National Academies Press: OpenBook

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

Chapter: 4 Whole Health in Practice

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Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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4

Whole Health in Practice

The committee identified several care delivery models whose program design and philosophical approach are well aligned with the committee’s five foundation elements of whole health. These five foundational elements are (1) people-centered, (2) comprehensive and holistic, (3) upstream-focused, (4) equitable and accountable,1 and (5) team well-being (see Chapters 2 and 3 for more detail on the five foundational elements). This chapter will describe in depth five delivery models that show promise in supporting whole health by addressing these five foundational elements. The models featured include the Department of Veterans Affairs (VA) Whole Health System (WHS), the Nuka-Southcentral Foundation system (an Alaska Native–owned system based in Anchorage, Alaska), Mary’s Center (a community health center based in metropolitan Washington, D.C.), the National Intrepid Center of Excellence (NICoE) (a Department of Defense program for active-duty service members with traumatic brain injury), and the Program for All-Inclusive Care for the Elderly (PACE) (a care model for nursing-home-eligible older adults with locations in 31 states). The committee chose to highlight these systems because descriptions and details of the implementation of their models are available, their program designs mostly align with the committee’s five foundational elements of whole health, and,

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1 As described in greater detail in Chapter 2, one aspect of equitable and accountable care is that it is accessible to all. The committee reviewed the systems highlighted in this chapter with the understanding that they each have specific catchment areas or populations that they serve, some with unique eligibility criteria. In the committee’s assessments, eligibility and catchment area were the baseline for accessibility.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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taken together, they target geographically and demographically diverse populations. This selection does not intend to be inclusive of all models that meet these criteria, and this chapter does not evaluate the outcomes of these programs. For a more detailed look at the evidence that these systems and others address the five foundational elements, see Chapter 5.

DEPARTMENT OF VETERANS AFFAIRS WHOLE HEALTH SYSTEM

VA has led numerous transformations in health care delivery in the United States. These include (1) implementing one of the first integrated electronic medical records in the country; (2) becoming an industry leader in patient safety research and practices; (3) developing and implementing telehealth practices (Ginsberg et al., 2013; IOM, 2012; VA, 2021); (4) developing innovative primary care and preventive practices; and (5) championing patient-centered approaches to care (Yano et al., 2014), among many others.

In 2014, VA began refining an enhanced version of patient-centered care (Bokhour et al., 2020a). Termed “whole health” (WH), this approach has the potential to radically transform the way VA delivers health care to the approximately 9 million veterans who receive VA care annually (Marchand et al., 2020; VA, 2022a). Efforts to deploy the WH approach within VA began in 2015–2016 when 25 design sites were selected at different VA medical centers, each receiving special-purpose funding to consider evidence-based practices and to operationalize specific aspects of the WH approach (Bokhour et al., 2020a). Passage of the Comprehensive Addiction and Recovery Act2 in 2016 to address the country’s opioid epidemic further advanced the effort. The bill required VA to address the complex challenges of pain management in the veteran population, to conduct research on the implementation and impact of alternative approaches on veteran health and well-being, and to include complementary and integrative health (CIH) modalities among its care options (Bokhour et al., 2022).

The VA Office of Patient Centered Care and Cultural Transformation responded to Congress’s mandate by formalizing a new approach to care, the WHS, which is built around patient goals and priorities, peer-led support, personalized health planning, and CIH alongside traditional medical treatment and prevention activities (Haun et al., 2021c). At its core, WHS focuses on individual well-being, life mission, aspirations, and purpose as well as physical, mental, behavioral, and spiritual health. During fiscal year 2018, VA designated 18 medical centers as WHS flagship sites—one in each of the 18 Veterans Integrated Service Networks (VISNs)—and funded a

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2 Public Law No. 114-198.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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3-year pilot implementation of WHS (Bokhour et al., 2020a). In 2019 an additional 37 VA sites implemented WHS, and the Veterans Health Administration (VHA) plans to implement WHS system-wide between 2024 and 2027 (Kligler et al., 2022).

Below is a description of WHS as it relates to the committee’s five foundational elements of whole health. The elements mapped below reflect VA’s description of and intent for WHS; however, it should not imply that each VA medical center has implemented and made available all five elements or that all sites implementing WHS are doing so with full fidelity to the model.

People-Centered

VA defines WH as an “approach to health care that empowers and equips people to take charge of their health and wellbeing and live their life to the fullest” (Reddy et al., 2021, p. 2). The goal is to “transform the organization and culture of care to a system which starts with understanding the veteran’s life mission, aspiration, and purpose (i.e., what matters most to the veteran) and provide care to improve veterans’ overall health and wellbeing” (Bokhour et al., 2022, p. 2). Person-centeredness is central to WHS, and the entire approach centers around what matters most to each individual. It is not diagnosis/disease focused, but rather it emphasizes the whole person and prioritizes their goals and aspirations. Person-centeredness moves beyond the traditional physician-directed approach to one of partnership with the care team that puts veterans in control of their care, focuses on self-care and support, and represents an individualized, lifelong plan that is more proactive than reactive (Marzolf, 2021). Taken together, people-centeredness provides an integrative approach that includes peer-led exploration of an individual’s mission, aspiration, and purpose; well-being classes and WH coaches; and allopathic, complementary, and integrative clinical care focusing on the veterans’ priorities and goals (Bokhour et al., 2022). This approach closely aligns with the committee’s description of people-centered, as presented in Chapter 2.

Comprehensive and Holistic

WHS provides a coordinated, integrated approach to care that is designed to address all domains that affect a person’s health and well-being. This approach aligns closely with the committee’s next foundational element, “comprehensive and holistic.” All WHS services, including traditional health and disease management, are designed to occur with this in mind. As described in Chapter 2, WHS comprises three major components or “pillars” (Haun et al., 2021a):

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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  1. The Pathway introduces veterans to the concepts of whole health. Ideally, veteran peers lead this component to facilitate identifying personal health and aspirational life goals and to develop a personal health plan with veteran participants.
  2. Well-Being Programs include CIH services, health coaching, and skill-building and self-care groups, all designed to equip veterans with skills to manage their health. Currently, VA mandates that all VA medical centers offer nine CIH modalities: acupuncture, chiropractic, meditation, massage therapy, biofeedback, clinical hypnosis, guided imagery, yoga, and tai chi.
  3. Whole Health Clinical Care is based on the whole health approach for providing care in both CIH and allopathic settings. Providers are trained to provide whole health and focus on veterans’ personal health plan and goals that are aligned with their mission, aspiration, and purpose as a foundation for treatment recommendations.

Veterans participating in WHS initially complete a self-assessment, called a Personal Health Inventory, with assistance as needed from VA staff or veteran peers. This tool assists veterans in identifying areas to work on and in creating a personal health plan. Veteran preferences are integral to the plan creation and execution, and they drive individual choices regarding well-being programs and clinical treatments. The Transforming Health and Resiliency through Integration of Values-Based Experiences (THRIVE) process is one element within WHS that illustrates how it is holistic and comprehensive. THRIVE is a 14-week, evidence-based group medical appointment process during which an interdisciplinary clinical team facilitates discussions in which groups of 10–15 veterans learn about the different components of wellness (Haun et al., 2020, 2021b). An evaluation of THRIVE found that it improves the veteran’s health care experience, including access, and enhances multidisciplinary care coordination. The curriculum, originally developed for female veterans and later expanded for use with male veterans, combines positive psychology, acceptance and commitment therapy, and integrative medicine to improve physical, psychological, and emotional pain thresholds for veterans (Haun et al., 2020).

