CBSD), may offer a way forward (Gullett et al., 2022). CBSD requires longitudinal investment in community-driven solutions and the development of trusting relationships and among community members. Based on this foundation, an experienced faciliator catalyzes community members to visualize the complex factors that produce systemic racism, and identify the levers to improve racial equity and whole health for the population. The causal loop diagrams that the community creates become the framework for action and evaluation. CBSD could also be applied to addressing systemic sexism, which we discuss in the next section.

The Role of Sexism

Sexism has historically referred to discrimination on the basis of gender—most commonly affecting women—which harms the discriminated-against individuals with respect to their health and personal wellbeing and also hinders their progression as leaders (Ceci and Williams, 2011). The committee recognizes the prominent role sexism plays in society and in the uniformed services. Sexism can be perpetrated against any gender and takes many forms—sexual objectification, demeaning or derogatory treatment, stereotypic expectations of gender roles at home or in the workplace, and gender-based violence, which includes intimate partner violence, female genital mutilation, and sexual harrassment and assault. Military sexual trauma has had lasting negative mental and physical consequences which can persist well beyond separation from active-duty service while veterans receive care at VA or in other settings.

There are now approximately 1.8 million female U.S. veterans and 200,000 on active duty. Unfortunately, women veterans frequently report sexual and gender harrassment while seeking care at VA facilitites. Depite a 2017 social marketing and training campaign aimed at staff and veterans to reduce the harassment of women veterans at VA facilities, a follow-up survey in 2018 revealed that the problem persisted with no significant improvement (Fenwick et al., 2021). The VA has implemented additional services to more comprehensively provide women’s health care, but the American College of Obstetricians and Gynecologists has noted the need for improved integration of these services into the VA health care infrastructure, which must include access to preventive health care services such as reliable, effective contraception (McCauley and Ramos, 2020). To promote whole health, steps must be taken in society at large, in the VA, and in the uniformed forces to address disparities in childbearing, fertility, depression, and post-traumatic stress disorder (PTSD). More action is needed to continue to provide adequate child care as well as paying attention to the specific physical and emotional traumas experienced by women both in and out of uniform (Disabled American Veterans, 2018).

Women in the military have a higher unintended pregnancy rate than the general population, and these rates are higher among less educated, nonwhite, and single women (Grindlay and Grossman, 2015; Heitmann et al., 2016). Thus there is an intersection between race and gender (e.g., identifying as black and female) which heightens the structural health inequities that people experience.

The Role of Homophobia and Transphobia

Homophobia refers to negative attitudes or discrimination toward individuals who identify as homosexual. Transphobia is a similar concept and refers to negative attitudes or discrimination toward individuals who identify as transgender. Lesbian, gay, bisexual, transgender, queer, and other individuals of minoritized identities (LGBTQ+) experience significant disparities across a variety of physical and mental health outcomes (IOM, 2013; Morris et al., 2019) due in part to implicit and explicit biases of health care professionals during health care encounters (Burke et al., 2015; Sabin et al., 2015). Compared to heterosexual individuals, LGBTQ+ individuals are also more likely to experience a variety of upstream stressors across the lifespan, including child abuse, sexual assault, and other violent assaults (Valentine et al., 2022). Other stressors that affect LGBTQ+ individuals include structural discrimination at the local, state, and federal levels across nearly every sector of society including education, housing, health care, employment, and religion. For example, 27 states have no protections against the discrimination of individuals based on sexual or gender identity (Freedom for All Americans, 2022). This structural discrimination was also the norm in the U.S. military until recently—openly lesbian, gay, and bisexual individuals have been allowed to serve in the armed forces only since 2011. Openly transgender individuals have been allowed to serve since 2021.

Relatedly, LGBTQ+ individuals are about 10 times more likely than the general population to develop PTSD (Valentine et al., 2022). This is highly relevant to VA as PTSD is a condition that is already associated with military combat trauma. An estimated 11 to 20 percent of veterans from Operation Iraqi Freedom and Operation Enduring Freedom have PTSD each year (VA, 2022a). LGBTQ+ veterans have even higher levels of PTSD than heterosexual and cisgender veterans yet a study of women LGBTQ+ veterans found that compared to heterosexual and cisgender women, they face additional barriers to care, such as experiencing more harassment and feeling unwelcome or unsafe when seeking care at VA facilities. One consequence of this is that women LGBTQ+ veterans are more likely to delay needed care to avoid negative interactions at VA facilities (Shipherd et al., 2018).