Upstream-Focused

WHS addresses this foundational element through use of a “Circle of Health” model that comprises four parts:

  1. Me, referring to the veteran who is at the center of care, has a unique history, and is focused on what matters to them
Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×
  1. Self Care, referring to the fact that every individual has the ability to affect their own health and well-being, with WH providing education, skills, and support for changes that are important to the veteran
  2. Professional Care, referring to the health team that assists with both prevention and treatment of disease and illness
  3. Community, referring to the people and groups important to the veteran and with whom they connect.

The Circle of Health model (see Figure 4-1) depicts the important connections between health and other aspects of a veteran’s life. As with the overall WHS approach, the model helps veterans explore connections and facilitate discussion about what is important in their lives and their own health and well-being. It supports people-centeredness by acknowledging the uniqueness of each individual, allowing veterans to identify what matters most to them, and facilitating veteran engagement with their care teams to develop a personal health plan. The model intends to show that improving in one element can influence other elements and improve one’s overall health physically, emotionally, and mentally. In that regard, the model acknowledges the interconnectedness of multiple elements essential to achieving whole health, including

  • Mindful awareness
  • Physical and emotional surroundings
  • Personal development in work and personal life
  • Nourishing and fueling through food and drink
  • Sleeping and refreshing to recharge
  • Relationships with family, friends, and coworkers
  • Growing and connecting spirit and soul
  • Relaxing and healing power of the mind
  • Energy and flexibility and moving the body.

Nearly all of the domains of this model target upstream factors that address the root causes of poor health as well as factors of daily life that can facilitate WH. Operationally, peers lead the Circle of Health model and introduce it to veterans through a 2-hour introduction to WH in general followed by an 8-week Circle of Health course (Gaudet and Kligler, 2019). It is unclear, however, how effective the Circle of Health course is addressing these domains for WHS participants.

As discussed in greater detail in Chapter 6, the Veterans Benefits Administration (VBA) has a variety of robust programs and services that target upstream factors for eligible veterans. For example, VBA manages the GI Bill benefits (which helps pay for higher education and training) and offers

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×
Image
FIGURE 4-1 WHS “Circle of Health” model.
SOURCE: VA, 2022b.

a variety of other programs and benefits related to housing security, home loans, personal finance counseling, employment, civilian transition, and others (VA, 2022c). However, VBA and the VHA—which oversees VA health care programs, including WHS—mostly operate separately from each other, with different leadership, system organization, and reporting structures. While VHA’s WHS has program components (most notably the Circle of Health program described above) designed to deliberately target, to some degree, many of these same factors in its own way, it does not have the dedicated resources and infrastructure to address them comprehensively, nor would it make sense for the VHA to duplicate VBA’s efforts (even if it was able to do so). It is the committee’s view that there is potentially a great

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

benefit to veterans if VBA and VHA were able to integrate benefits into a single, whole health system of care that would enable a WHS to comprehensively address the upstream factors that affect health and well-being in a more coordinated fashion. For a more detailed discussion on the potential integration of VBA and VHA services, as well as an example of successful collaboration across the two administrations, see Chapter 6.

Equitable and Accountable

Viewed through an equity lens, while all veterans receiving care at VA are technically eligible to receive WHS, there are variations in access to the services throughout the system. While the committee is not aware of demographic information regarding who does and who does not use WHS services, in February 2020, WHS published a progress report, Whole Health System of Care Evaluation—A Progress Report on Outcomes of the WHS Pilot at 18 Flagship Sites (Bokhour et al., 2020b). This evaluation demonstrates that VA appears committed to continuously learning about and refining WHS as it learns more about its effectiveness (Chapter 5 examines the results in detail). Results showed that all 18 flagship sites made some progress toward implementation. However, the analysis found significant variability in implementation stages, components, veteran usage and impact, and employee impact, suggesting that WHS services are not fully accessible even within the 18 sites. At the same time, the evaluation noted a threefold reduction in opioid use among veterans with chronic pain who used WHS services compared with those who did not (Bokhour et al., 2020b). The report also discusses key implementation facilitators and barriers. In summary, some success was evident in VA’s efforts to move toward a WHS approach to care at the 18 flagship sites. However, the report noted that further efforts are needed to affect a cultural change necessary to fundamentally alter care delivery throughout VA.

In another study in 2022, researchers published results of a partnered evaluation of patient outcome findings from the 18 WHS pilot sites (Bokhour et al., 2022). Data sources included electronic health records (EHRs) of 1,368,413 patients and a longitudinal survey of veterans (baseline and at 6 months). The evaluation focused on the impact WH services had on veteran opioid use, care experiences and engagement, and well-being. The researchers also compared outcomes in veterans using WH services with veterans who were not, according to EHRs. Findings included a 23 percent decrease in opioid use among WH users compared with an 11 percent decrease in veterans receiving conventional care. In addition, when compared with conventional care, veteran users of WH services reported greater improvements in perceptions of care (standardized mean difference [SMD] = 0.138), engagement in health care (SMD = 0.118), and self-care (SMD

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

= 0.1); life meaning and purpose (SMD = 0.152); pain (SMD = 0.025); and perceived stress (SMD = 0.191). Findings of this study (see Chapter 5 for more details) contributed to policy changes aimed at expanding WHS via integration into primary care and mental health across the VA system (Bokhour et al., 2022).

While evidence is growing to support the benefits of the WHS, reliably providing high-quality, equitable whole health care to all veteran users of the VA is a monumental task, one that will require extensive policy and resource support. Nevertheless, VA appears committed to ensuring that, as the WHS grows within the VA system, it does so with a commitment to health equity and accountability (Kligler, 2022). Toward that end, the VA has held cyberseminars focused on promoting health equity in veterans with a Whole Health approach. In May 2022, for example, a cyberseminar addressed the unique barriers that Black, Hispanic, and Latino/a veterans face regarding diabetes self-management and highlighted a quality-improvement project that used the VA’s Primary Care Equity Dashboard (PCED)3 to improve diabetes self-care among those individuals. The PCED is a tool that VA clinicians can use to easily identify disparities in health across populations. While laudable, these efforts do not sufficiently address equity issues across the many subpopulations the VA serves across the country. The committee is not aware of additional efforts that operationalize or target issues of equity within the VA WHS.

Team Well-Being

The VHA WHS acknowledges the importance of employee and team health in promoting veteran whole health. As the COVID-19 pandemic emerged in the United States in early 2020, most WHS sites ramped up efforts to strengthen their whole health services. The additional stress on the workforce during this time also highlighted that employees need whole health services as well, and employee whole health was implemented as a promising approach to support health care worker well-being (Dryden et al., 2021).

Recognizing that it has never been more important to care for one’s physical, mental, emotional, and spiritual health and well-being, many VA facilities are offering classes in CIH and whole health to employees. VA also provides a wide array of online resources to support individual employee and team health, wellness, and whole health. Online resources include, but are not limited to,

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3 Information on this cyberseminar is available at https://www.va.gov/healthequity/fhea_cyberseminar.asp (accessed June 10, 2022).

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×
  • VA’s Life Whole Health mobile app
  • Videos that support resilience and balance via topics such as guided meditation, chair yoga, acupressure, gratitude, and relaxation techniques
  • Videos, podcasts, music, and handouts on topics such as reconnecting with the mission, value and appreciation, supervisors helping their employees, staying VA strong, stress management and addressing burnout, social connection and community, spiritual health/spirit and soul, and parenting and other caregiver resources.

Urgent and crisis-level employee needs are also addressed by providing ready access to the 24/7 National Suicide Prevention Lifeline, 24/7 Veterans Crisis Line, Physician Support Line, and the Disaster Distress Helpline. VA notes that employee whole health may provide some protection against stress and burnout, a pervasive problem in health care systems today (NASEM, 2019). In fact, VA employees who are involved with WHS did experience slightly lower rates of burnout and turnover, had slightly higher rates of motivation, and had a more positive view of their workplace compared with employees not involved in WHS (Bokhour et al., 2020b). For more detail on these data and this analysis, see Chapter 5.

While these efforts are laudable, they focus primarily on individual-level interventions and self-care strategies designed to build resilience and mitigate stress and burnout, rather than addressing some of the systemic issues that cause burnout in the first place. As Chapter 3 describes, the 2019 National Academies report Taking Action Against Clinician Burnout: A Systems Approach to Professional Wellbeing found that organizational-level interventions, such as those designed to reduce workload, lessen administrative burden, or enhance teamwork, are more effective at preventing and reducing burnout than interventions directed at individual behaviors and self-care strategies such as CIH, relaxation techniques, and stress management. While some of these systems-level strategies may be implicit in some of the WHS design, the explicit efforts to target team well-being are focused on individual-level and self-care-related interventions.

How Is the VA Whole Health System Illustrative of Whole Health?

The VA WHS represents a dramatic shift in the way care is delivered. It marks a drastic move away from a medical/disease-focused approach to one that is systematically focused on health promotion and disease prevention with potential to significantly improve the health, wellness, and lives of veterans (Marchand et al., 2020). It is grounded in principles that closely align with the committee’s definition of whole health and the foundational elements of whole health the committee presents in Chapter 2. Table 4-1

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

TABLE 4-1 Congruence of the VA Whole Health System with the Foundational Elements of Whole Health

Foundational Element Components that Address the Foundational Elements VA Indicators
People-centered Achieving a sense of purpose through longitudinal, relationship-based care Table
People/families/communities direct goals of care Table
Care delivered in social and cultural context of people/family/community Table
Comprehensive and holistic Address all domains that affect health—acute care, chronic care, prevention, dental, vision, hearing, promoting healthy behaviors, addressing mental health, integrative medicine, social care, and spiritual care Table
Attend to the entirety of a person/family/community’s state of being Table
Components and team members are integrated and coordinated Table
Upstream-focused Multisectoral, integrated, and coordinated approach to identifying and addressing root causes of poor health Table
Address the structures and conditions of daily life to mak them more conducive to whole health Table
Equitable and accountable Whole health systems need to be accountable for the health and well-being of people/families/communities Table
Care needs to be accessible to all Table
Team well-being The health of the care delivery team is supported

NOTE: Based on the program descriptions, Table indicates that the component is addressed; — indicates that it is partially addressed; a blank space indicates that it is not addressed. The committee determined that VA WHS care is not accessible to all because it has not been fully implemented system-wide. The committee determined that team well-being is partially addressed because well-being interventions target individual resilience rather than systems-level changes.

summarizes how the VA WHS design maps to the committee’s five foundational elements of a whole health approach to health care. It is notable, however, that VA evaluations have revealed that there is some variation in the fidelity of the WHS implementation across the locations where it is available. It is also not yet available throughout the system. The implications of this are that, while the WHS addresses (at least partially) each of the foundational elements in its intended design, the reality experienced by veterans and the workforce may not reflect this.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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Southcentral Foundation/The Nuka system of care

Southcentral Foundation (SCF) is an Alaska Native–owned, nonprofit health care organization serving nearly 65,000 Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Borough, and 55 rural villages (Schneider et al., 2020). Southcentral Foundation describes its Nuka System of Care (Nuka) as a relationship-based, customer-owned approach to transforming health care that improves outcomes and reduces costs (Gottlieb, 2013; Muller et al., 2017; Southcentral Foundation, 2017a). Initially incorporated in 1982 under the tribal authority of Cook Inlet Region, Inc. (CIRI), Southcentral Foundation is the largest of the CIRI nonprofits, employing more than 2,500 people in more than 80 programs (Southcentral Foundation, 2022c). In the late 1990s, in response to long wait times and low satisfaction, Alaska Native leaders and community members chose to assume ownership of the health system from the Indian Health Service. In 1998, SCF began managing primary care, and, in 1999, SCF entered into a co-ownership and co-management agreement with the Alaska Native Tribal Health Consortium (ANTHC) to take over the Alaska Native Medical Center, which is responsible for delivering hospital services to Alaska Native and American Indian people (Southcentral Foundation, 2017a). SCF moved to a customer-ownership model to enhance culture and empower individuals and families to take charge of their lives, earning a Malcolm Baldridge Quality Award in 2011 and again in 2017 (SCF Public Relations, 2011; Southcentral Foundation, 2017b). SCF is a federally qualified health center (FQHC) and meets the Health Resources and Services Administration’s (HRSA’s) Health Center Program requirements.

The Nuka care model refers to the entire health care system created, managed, and owned by Alaska Native people as part of Southcentral Foundation to achieve physical, mental, emotional, and spiritual wellness. It includes all parts of SCF devoted to behavioral, dental, medical, and traditional services and all the systems, processes, and departments supporting the service delivery. SCF’s vision for Nuka is “a Native Community that enjoys physical, mental, emotional and spiritual wellness” (Gottlieb, 2013). Southcentral Foundation’s barometer for success is whether the population it serves is able to truly experience multidimensional wellness and if improvements in wellness are experienced from one generation to the next (Gottlieb, 2013). Its mission statement focuses on “working together with the Native Community to achieve wellness through health and related services” (Gottlieb, 2013), with a strong emphasis on building and maintaining relationships.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

People-Centered

The Nuka system provides customer-driven whole person care that is focused on the individual (described as the ‘‘customer-owner’’) and their family at the center of care rather than the interprofessional team. Services are woven into customers’ lives and built around them, rather than around a clinical medical office. The goal is to advance a system of care using an approach that addresses the whole person and their family in a well-coordinated and personal way that results in ‘‘customer- and family-driven integrated care provided on their terms’’ (Gottlieb, 2013). The Nuka system prioritizes shared responsibility, a commitment to quality and representation, and a focus on family wellness that emphasizes community as core values (see Box 4-1) (Gottlieb, 2013).

The Nuka System of Care also places a strong emphasis on building and maintaining relationships (Gottlieb, 2013). One of the chief responsibilities of each provider is to “work with customer-owners to establish trusting, accountable and long-term relationships,” based on the premise that a strong provider–client relationship affords the clinician the opportunity to better understand the context in which the patient lives, enabling the clinician to “better understand symptoms, answer questions, have meaningful conversations about risks and benefits, and work with each customer to make better health decisions” (Gottlieb, 2013).

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

Comprehensive and Holistic

Nuka provides comprehensive primary care in outpatient and home settings as well as in dentistry, outpatient behavioral health, residential behavioral health, traditional healing, complementary medicine, health education, and more. It consists of a medical center—Alaska Native Medical Center’s 150-bed hospital and the Anchorage Native Primary Care Center—and other Southcentral Foundation facilities and services. Care delivery modalities include ambulatory office visits, home visits, email and telephone visits, health information and education, inpatient hospital services, day and residential treatment, as well as consultation with and referral to higher levels of specialty care. Southcentral Foundation engages with the tertiary and specialty medical services division of ANTHC when higher-level complex care is needed.