To help address some of these structural barriers, VA employs an LGBTQ+ care coordinator at every VA facility (VA, 2022b). Whole health is also included in the list of services available to LGBTQ+ veterans; however, the committee was unable to find any specifics regarding whole health services that are designed specifically for LGBTQ+ veterans (VA, 2022b). Whole health care, by definition, is care that recognizes the whole person, and any system addressing it (VA or otherwise) must do its best to mitigate

structural inequities and the interconnections among inequities related to race and ethnicity, sex, sexual orientation, and gender identity.

Environment

The environments in which people and communities reside, work, learn, and rest are dominant factors contributing to human health. During the 20th century, infectious disease–related death in the United States declined by a factor of more than 20 (Armstrong, 1999). Overcrowding and poor sanitation, which accompanied industrialization in the 19th century, facilitated the spread of communicable diseases such as cholera, typhoid fever, tuberculosis, yellow fever, and malaria. The reshaping of these environments by public water supplies, sewage disposal, organized solid waste removal, vector control, and housing reforms were no less central to these gains than the development of effective antimicrobial therapies in reducing mortality related to infectious diseases (CDC, 1999). The COVID-19 pandemic demonstrated that environmental factors that facilitate the transmission of communicable disease remain important upstream determinants of health (Blocken et al., 2021; Emeruwa et al., 2020). Environmental factors are also central in shaping the vulnerability of communities to noncommunicable diseases. Heart disease, cancer, accidents, chronic respiratory diseases, and diabetes are leading causes of mortality in the United States, with well-characterized and modifiable environmental determinants.

Air pollution is a leading cause of global disease burden. Studies have linked outdoor pollution in the form of ozone and fine particles (PM_2.5) to ischemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lower respiratory infection, and lung cancer (Cohen et al., 2017). Exposure to these pollutants, which industrial processes and combustion of fossil fuels emit, differs according to the racial and socioeconomic composition of neighborhoods (Colmer et al., 2020). Indoor air quality that has been degraded by fossil fuel combustion for heating and cooking (carbon monoxide, fine particles), indoor smoking, substances that penetrate the structure (radon), products employed for cleaning and maintenance (volatile organic compounds), mold, and inadequate ventilation is an important exacerbator of respiratory illness (Bernstein et al., 2008; Blocken et al., 2021; EPA, 2003; IOM, 2004).

The development of public water supplies and treatment centers has led a tremendous improvement in water quality in the United States, but these gains have not been distributed equitably across communities. Some regional water systems in the United States have been found to have recurrent violations of health standards, characterized by contamination of drinking water with pathogenic bacteria, nitrates, arsenic, lead, and other contaminants (Allaire, 2018). The 2014 water crisis in Flint, Michigan,

stands as a painful reminder of the need for vigilance to ensure a supply of clean drinking water, particularly in historically marginalized communities (Abbasi, 2021).

Climate change is an increasingly important influence on the environmental factors that shape human health. The U.S. Fourth National Climate Assessment, published in 2018, concluded that changes in weather and climate attributable to human greenhouse gas emissions have degraded air and water quality and increased transmission of infectious diseases through food, water, and insect vectors (NCA, 2017).

Recent research has also highlighted the importance of the foodscape, built environment, and neighborhood safety (Janssen, 2014) as important environmental determinants of health outcomes. Proximity, favorable pricing, and selective marketing of calorie-dense, nutrient-low, processed foods may contribute to the prevalence of diets that contribute to obesity in so-called food deserts (Brown and Perrin, 2018). The effect of toxic food environments may be exacerbated by insufficient access to spaces for recreational activity or the perception, common in low-resource neighborhoods, that the safety-related risks of time spent out-of-doors outweigh the benefits of physical activity. These and other factors may contribute to an obesogenic environment for children and adults, and the factors may have long-term consequences on metabolic and cardiovascular health (Townshend and Lake, 2017). These environmental factors may limit the capability to effect behavior change (Ferrer et al., 2016).