In addition to clinic-based care, clinical teams provide home visits in which they regularly travel to villages accessible only by air or boat to deliver family medicine, behavioral health, and dental and optometry services. This helps ensure that populations that may otherwise have trouble accessing services are able to do so and that the system is accountable to those who are not able to travel to receive services. E-consults also improve access by virtually connecting to remote areas where village clinics are in place. Nuka clinicians also use electronic communication, including state-of-the-art telemedicine technology, to consult on assessment and treatment (Gottlieb, 2013).

In the Nuka system every family has a comprehensive, clearly identified patient-centered medical home (see Figure 4-2) (Eby, 2007). Coordinated care is delivered by interprofessional teams rather than by individual clinicians. These teams include primary care physicians or physician assistants, nurses, certified medical assistants, and other clinicians. Since the system’s inception, the interprofessional care teams have added behavioral health consultants, nutritionists, HIV consultants, and appointment schedulers (Driscoll et al., 2013). Nuka also embraces a whole person orientation as defined in the New Model of Family Medicine (Martin et al., 2004), which commits to integrated, whole person care through a variety of mechanisms (e.g., partnerships with services or organizations that extend beyond the practice setting that help meet the full range of needs for the patient population). The focus of the practice is to build capacity to help guide a patient through the health care system by integrating and not simply coordinating care (Eby, 2007).

Nuka offers other resources to support the overall health and wellness of its customer-owners. Learning circles, for example, are community-centered gatherings based on the Alaska Native value of sharing story and listening to others share theirs. SCF developed them as part of Nuka to

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×
Image
FIGURE 4-2 Southcentral Foundation’s circle of care.
SOURCE: Eby, 2007.

provide more immediate access to behavioral health services and to create supportive communities (Southcentral Foundation, 2022d). For example, the Family is Sacred learning circle provides tools for families with children to promote positive changes in the home and community.

Upstream-Focused

SCF places a strong emphasis on addressing the social, environmental, and behavioral determinants of health in order to improve the overall health and well-being of its customer-owners (Southcentral Foundation Nuka System of Care, 2022). As noted above, the Nuka System of Care’s relationship-building focus is designed to provide the clinician with the opportunity to better understand the context of their patients’ lives. To further help clinicians, SCF has an ongoing effort to track social determinants of health in the system’s EHR and create a means of expanding access to this information without stigmatizing customer-owners.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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SCF has developed a number of programs to augment the direct health care services that Nuka provides. Its Lose to Win program is a 13-week weight management program that emphasizes healthy lifestyle changes to improve overall health in addition to helping participants lose weight. Registered dietitians provide nutrition counseling for disease management and prevention, meal planning, and weight management. The My AK Wellness program created a free website and mobile app that tracks the user’s exercise and food intake, provides exercise plans and videos, and logs health information such as blood pressure, glucose levels, and cholesterol levels (Southcentral Foundation, 2022e). SCF’s Raise Program (Southcentral Foundation, 2022f) offers internships that introduce customer-owners to potential health care, administrative, and related careers; support educational goals; and provide workplace experiences. Interns develop a portfolio they can use to apply for scholarships or jobs and skills that reflect Alaska Native cultural values. Through a partnership with the Cook Inlet Housing Authority, SCF helps customer-owners find housing, secure a mortgage, and improve and weatherize their homes. SCF also has an employee and community assistance fund that provides emergency financial relief to customer-owners as a means of supporting its vision of a “Native community that enjoys physical, mental, emotional, and spiritual wellness” (Southcentral Foundation, 2022a).

Besides providing health care for the individual, the Nuka system makes a concerted effort to improve family and community well-being. The Nuka Family Wellness Warriors program, for example, focuses on equipping organizations and individuals to address the spiritual, emotional, mental, and physical effects of domestic violence, abuse, and neglect through training, education, and community engagement (Southcentral Foundation, 2022b). The Dena A Coy Residential Treatment program serves women experiencing problems related to alcohol and other drugs and experiencing emotional and psychological issues. The Native Men’s Wellness program supports Alaska Native and American Indian men in areas such as employ-ability, cultural connectivity, and healthy living, while the Beauty for Ashes program “uses culturally-grounded approaches to health and healing from trauma, such as relationship building, intergenerational role modeling, and sharing story, to develop knowledge and skills that promote healing and improved social health outcomes” (Southcentral Foundation Nuka System of Care, 2022).

Equitable and Accountable

There are several aspects of the Nuka system that focus on equity and accountability. Open-access scheduling, expanded office hours, and increased availability of electronic communication between patients and

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

care team members reduce barriers to access (Driscoll et al., 2013). The system also employs universal empanelment, a hallmark of equity and accountability, as all the individuals in the system either self-select or are assigned to a specific integrated and comprehensive care teams that are accountable for their care (Driscoll et al., 2013).

As noted above, SCF operates on a customer-ownership model as a means of enhancing Native culture and empowering individuals and families to take charge of their lives. This model represents a deliberate and proactive way to ensure that customer-owners hold the system accountable, and customer-owners provide guidance on all quality improvement and new program development activities. SCF designed Nuka based on a year-long effort to identify Alaska Native communities’ needs and values, and Alaska Native people have been running the health care system for over two decades.

Several features of HRSA’s Health Center Program certification requirements help ensure equity and accountability at Nuka and other health centers (for a description of HRSA’s Health Center Program, see Chapter 2). For example, health centers must accept all patients regardless of their ability to pay for service and have a sliding fee scale for those who do not have insurance. Another health center requirement is that governing boards must constitute a majority of individuals that use the health center for their own care (HRSA, 2018). In the case of Nuka, all come from the Alaska Native community that SCF serves, and its chief executive officer and vice president of executive and tribal services both come from the Alaska Native community. To keep its customer-owners engaged with SCF’s operations, organization leadership holds regular fireside chats with the community (Southcentral Foundation Nuka System of Care, 2021).

HRSA health center certification also requires annual reviews of catchment areas and population needs assessments every 3 years. Needs assessments are required to inform and improve services and must assess access to care and health care use, population geography, transportation needs, transience, unemployment, income level, educational attainment, morbidity and mortality, and any disparities in the above within the population served. This process ensures that the services offered by Nuka (and all federally qualified health centers) are designed to meet the specific needs of the population served (HRSA, 2018).

SCF regularly reports very high patient satisfaction; a survey of customer-owners found that 98 percent were satisfied with the care they received from SCF, 97 percent reported that they participate in care decisions, and 96 percent said that care was delivered in a manner that respected their culture and traditions (Southcentral Foundation Nuka System of Care, 2020). They also report other positive outcomes which are described in greater detail in Chapter 5. For example, a 2013 study found that prior to

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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the implementation of the Nuka system, emergency department care was increasing among Alaska Native and American Indian people in the system’s service area, but that it decreased after the implementation (Driscoll et al., 2013). SCF also reported that both emergency department visits and hospitalizations fell by 36 percent between 1996 and 2013, while specialty clinic visits decreased by 58 percent over the same period (Gottlieb, 2013). On measures of health care effectiveness, as measured by the Healthcare Effectiveness Data and Information Set, SCF exceeded the 90th percentile for diabetes annual care testing, and made significant improvements on other measures, including adolescent immunization and colorectal screening (Blash et al., 2012).

Team Well-Being

Nuka’s focus on relationships relates not only to the relationships between providers and customer-owners, but also to the relationships between providers themselves. Nuka makes use of integrated care teams to provide care to customer-owners, with each team consisting of a primary care provider, nurse case manager, case management support person, and a certified medical assistant. Other providers, such as nutritionists, behavioral health consultants, and pharmacists are added to the care team as they are needed. The primary care provider, nurse, the certified medical assistant, and the case management support person share an open workspace with other providers. This allows for the coordination of care and helps foster strong relationships among care workers, which increases their effectiveness when working with each other (Southcentral Foundation, 2017a).

There are challenges, however, to providing this level of team-based care. A 2013 article that describes Nuka’s implementation of the patient-centered medical home (PCMH) notes despite substantially increased resources for primary care, 65 percent of primary care clinicians thought that the increased demand for primary care services during the transition to a PCMH model outpaced the rate at which resources to meet that demand were increasing (Driscoll et al., 2013). For example, open-access scheduling resulted in overbooking and the addition of unscheduled daily clinical encounters throughout the day without limit. In the words of one physician, “I’ve seen providers cry, you know? Because they had 14 appointments at 4:30 and they had to get home to their family, and we had this unlimited overbook and that is the expectation. For some teams it was really hard to manage. I think there was a lot of stress around that in the clinic” (Driscoll et al., 2013, p. S46).

Moving to the PCMH did result in some clinician attrition and turnover. One study described a leadership focused on implementing empanelment and team-based models and how the implementation conflicted with

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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the experiences or expectations of some clinicians (Driscoll et al., 2013). In the words of one physician, “Some doctors who were kind of trained in a private practice mentality had a hard time with a system that valued the patient maybe more than they valued the doctor. The doctor was just one of the peer groups that assisted in taking care of that patient population” (Driscoll et al., 2013, p. S48). The study describes feedback mechanisms such as anonymous workforce and customer satisfaction surveys, which were implemented as the transition took place and used by the leadership to adopt new processes to ameliorate some of the tensions among employees while improving efficiency for customer-owners (Driscoll et al., 2013). However, there is limited discussion of the enabling structures built within the teams to foster resilience of care team members and to facilitate and sustain these changes to care delivery. Similarly, it is not clear if employee burnout and well-being are measured or if systems-level approaches are employed to minimize the known causes of burnout (e.g., reducing administrative burden and excessive workload and improving workflow efficiency, among others) (NASEM, 2019).

How Is the Nuka System Illustrative of Whole Health?

The Nuka system is a leading example of health care redesign based on the needs of the community it serves. While it offers a full range of health care services, including both traditional approaches to medical care and CIH modalities, it also provides a wide range of services that address many of the social determinants of health and that are designed to create a healthy and thriving community based on Native Alaska culture and practices. The entire system is intended to provide integrated and comprehensive care through a PCMH and is accountable to its customer-owners. Table 4-2 summarizes how the foundational elements of the SCF/Nuka system of care address the five foundational elements of a whole health approach to health care.

MARY’S CENTER4

Mary’s Center is an FQHC that provides that provides health care, social services, and family literacy programs in the Washington, D.C., region. Mary’s Center refers to this integrated approach as its Social Change Model. In 2020, roughly 800 staff served roughly 52,000 individuals and families from over 50 countries. Nearly 97 percent of the population that

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4 Much of the information presented in this section is based on committee member Dr. Seiji Hayashi’s personal knowledge of Mary’s Center. Dr. Hayashi was the chief transformational officer at Mary’s Center until September 2022.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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TABLE 4-2 Congruence of the SCF/Nuka System of Care with the Foundational Elements of Whole Health

Foundational Elements Components that Address the Foundational Elements Nuka Indicators
People-centered Achieving a sense of purpose through longitudinal, relationship-based care Table
People/families/communities direct goals of care Table
Care delivered in social and cultural context of people/family/community Table
Comprehensive and holistic Address all domains that affect health—acute care, chronic care, prevention, dental, vision, hearing, promoting healthy behaviors, addressing mental health, integrative medicine, social care, and spiritual care Table
Attend to the entirety of a person/family/community’s state of being Table
Components and team members are integrated and coordinated Table
Upstream-focused Multisectoral, integrated, and coordinated approach to identifying and addressing root causes of poor health Table
Address the structures and conditions of daily life to make them more conducive to whole health Table
Equitable and accountable Whole health systems need to be accountable for the health and well-being of people/families/communities Table
Care needs to be accessible to all Table
Team wellbeing The health of the care delivery team is supported

NOTE: Based on the program descriptions, Table indicates that the component is addressed; — indicates that it is partially addressed; a blank space indicates that it is not addressed. The committee determined that team well-being was partially addressed because it was unclear if well-being interventions employed systems-level approaches to minimize burnout and there was limited discussion of the enabling structures that foster resilience of care team members in the literature.

Mary’s Center serves earns below 200 percent of the federal poverty level. In addition, 95 percent of patients identify as belonging to a racial or ethnic minority group, and 76.3 percent identify as Hispanic or Latinx. Nearly 72 percent of the patient population is best served in a language other than English (Corallo et al., 2020), with Spanish and Amharic being the two most commonly spoken languages by patients. Just over half of Mary’s Center patients receive Medicaid, and 15 percent are uninsured (HRSA, 2020).

Mary’s Center’s service area is large for an urban health center, extending over 30 miles in each direction from its headquarters in Washington, D.C. Although the bulk of the patients live in clustered neighborhoods,

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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gentrification has pushed families outside of the District of Columbia. Known for its bilingual services in English and Spanish, it is not uncommon for the centers to have new patients come from as far north as Baltimore.

Services are offered at five community health centers and two senior wellness centers. Behavioral health therapy is offered at all clinical sites in addition to 26 public schools, and comprehensive school-based primary care is offered at one public high school and one middle school. Separately, the Briya Public Charter School has campuses co-located at three Mary’s Center community health centers. Two mobile units and three mobile pods extend the availability of services for dental, mammography, HIV and sexual health services as well as of COVID-19 testing and vaccinations.

People-Centered

Mary’s Center provides people-centered services by ensuring personalized access, affordability, and quality in addition to understanding each person’s values and wishes. Mary’s Center uses the term “participants” to refer to its clients in recognition of the fact that people at the center actively participate in their care and are true partners with shared expectations and goals concerning outcomes. In addition, Mary’s Center provides many services outside of health care, and the term “patient” inadequately characterizes program participants.

Mary’s Center provides culturally and linguistically appropriate services by hiring staff from the community it serves and by hiring multilingual staff. Program participants come from roughly 50 different countries, and, according to a Mary’s Center human resources document, employees come from 40 countries and speak over 35 different languages (Mary’s Center, 2018). The vast majority of participant-facing staff are able to provide services in a language other than English, with Spanish and Amharic being the two languages most spoken by participants and staff. When a staff member does not speak a participant’s language, interpreters are used to ensure proper communication.

Mary’s Center ensures direct input from the users of its services in three main ways. Like Southcentral Foundation, Mary’s Center maintains a patient-majority board of directors, which is also a HRSA requirement for all FQHCs. The board has the authority to hire and fire the chief executive and decides on organizational priorities. Mary’s Center also convenes a monthly community engagement council composed exclusively of current participants. The council advises organizational leaders on service priorities and on how to improve participant experience. Mary’s Center also uses an external company to continually survey patients on their experiences, and it uses multiple surveys and questionnaires to identify the specific needs

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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of individuals. Surveys cover health issues and non-health issues. Mary’s Center uses the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool (PRAPARE, 2022) to collect information on its participants’ social determinants of health. Finally, Mary’s Center has a specific staff member, a patient care advocate, dedicated to addressing patient complaints including customer service issues, access to care, and quality of care.