Health care systems that promote whole health may seek to build healthy communities by affecting the environmental determinants of disease most salient to the people and communities in which they operate. Approaches could include developing resources that enable people and communities to identify and mitigate the environmental causes of disease in homes, workplaces, and neighborhoods. Health systems may not always be the best equipped organizations for addressing the environmental needs of communities, and they may benefit from partnerships with community organizers, philanthropic organizations, and academia (Center for Justice, 2004). Such partnerships have shown promise in generating policy change to address the disproportionate burden of pollution and other environmental hazards borne by communities of color and low-income communities in the United States.

Requiring a Multisectoral, Integrated, and Coordinated Approach

Addressing upstream factors—individual behaviors, social needs, racism, and the environment—will promote whole health, but doing so will require collaborations across sectors of care that go well beyond physical, mental, and behavioral health. For example, whole health requires housing,

safety, and access to food, transportation, education, and other services. Collaboration requires helping assemble and participate in a network that is effective in both reaching out and connecting the people residing in communities with their local social services and health care systems and, where needed, providing support to optimize success. Community health workers and peer health coaches (see Chapter 6) can provide important bridges to link clinical systems with community needs (Fiori et al., 2020). Similarly, workplaces and schools also provide potential access points to services and programs that can address the whole health needs of communities (CDC, 2016, 2019). Ultimately the structural factors that cause the upstream causes of poor health will need to be addressed with multisector collaborations.

ELEMENT FOUR: EQUITABLE AND ACCOUNTABLE

One working definition of health equity is a state “where everyone has the fair and just opportunity to be as healthy as possible” (Braveman et al., 2017, p. 2). In the context of whole health, equity is a commitment by an interprofessional team and system to equitable access and treatment of the people and communities they serve. While there is limited direct evidence that health care systems with a health equity focus increase population lifespan, there is considerable evidence that societies with more social equity (smaller disparities in household income, assets, and educational status) have better health and longer lifespans (Marmot, 2020; Marmot et al., 2008). For this reason, the health equity definition cited above goes on to state that health equity “requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care” (Braveman et al., 2017, p. 2).

A commitment to equity makes a difference in the health of populations. There is considerable evidence that practices and health systems that are committed to care for underserved and vulnerable populations (i.e., those that are explicitly committed to equity) improve health outcomes for the people and families they serve and for the communities in which they are embedded. Decades of evidence on community health centers (CHCs), which broadly include a range of practices that care for underserved and vulnerable populations (e.g., free clinics, federally qualified health centers, safety net practices, public health clinics, etc.), have been shown to increase the number of uninsured people who have a usual source of care and have regular contact with a clinician (Carlson et al., 2001; Starfield and Shi, 2004), improve processes of care (Porterfield and Kinsinger, 2002; Ulmer et al., 2000), increase delivery of recommended preventive care and counseling (Klein et al., 2001), reduce hospitalizations (Epstein, 2001; Falik et al.,

2001), and even increase employment and wages (Hunt, 2005). Studies have demonstrated that CHCs provide care to people with chronic conditions that is at least equivalent in quality to that delivered by conventional private practices, and the outcomes are significantly better than in cases where people received no medical care. For example, patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared with non-users of CHCs (Richard et al., 2015). Furthermore, increasing funding for CHCs has been shown to allow practices to care for more people, which in turn reduces emergency room visits for non-emergent primary care—treatable conditions (Myong et al., 2020).

For a system to be equitable, however, it must have not only a commitment to equity but also adequate resources or inputs. The Medicaid Expansion provisions of the Affordable Care Act (ACA) in 2014 provide a valuable natural experiment on the impact of a more equitable approach to health care resources. Under the expansion, Medicaid eligibility was extended to adults up to age 64 with incomes up to 138 percent of the federal poverty level, whereas pre-ACA, Medicaid was generally never available to non-disabled adults under age 65 unless they had minor children. The ACA called for Medicaid expansion nationwide, but a Supreme Court ruling determined that states could not be forced to expand their Medicaid programs, so participation was ultimately left up to each state. As of 2022, Medicaid had been expanded in 38 states and the District of Columbia, and 21 million Medicaid enrollees gained eligibility because of Medicaid expansion (Health Insurance, 2022). A U.S. Government Accountability Office report found that in 2016 low-income adults in expansion states were less likely to report having any unmet medical needs than those in non-expansion states (GAO, 2018). Other studies have shown that Medicaid expansion is associated with sustained increases in recommended clinical preventive services among lower-income people (Song and Kucik, 2022), an increased use of outpatient primary care services with a corresponding reduction in acute emergency room use (Holderness et al., 2019), reductions in delayed receipt of medical care due to cost, and reduced out-of-pocket spending and medical debt for low-income people (Selden et al., 2017).