Comprehensive and Holistic

Mary’s Center refers to its holistic and comprehensive integration of health care, social services, and family literacy programs and educational services as its “Social Change Model” (Galvez et al., 2019). Mary’s Center developed the model based on the philosophy that social and economic well-being are an integral part of overall wellness in addition to comprehensive primary care that includes oral health and behavioral health services. Because of the behavioral health needs of the population, Mary’s Center currently employs more behavioral health providers than medical providers. The organization uses an integrated behavioral health model where therapists are embedded into the primary care team and “warm handoffs” occur between primary care clinicians and behavioral health therapists. Warm handoffs also occur between social services, nutrition, and health education which are also on site and integrated into the care team. Virtual warm handoffs have become common as some staff have been working remotely during the pandemic. Mary’s Center does not offer complementary and integrative health, vision care, or hearing services.

Upstream-Focused

As mentioned earlier, Mary’s Center offers social services and educational programs in addition to traditional treatment and preventative health care services. The majority of Mary’s Center staff focus on upstream issues and are nonclinicians. The PRAPARE tool is integrated into every participant’s EHR as a means of guiding staff on what services are necessary for each participant.

To augment access to its services, Mary’s Center offers myriad programs to address patients’ social determinants of health. Care coordination and case management are at the heart of the social services program, which assists patients in obtaining food, clothing, housing, and direct cash assistance. Staff implement priority programs directly, and partnerships with hundreds of community-based organizations provide additional resources, such as legal services and housing (Galvez et al., 2019). For example, a bilingual staff member accompanies survivors of domestic violence through

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

the court system and helps them find safe housing. Mary’s Center also has a robust program to offer case management, counseling, and coaching through its home visiting programs for at-risk mothers and infants. All sites offer multilingual services to help patients enroll in health insurance and other benefits, and Mary’s Center has recently added services for refugees, asylees, and parolees.

Mary’s Center also offers a variety of educational programs for its patients. In partnership with Briya Public Charter School, originally a program of Mary’s Center, parents and children enroll together in a two-generation program in which parents learn English, digital literacy, and parenting while their children receive high-quality early education. This focus on family literacy stems from the center’s experience that the English language and literacy are essential to gaining employment and accessing resources. Since the socioeconomic trajectory of a family is dependent on the successes of each member and as a unit, Mary’s Center and Briya use a family-centered approach (Galvez et al., 2019). Through this partnership, participants can receive a high school diploma and training for medical assistant certification and child development associate credentials. In addition, Mary’s Center runs an afterschool program to support teen participants to be college or career ready. In 2022, 100 percent of high school seniors enrolled in the Mary’s Center Teen Program (32 students) were accepted into college.

Mary’s Center participates in several care coordination and case management programs for complex patients. One program, for example, serves participants with severe mental illness who receive support from the D.C. Department of Behavioral Health. Another program serves participants with multiple chronic diseases who are D.C. Medicaid program clients. Both of these programs integrate social services, behavioral health services, and clinical services.

Equitable and Accountable

Mary’s Center provides people-centered services by ensuring personalized, equitable access; affordability; and quality. Like SCF Nuka, Mary’s Center must meet requirements to maintain certification by the HRSA Health Center Program. As described earlier in the chapter, these requirements include implementing a sliding pay scale for the uninsured, community-majority governance and board membership, annual catchment area analysis, and triennial population needs assessments. All of these requirements help ensure that Mary’s Center is accountable to its participant population, that it understands that population’s unique needs, and that it considers equity in its service delivery and design.

Mary’s Center also has staff dedicated to helping its participant’s access benefits and entitlements, including insurance. It also participates in the

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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340B drug pricing program5 which provides uninsured or underinsured patients medications at a discount.

Mary’s Center has an infrastructure for accountability and continuous quality improvement and publicly reports its clinical quality measures to HRSA (HRSA, 2020). It has received Community Health Quality Recognition awards from HRSA for being a national quality leader and COVID-19 data reporter as well as for advancing health information technology for quality. It has also maintained recognition by the National Committee for Quality Assurance as a PCMH for many years.

An Urban Institute evaluation found that Mary’s Center provided a welcoming environment for patients and that its customer service ratings were very high (Galvez et al., 2019). A review of evidence regarding health centers found that those offering services similar to those offered by Mary’s Center provided higher quality of care (Martinez et al., 2020). Preliminary findings from a retrospective review of EHR data showed that receiving services beyond traditional medical care at Mary’s Center was associated with greater protection against hypertension, obesity, diabetes, and hyperlipidemia.

To address issues of health equity, Mary’s Center convenes a Health Equity Taskforce. The Taskforce reviews data on health equity issues, including race/ethnicity, sexual orientation, and gender identity, and develops interventions. The Taskforce works closely with Mary’s Center’s Inclusion, Diversity, Equity, Awareness Committee which is composed of frontline staff and senior leadership. Mary’s Center received a top score of 100 on the Human Rights Campaign’s Health Care Equality Index in 2020. In addition, all Mary’s Center staff have received multiple trainings on the topics of diversity, equity, and inclusion. Specific topics covered include race and racism, sexual orientation and gender identity, and trauma-informed care.

Team Well-Being

Mary’s Center integrates many programs and activities focused on staff well-being throughout the organization, and it has received the Washington Post’s Top Workplaces award every year since 2018 (Top workplaces 2021, 2021). For example, Mary’s Center implements an annual staff satisfaction survey to gather information and input on how to improve the workplace for staff. Burnout reduction initiatives focus on improving workflow efficiency, such as through technology adoption; building personal resilience through retreats, exercise classes, and meditation classes; and improving organizational communications through activities such as virtual townhalls

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5 Additional information is available at https://www.hrsa.gov/opa/index.html (accessed June 10, 2022).

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

and intranet development. Work-hour reductions and liberal telework policies have also improved staff morale and reduced stress. Mary’s Center has a Trauma-Informed Practice Workgroup designed to create a work environment in which staff feel safe to voice concerns and address issues. Since the majority of employees at Mary’s Center are people of color and may also identify as members of other marginalized groups, such as LGBTQ+, the diversity, equity, and inclusion training noted above also focuses on creating a work environment that is more welcoming and inclusive for all staff.

How Is Mary’s Center Illustrative of Whole Health?

Mary’s Center provides comprehensive physical and behavioral health care that is well integrated with social and educational services, many of which it provides through an extensive network of community partners (Table 4-3). Reflecting the multinational client base that it serves, Mary’s Center provides culturally and linguistically appropriate services, and its participants engage actively in their care and are true partners with shared expectations and goals on the outcomes. Staff can provide services in a wide variety of languages. Its focus on providing educational services is intended to equip its participants with the knowledge and skills they need to improve their overall well-being in ways that extend beyond physical and mental health. Maintaining its FQHC status helps ensure that its services are deliberately designed with equity and accountability in mind. Mary’s Center also focuses on the health of its team members and takes a number steps to help ensure their well-being, both organizationally and individually.