Addressing health equity is an important moral obligation. More work is needed to define the health system’s role and the value proposition of adopting a health equity lens (Frick et al., 2007). However, more whole health will be produced if health systems deploy their resources with a commitment to equity, particularly focusing on upstream factors as discussed in the previous section, as part of a larger systems approach in the communities they serve that provides sufficient input resources.

Accountability

In Chapter 2 the committee asserts that whole health systems need to be accountable for the health and well-being of a defined population to the people, families, and communities they serve and to their funding entities. Accountability is a key pathway to ensuring the quality, safety, and the equity of care. It includes three components: who is being held accountable, whom are they accountable for, and for what are they accountable. The committee envisions that once whole health care is fully realized, whole health systems and their interprofessional teams and team members will be accountable for the whole health of defined populations of veterans, people, families, and communities.

There is considerable evidence that holding individual clinicians and groups of clinicians accountable for the quality of care they render can improve that quality. In medicine this accountability has been achieved traditionally through the practice of professionalism—groups of clinicians self-defining standards for training, practice maintenance of licensure, and enforcement (ABMS, 2020). A system of legal torts also polices outlier behavior.

Beginning in the 1980s this standard of internal accountability was augmented by external accountability. As research and data aggregation and sharing capacity improved, the ability to define best clinical practices—in terms of desired outcomes and the structures and processes that facilitate those outcomes—and then to measure adherence to them (Donabedian, 2005) also improved. Health care quality measurement, using instruments such as the Consumer Assessment of Healthcare Providers and Systems (LaVela and Gallan, 2014), has since evolved to encompass measures of patient satisfaction and well-being and the quality of care rendered to entire populations for which a health care practice (O’Malley et al., 2019a) or system, such as an accountable care organization (Fisher and Shortell, 2010), is being held accountable (Etz et al., 2019; Zyzanski et al., 2021).

Evidence demonstrates that you cannot improve what you cannot measure. Twenty years after the hallmark Institute of Medicine report on patient safety To Err is Human: Building a Safer Health System (IOM, 2000) documented the harm caused by medical errors, a review article concluded that the risk of preventable errors remained high (Bates and Singh, 2018). While the report identified a critical problem, process and outcomes measures are needed for change. Defining and measuring a simple process to promote patient safety—hand washing—has shown improvements in both process (increased hand washing) and outcomes (reduced acquired infections by over 50 percent) (Hermann et al., 2020). Similarly, the Center for Medicare and Medicaid Innovation has documented how measuring and providing feedback to health care systems has improved

their performance on specific clinical quality measures (Crook et al., 2021). The national increase in colorectal cancer screening from 40 to 60 percent of people eligible for screening between 2004 and 2014 further highlights how defining, tracking, and holding clinicians accountable for an action can improve quality (Davidson et al., 2021; Dougherty et al., 2018). Now it is standard practice to measure, hold accountable, and even pay clinicians for specific measures to improve care (IOM, 2011; Kromm, 2011).

This is not to say that merely defining and measuring care will improve outcomes. Even in organized systems of care, such as Great Britain’s National Health Service, systematic efforts to improve the quality performance of the overall system have proven to have only mixed impact (Dixon-Woods, 2019). Identifying the right measures, developing feasible and meaningful actions for improvement, and holding teams accountable for change are all necessary for success—and all will be necessary for whole health to succeed.

Empanelment

The concept of empanelment illustrates how a specific form of accountability can facilitate equity within a given population. Empanelment is the process of assigning everyone in a given population to an interprofessional care team or team member that is responsible and accountable for their care. Empanelment can occur by geography (some countries empanel their entire population based on where they live) or by health system (some systems, such as Southcentral Foundation’s Nuka System of Care, empanels their user populations). Currently in the United States, health systems and clinicians are held accountable for the people who seek their care, and insurers are held accountable for all their beneficiaries. This process runs the risk of reverse targeting, with those who are in greatest need also being those who do not seek care and who are not insured (Woolhandler, 1988).

A specific strategy to promote equity through empanelment is to first empanel high-social-risk and high-clinical-risk populations, ensuring that they have a consistent and reliable source of care. This can help build trusting, continuous relationships between an interprofessional team or team member and an individual seeking care, providing the individual with easy access to services when needed (Bodenheimer et al., 2014). It also shifts care from being reactive to proactive by holding a system accountable for the individuals’ outcomes regardless of whether they have sought care.

Evidence from a number of health systems supports the effectiveness of empanelment (Bearden et al., 2019) as a contributor to whole health (College of Family Physicians of Canada, 2012; Ostbye and Hunskaar, 1997). To contribute to whole health, empanelment needs to be people-centered

rather than taking a traditional provider-centric approach which often treats people as nothing more than a set of diseases and conditions (Bearden et al., 2019). The hallmark of a people-centered approach to empanelment would be for all members of a population to make a facilitated declaration of a usual source of care, such as at the time of enrollment in an insurance scheme or annually. However, there are both practical and cultural barriers to the universal declaration of a usual source of care, including the perceived limitation of clinician choice and not aligning empanelment and capacity. Furthermore, merely designating a usual source of care does not create true accountability.

While it is logical to assume that larger panels are associated with worse patient outcomes, worse patient experiences, and clinician burnout, a recent systematic review on the topic revealed that the evidence substantiating these assumptions is limited (Paige et al., 2020).

Costa Rica’s community-oriented primary health care model provides a good example of how universal empanelment can help facilitate health equity. The model is built upon fully integrated community-based interprofessional primary care teams, integration with the national public health system, a universal health information technology system, a robust measurement and quality improvement system, and geographic empanelment for every citizen in the country (Bitton et al., 2019; VanderZanden et al., 2021). Interprofessional teams are responsible for specific geographic areas and for caring for the residents who reside within them. Team members, often community health workers, proactively move throughout their assigned catchment, visiting each household at least once a year. These home visits provide opportunities for teams to deliver more traditional health care services and to address many upstream factors that contribute to health, as described earlier in the chapter. To address health equity, the national empanelment effort began by focusing on the most underserved populations, which reside mostly in the more remote, rural regions of the country. In 2019 more than 94 percent of the overall population was empaneled, with ongoing efforts to target resources to underserved populations (nearly one-third of the budget is directed at the poorest 20 percent of the population). While it is difficult to attribute equity outcomes solely to empanelment, between 1980 and 2000 there were greater declines in premature mortality among the lowest-income quintile (48 percent) than among the wealthiest quintile (39 percent). An analysis of infant mortality in 2009 also found equity across all regions, with no geographic differences (VanderZanden et al., 2021). This model could inform a process whereby whole health systems could improve equity through accountability.

ELEMENT FIVE: TEAM WELL-BEING

In addition to the main focus of the whole health approach on improving the overall well-being of patients, team well-being is also a foundational element of any whole health approach, with benefits both for the interprofessional team and the people to whom they are providing services.⁴ The committee considered team well-being as care team members experiencing whole health themselves. Whole health systems can enable their team members to experience whole health by providing the necessary systems to effectively and efficiently deliver whole health care in a supportive and positive work environment.

There is substantial evidence that high-functioning teams—a key component of whole health care—can play an important role in fostering clinician well-being and reducing burnout, though the evidence is focused largely on addressing and preventing burnout rather than on actively promoting well-being (Budge et al., 2003; Chang et al., 2019; Day et al., 2009; Dehn et al., 2015; So et al., 2011; Sutinen et al., 2005; Welp et al., 2016; Willard-Grace et al., 2014). As a discussion paper from the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience concludes, “Studies indicate that optimizing team-based care is one potential lever to help solve the complex problem of decreased clinician well-being” (Smith et al., 2018, p. 4). Research has shown, in fact, that teamwork quality is inversely related to the level of staff burnout experiences (Bowers et al., 2011). Features of burnout—one consequence of not attending to well-being—include emotional exhaustion, feelings of cynicism and detachment from the job, and a lack of motivation and feelings of accomplishment (NASEM, 2019b).