NATIONAL INTREPID CENTER OF EXCELLENCE (NICoE)

Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq triggered an unprecedented pace of deployment, with over 2 million U.S. troops deployed as part of these conflicts. Advances in medical technology and improvements in body armor enabled many service members to survive injuries that would have been fatal in previous conflicts. While minimizing battlefield casualties is obviously a goal in any wartime conflict, increased survival of battlefield injuries contributed to the increase of “invisible wounds” such as cognitive disorders and mental health conditions among service members who might have been casualties in previous conflicts (IOM, 2013). In response to this increased survivorship of battlefield injuries, psychological health services have grown rapidly in the past couple of decades as part of the extensive health care delivery system serving uniformed service members, retirees, and their families, improving

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

TABLE 4-3 Congruence of Mary’s Center with the Foundational Elements of Whole Health

Foundational Elements Components that Address the Foundational Elements Mary’s Center Indicators
People-centered Achieving a sense of purpose through longitudinal, relationship-based care Table
People/families/communities direct goals of care Table
Care delivered in social, cultural, and linguistic context of people/family/community Table
Comprehensive and holistic Address all domains that affect health—acute care, chronic care, prevention, dental, vision, hearing, promoting healthy behaviors, addressing mental health, integrative medicine, social care, and spiritual care
Attend to the entirety of a person/family/community’s state of being, with a focus on behavioral health Table
Components and team members are integrated and coordinated Table
Upstream-focused Multisectoral, integrated, and coordinated approach to identifying and addressing root causes of poor health. Table
Address the structures and conditions of daily life to make them more conducive to whole health Table
Equitable and accountable Whole health systems need to be accountable for the health and well-being of people/families/communities Table
Care needs to be accessible to all Table
Team wellbeing The health of the care delivery team is supported Table

NOTE: Based on the program descriptions, indicates that the component is addressed; — indicates that it is partially addressed; a blank space indicates that it is not addressed. The committee gave a partial score for addressing all domains that affect health because Mary’s Center does not offer complementary and integrative health, vision, or hearing services.

a system that the Department of Defense (DoD) described as insufficient (Defense Health Board Task Force on Mental Health, 2007).

In the early 2000s, despite the significant allocation of resources and seemingly extensive support network to bolster it, the Military Health System (MHS) still faced significant challenges in providing adequate care for injured service members. A DoD Task Force report highlighted the increasing challenges from post-traumatic stress disorder (PTSD), depression, and mild traumatic brain injury (mTBI), and it indicated that without greater efforts to enhance the systems of care, the prevalence of these conditions would continue to remain high (Defense Health Board Task Force on Mental Health, 2007). In addition, the report highlighted challenges with access

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

to care, quality care, culture and the stigma associated with psychological health disorders, and consideration of families in treatment.

The study findings triggered a congressional mandate to create the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). MHS, the Defense Health Agency, and the medical components of each service branch have used the National Defense Authorization Act of 2007 (NDAA) as a catalyst for change and to create true value for service members. Under NDAA, DCoE was established to provide clinical guidance and share best practices for treating psychological health and traumatic brain injury (TBI). The increased rate of troop deployments to Iraq and Afghanistan significantly influenced the immediate need to provide expanded services (DCoE, 2009). As a result, DCoE developed the NICoE to complement the current efforts of the existing centers. NICoE offers clinical care, diagnosis, research, and education for active-duty service members with TBI and psychological health needs that do not respond to traditional treatment.

People-Centered

The NICoE uses an integrative model known as the Intrepid Spirit University (ISU) (Figure 4-3) with the goal of combining integrative medicine modalities with traditional care for post-concussive treatment (Lee et al., 2019). To achieve this goal, the model places the person at the center of care and redefines therapeutic end points by enhancing the person’s understanding of their plan of care, optimizing individualized precision medicine with the right patient receiving the right care at the right time, and institutionalizing process and language. The model views each participant as a student, and physician or nurse practitioner admission officers assess each individual’s needs fully as well as the impact of the injuries on the student’s family. An admissions committee comprising physicians, physician assistants, neuropsychologists, behavioral health, and rehabilitation professionals reviews the application packet and develops an individualized curriculum that takes into account the number of credits required for graduation. Once the student has completed the requirements for graduation, the clinical providers hold a commencement ceremony with the student and his or her family to highlight positive gains and provide an opportunity for the student to give an experiential testimony before his or her family and providers (Lee et al., 2019).

ISU uses goal attainment scaling, an empirically based method that provides an individualized, criterion-referenced measure of change that serves as a means for collaboratively tracking student’s progress (Turner-Stokes, 2009). The involvement of the student’s spouse/significant other is strongly encouraged by offering individual appointments with a licensed clinical

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×
Image
FIGURE 4-3 The Intrepid Spirit University process map.
NOTE: CHCS = Composite Health Care System; pt = patient; AHLTA = Armed Forces Health Longitudinal Technology Applications; TBI = traumatic brain injury; RN = registered nurse; BH = behavioral health; MRI = magnetic resonance imaging; VS = vital signs; BHDP = Behavioral Health Data Portal; RA = research assistant; POC = point of contact; AC = admissions committee; CM = case manager; NP = nurse practitioner; RCC = regional care coordinator; f/u = follow-up.
SOURCE: Lee et al., 2019.
Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

social worker, who develops an individualized plan for family members ranging from familiarization with the student’s medical conditions and treatment recommendations to specific therapies for family members. A 2019 study of this model of care found that it had a destigmatizing affect among participants and reduced the average length of treatment to 126 days from 202.6 days when compared with standard referral-based care. It also reduced costs from $103.24 to $85.57 in relative value units compared with standard referral-based care (Lee et al., 2019).

Comprehensive and Holistic

NICoE offers both an outpatient mTBI program and an intensive outpatient program which last 4 weeks. For the intensive program each participant has an intake appointment with an interprofessional care team to hear the patient’s story. This helps to ensure that participants do not have to repeat the same information to multiple team members. After a service member has received a full evaluation by the NICoE care team over a 4-week stay, the care team compiles a discharge report with diagnostic findings and an individualized treatment plan. The care team, patient, and family collaborate on designing the treatment plan, which providers at the service member’s home station implement following discharge.

Over the course of 4 weeks, each patient meets with a variety of care team members on an as-needed basis. Core team members include an internist, neurologist, psychiatrist, neuropsychologist, family therapist, and a designated nurse specialist who serves as the student’s point of contact throughout the program (DeGraba et al., 2020). Care teams can also include an audiologist, art therapist, chaplain, licensed clinical social worker, nutrition specialist, occupational therapist, optometrist, physical therapist, recreational therapist, sleep medicine physician, and speech and language pathologists.

In addition, NICoE provides traditional and alternative treatments such as group counseling, psychoeducation, yoga, tai chi, and a canine program, where patients are encouraged to interact with and train a service animal. Patients engage in a treatment modality during their stay to assess whether continued engagement with a given treatment approach would benefit the participant and be included in their long-term treatment plan. NICoE also offers short-term services, and participants continue their treatment at their home clinical centers. NICoE accepts active-duty service members from any service branch, including the National Guard and reserve components.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

Upstream-Focused Care

NICoE’s interprofessional care team includes behavioral health specialists and family counselors, and it may also include a licensed clinical social worker, nutritionist, and sleep medicine physician. All of these professions address upstream factors. However, the committee could not find a detailed description of how NICoE operationalizes this upstream care.