Consistent with the findings above, the authors of the NAM discussion paper also concluded that the converse is true, stating that “ineffective teamwork may be demanding for its members, leading to a higher workload and decreasing well-being.” Research bears this out, too, as it shows that units with poor teamwork tend to have staff with higher levels of fatigue (Bowers et al., 2011) as well as of emotional exhaustion and depersonalization, both of which are key features of clinician burnout (Wang et al., 2022). Research has also shown that emotional exhaustion appears to have a feedback effect that leaves clinicians less able to engage in positive teamwork (Welp et al., 2016).

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⁴ Most of the research regarding health care team well-being focuses on clinicians and not the broader health care workforce, and within this literature, the vast majority of studies focus on physicians. The studies included in this section reflect this imbalance.

Burnout

Burnout is a workplace syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work (NASEM, 2019b). Among clinicians, burnout is linked to poor quality of care and suboptimal patient outcomes (Linzer, 2018) as well as to increased odds of suicidal ideation and depression (Menon et al., 2020). A systematic review found a relationship between high levels of burnout and reductions in patient safety (Garcia et al., 2019). There is also evidence that patient experience is better with physicians who are less burned out (McKee et al., 2020). It also affects productivity: a longitudinal cohort study of nearly 27,000 nonphysician health workers found that those who experienced burnout reduced their work effort over the next 24 months (Dyrbye et al., 2021). On the other hand, clinician well-being supports improved patient–clinician relationships, a high-functioning care team, and an engaged and effective workforce (NASEM, 2019b).

While most burnout and well-being research is focused only on clinicians, a large study of over 10,000 individuals that included nonclinical office staff as well as physicians and advanced practice clinicians across 1,380 primary care practices found that 20.4 percent of the respondents reported that they experienced burnout; the percentages were 20.6 percent for the clinical staff and 18.0 percent for nonclinical staff. The odds of burnout were higher among non-solo practices than among solo practices and were higher in hospital, health system, or federally qualified health center settings than in physician or advanced practice clinician-owned settings (Edwards et al., 2018b).

A 2019 National Academies consensus study identified seven potentially modifiable factors contributing to burnout and professional well-being, the first five of which high-quality teams can address with the support of effective systems-level interventions and design (NASEM, 2019b):

• Job demands that require sustained physical or psychological effort or skills, including excessive workload, unmanageable schedules, and inadequate staffing
• Excessive administrative burden
• Workflow, interruptions, and distractions
• Time pressure and encroachment on personal time
• Inadequate technology usability
• Moral distress
• Patient factors

That report also listed job resources that can ameliorate the detrimental effects of these factors on well-being:

• Professional relationships and social support
• Job control, flexibility, and autonomy
• Meaning and purpose in work
• Organizational culture
• Alignment of values and expectations
• Rewards
• Work—life integration

While Chapter 5 describes that there is scant evidence linking whole health approaches to improved team well-being, it is logical to see how a whole health approach could potentially enhance several of the above job resources. For example, whole health could enhance meaning and purpose in work among the interprofessional team by facilitating a deep connection between the team and the individuals they are holistically and comprehensively caring for. Additionally, the fact that whole health is inherently a team-based approach should foster a positive work environment based on strong professional relationships and social support, assuming that teams have the resources and staff coverage they need to fulfil their duties. On the other hand, if teams are stretched thin and job demands, workload, and pressure exceed the available resources, the well-being of a whole health team may suffer.

Organization-Level Interventions

According to a systematic review and meta-analyses on interventions designed to prevent or reduce physician burnout (Panagioti et al., 2017), organization-directed interventions are more likely to reduce the incidence of burnout than individual-directed interventions, such as mindfulness-based stress reduction training. For example, the VA’s Civility, Respect, and Engagement in the Workplace (CREW) intervention places participants in workgroups, each led by a trained facilitator, to set goals and discuss ways to improve how they work together (Osatuke et al., 2009). Two studies have found that nurses participating in CREW reported improved job satisfaction and significant reductions in the depersonalization/cynicism dimension of burnout (Laschinger et al., 2012; Leiter et al., 2011). While not designed to target burnout specifically, the authors suggest that improving work relationships may have helped reduce burnout. Supporting this idea, research shows that team dynamics play an important role in minimizing the negative personal and professional consequences that staff experience when preventable harm to a patient occurs (Seys et al., 2013).

Another systematic review of some 50 studies concluded that strategies that promoted team-based care and incorporated medical assistants or scribes to complete electronic health record (EHR) documentation and

other administrative tasks were strongly linked to reducing clinician burnout and stress, as measured by the Maslach Burnout Inventory, the Physician Job Satisfaction Scale, and the Epworth Sleepiness Scale, among other measures (DeChant et al., 2019). Other aspects of teamwork that reduced burnout included improved communication among physicians and expanded team member responsibilities that allowed team members to work at the top of their skills and better allocate clinical workload. According to the authors, “High-quality evidence provided the value of teamwork to improve clinic workflow efficiency, such as timely and accurate medical record completion” (p. 404), while two low-quality studies found productivity increases resulting from team-based care led to fewer hours spent on EHR documentation outside of work. One study from the VA found that physician burnout was more prevalent when other team members did not share tasks and responsibilities (Kim et al., 2018).

A study of 715 small- to medium-sized primary care practices participating in an Agency for Healthcare Research and Quality initiative to implement evidence-based cardiovascular preventive care was intended to identify the characteristics of the 30 percent of practices that reported zero burnout as compared with practices that reported high levels of burnout. Several system-level practices and organizational interventions were associated with the zero-burnout practices. These included implementation of quality improvement strategies and high levels of facilitative leadership that prioritized fostering relationships, enhancing communication, attending to social influence and power imbalances, ensuring psychological safety, and cultivating teamwork rather than hierarchical leadership that relies on a command-and-control mechanism. Higher patient volume and a high proportion of Medicaid patients had no effect on levels of burnout, nor did EHR features or EHR satisfaction (Edwards et al., 2021).

Job Demands

When resources are not sufficient to meet a job’s demands, workers can become overloaded and frustrated and may fail to meet personal or organizational goals (Caplan, 1987). In fact, excessive workload and perceptions of inadequate staffing are associated with increased worker stress, decreased job performance, and an increase in errors, which are predictors of burnout (Van Bogaert et al., 2017; Xu et al., 2017). The COVID-19 pandemic demonstrated this clearly, when inadequate staffing and increased workload led to higher rates of fatigue and burnout in health care settings (Lasater et al., 2021; Miller et al., 2021; Sikaras et al., 2022).

Proper staffing, which reduces job demands, is an essential component of team-based care that benefits well-being. One study of VA’s team-based model, the Patient-Aligned Care Team (PACT), found that many teams

were understaffed (Helfrich et al., 2014). However, clinicians on adequately staffed PACT teams and those who reported that their teams used participatory decision making had significantly lower odds of emotional exhaustion. In a second study, PACT team members (including primary care physicians, nurse practitioners, physician assistants, nurse care managers, clinical associates, and administrative clerks) reported insufficient staffing, lack of training, poor scheduling practices, new responsibilities without promised resources, less time with veterans, and team dysfunction when a PACT team included a weak team member (Ladebue et al., 2016). Numerous studies have shown that extra hours of work resulting from insufficient staffing increase the odds of burnout, with one analysis finding that every hour of extra work increases the odds of physician burnout symptoms by some 2 percent (Dyrbye et al., 2013). Similarly, a study of more than 50,000 nurses found that those who had already left or were planning to leave their jobs because of burnout reported that a stressful work environment and inadequate staffing were the top reasons for doing so (Shah et al., 2021). These findings align with several reports that have associated increased nurse burnout with inadequate, inappropriate, or short staffing (Edwards et al., 2018a; Garrett, 2008; Simpson et al., 2016).

However, team-based care delivery can help alleviate excessive job demands by better allocating job responsibilities (Leape et al., 1999) and allowing team members to work at the top of their skills (Helfrich et al., 2014), which together increase efficiency (Wright and Katz, 2018) and can reduce burnout (Helfrich et al., 2014). One study of a patient-centered medical home, for example, found that team-based care reduced stress, anxiety, and burnout among clinicians, in part by better allocating staff resources to reduce clinician workload (Reid et al., 2010). Teamwork became essential for at least partially reducing work overload and burnout among clinicians during the COVID-19 pandemic (Ehrlich et al., 2020; Kerrissey and Singer, 2020; Sangal et al., 2020), and anecdotal reports suggest that institutions that organized their staff into teams were able to reduce fatigue without negatively affecting patient care (Habib and Zinn, 2020; Holthof and Luedi, 2021).

FINDINGS AND CONCLUSIONS

This chapter summarizes the evidence supporting the committee’s five foundational elements of whole health: (1) people-centered, (2) comprehensive and holistic, (3) upstream-focused, (4) equitable and accountable, and (5) team well-being. Whole health systems must address all five foundational elements to some degree, though implementation and program design will differ depending on local resources and the needs of the people, families, and communities they serve. The foundational elements

are overlapping, synergistic, and, in the case of whole health, should be embedded in the care delivery process rather than delivered as individual, separate components.

The committee found that not only do the five foundational elements make conceptual and logical sense as being essential building blocks for whole health care, but there are also decades of robust evidence supporting their benefit to help people, families, and communities achieve whole health. Evidence demonstrates that people-centered care improves the experience of receiving care, which in turn helps people to feel subjectively better and improves some physiologic measures. It also helps to create a sense of purpose and engage people as partners in their care, allowing improved self-management. Comprehensive and holistic care further improves patient satisfaction, lowers health care costs, reduces hospitalizations, and lowers clinician and team burnout. Upstream factors are well-known drivers of poor health outcomes, contributing more to health than does health care itself. There is evidence that health systems can improve many upstream factors such as health behaviors and mental health, and there is a growing body of evidence that shows that health systems can even improve social determinants, environment, and systemic racism and sexism. To address these complex issues, partnerships and collaboration are needed among health systems, community programs, social services, and public health agencies. More evidence is needed to understand the role of health care systems and how health care systems can be part of broader whole health systems to partner with other sectors to address these complex issues. The adverse effects of racism and sexism require implicit bias education, cultural tailoring of information and interventions, and training a racially and ethnically diverse workforce that reflects the composition of the communities being served.

To improve the quality of care, health systems must provide the right care at the right time to the right people. Because health inequities are such a key driver of poor health, evidence shows that equity and accountability are essential for ensuring whole health. There is compelling evidence that societies with high levels of social equity live longer and healthier lives. Similarly, practices and systems focused on caring for vulnerable and underserved people have been shown to increase access to care and the receipt of recommended services and to reduce acute care such as emergency room visits and hospitalizations. Evidence further demonstrates that assuming accountability for people, family, and communities is an essential pathway to equity, ensuring that all have access to care and shifting processes of care from being reactive (waiting for people to access care) to being proactive (reaching out to delivery care when it is needed). Evidence shows that a “no wrong door” type approach, allowing people to access care through many avenues and embedding whole health supports, resources, and care

where people live, work, learn, and play, further improves access and quality of care. While whole health systems cannot solve all of society’s ills, they need to address the root causes of inequity, including intrapersonal, interpersonal, institutional, and systemic mechanisms as well as the unequal distribution of power and resources. Finally, there is strong evidence supporting the importance of team well-being. Evidence shows this reduces team member burnout, which improves patient outcomes and quality of care. Some team-based models of care show promise in improving team functioning and mitigating risk factors that can cause burnout. Interventions directed at the system and organization level, such as those dedicated to improving workflow, technology usability, and effective staffing and delegation, are more effective than those focused on individuals at preventing burnout and promoting well-being.

This chapter shows the evidence supporting each foundational element as a singular characteristic—an essential first step for understanding the value of whole health care. Chapter 4 demonstrates how five whole health systems address the foundational elements, and Chapter 5 assesses the evidence of whole health systems that have operationalized all five foundational elements, further reinforcing the benefits shown in this chapter.

REFERENCES