Equitable and Accountable

The committee found one published study that examined how effective the NICoE is at producing symptom recovery from combat-related mTBI in 1,456 service members with residual symptoms from mTBI and psychological health conditions who received treatment at NICoE at Walter Reed National Military Medical Center (DeGraba et al., 2020). That study reported that “after treatment in the 4-week intensive outpatient program, patients whose symptom severity was at or above threshold at admission showed clinical improvements at discharge and return to duty in each of the seven assessments” (DeGraba et al., 2020). The assessments included the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) (DeGraba et al., 2020). The investigators reported that 77 percent of the service members who had symptoms above the admission threshold improved on the NSI scale; improvements were also seen on GAD-7 (72 percent), ESS (72 percent), PCL-M (57 percent), PHQ-8 (55 percent), SWLS (53 percent), and HIT-6 (33 percent). The researchers postulated that these improvements resulted from comprehensive and coordinated care and the establishment of trust between the participant and the care team.

The committee found little information explicitly pertaining to equitable care; however, all service members who meet the admissions criteria are technically eligible to participate in the program. That said, there are documented issues with geographic access to NICoE services, and home station providers are not always aware of NICoE, the eligibility criteria, or the specific services offered and how they differ from what is available elsewhere in the military health system. One report recommended that NICoE should better develop its outreach efforts to raise awareness of the program. The report also recommended that NICoE focus on recruiting eligible participants from locations with the greatest need and that it better evaluate the effects of its assessments, treatment, patient outcomes, and cost-effectiveness (Ayer et al., 2015).

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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Team Well-Being

The committee was not able to find any information suggesting that team well-being was part of the NICoE program design or implementation.

How Is NICoE Illustrative of Whole Health?

While NICoE is focused on post-concussive symptoms, depression, and PTSD rather than overall health and well-being, it operates through a whole health lens (see Table 4-4). It is a short-term intervention, and, despite this limited focus, it does align well with several of the committee’s five foundational elements of whole health. The model holistically and comprehensively addresses the participants’ needs and keeps them at center of the program. A dedicated, interprofessional team supports and empowers participants to take ownership of their health, an approach that they can ideally carry with them through their life course to improved well-being.

PROGRAM FOR ALL-INCLUSIVE CARE OF THE ELDERLY (PACE)

On Lok, a community-based organization in San Francisco, developed the Program for All-Inclusive Care for the Elderly (PACE) as an alternative to nursing home care in 1972. The goal of PACE is to extend participant independence in the community and to enhance the quality of their lives and overall well-being; the program is also designed to keep frail elderly in the community and allow them to age safely in place, instead of in a nursing home, for as long as possible (On Lok, 2022). It does this by providing the elderly with adequate medical care, social services, and maintenance rehabilitation services (Fretwell and Old, 2011; Lehning and Austin, 2011). Unlike the other approaches described in this chapter, PACE is a delivery model implemented by different systems around the country.

PACE is a federally authorized Medicare/Medicaid managed-care benefit available to frail adults aged 55 years and older whom the state certifies as nursing home eligible but who want to remain in their community. PACE participants must be able to live safely at home within a PACE site’s geographic area. Most participants are dually eligible for Medicare and Medicaid, and the program provides all Medicare- and Medicaid-covered services, paying for care via monthly capitation payments from Medicare and Medicaid. The program has grown steadily since 2012, and in 2022 there were 145 PACE programs operating 273 PACE centers in 31 states, serving over 60,000 participants (National PACE Association, 2022b). Participation in PACE is associated with improved care quality, reduced mortality, preservation of function, fewer unmet assistance needs, greater

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

TABLE 4-4 Congruence of NICoE with the Foundational Elements of Whole Health

Foundational Elements Components that Address the Foundational Elements NICoE Indicators
People-centered Achieving a sense of purpose through longitudinal, relationship-based care Table
People/families/communities direct goals of care Table
Care delivered in social and cultural context of people/family/community Table
Comprehensive and holistic Address all domains that affect health—acute care, chronic care, prevention, dental, vision, hearing, promoting healthy behaviors, addressing mental health, integrative medicine, social care, and spiritual care Table
Attend to the entirety of a person/family/community’s state of being Table
Components and team members are integrated and coordinated Table
Upstream-focused Multisectoral, integrated, and coordinated approach to identifying and addressing root causes of poor health
Address the structures and conditions of daily life to make them more conducive to whole health
Equitable and Accountable Whole health systems need to be accountable for the health and well-being of people/families/communities
Care needs to be accessible to all
Team well-being The health of the care delivery team is supported Table

NOTE: Based on the program descriptions, Table indicates that the component is addressed; — indicates that it is partially addressed; a blank space indicates that it is not addressed. The committee gave a partial score for both upstream-focused components because it was unable to find details of how the components were operationalized, aside from the participation of upstream-focused professionals. The committee also gave a partial score for the accountable component of equitable and accountable because NICoE is focused on individual participants and not their families or communities. This is, however, by design. The committee determined that care provided by NICoE is not accessible to all, given the limited locations of available services. The committee was unable to find any information regarding efforts to foster team well-being.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

participant satisfaction, greater team member satisfaction, and less hospital and nursing home use (Arku et al., 2022; Fretwell and Old, 2011). Studies of cost savings have produced conflicting reports. A 2012 study concluded that PACE produced a substantial savings for Medicaid (Wieland et al., 2013), while a 2015 study found that PACE does not generate savings for Medicare and increases Medicaid costs (Ghosh et al., 2015).

On Lok founded PACE on the belief that everyone should have the choice to age at home, regardless of their physical, medical, and financial circumstances. This is based on the idea that when patients have their medical and long-term care needs taken care of, participants can live to their fullest, at any age and level of ability. PACE makes aging at home possible by

  • Working with patients and their family to design a personalized care plan
  • Carefully assessing patient needs and managing every aspect of their health care—using a high-touch approach designed to make patients feel valued and supported—by an interdisciplinary team
  • Providing patients with in-home support, as well as transportation from their homes to their clinics and adult day health centers and to their networks of thousands of local providers
  • Assisting with the tasks of daily living, such as preparing a meal or doing laundry (On Lok, 2022)

People-Centered

PACE is designed for patients who are nursing home eligible but would like to remain living independently in the community. PACE makes aging at home possible by working with patients and their families to design a personalized care plan. While the concepts of people-centeredness are intrinsic in the program philosophy—i.e., it is based on the premise of catering to people who are eligible for nursing care but wish to remain in their own community—the operational details of the approach are less clear in the available literature.

The professionals in a PACE care team are selected for their experience and qualifications in senior care. They meet regularly to exchange information and review the patient’s plan as their needs change and handle all aspects of their care (On Lok, 2022). This frequent contact with each other and with the program participants allows close monitoring of chronic conditions and ongoing needs assessment. The arrangement also enables team members to build close, longitudinal relationships with program participants. Team members partner with patients to schedule and coordinate appointments with their vast network of specialists, fill prescriptions, and

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

provide transportation and support at home when needed (Gross et al., 2004).

Comprehensive and Holistic

The PACE model is designed to be comprehensive and holistic. Care is delivered by an interdisciplinary PACE team that includes a primary care physician, a nurse, a social worker, a physical therapist, an occupational therapist, a recreational therapist or activity coordinator, a dietitian, a PACE center supervisor, nursing aids, and drivers. The team develops a comprehensive care plan based on its assessment, which is aligned with the patient’s care preferences. This care plan addresses a standard set of biopsychosocial/functional issues or domains that are relevant to the health of frail older adults: diagnoses and medications, nutrition, bowel and bladder function, cognition, emotion, social activity, mobility, activities of daily living, and cooperation with the care plan. To ensure continuity, the interdisciplinary team meets regularly. The team evaluates and revises the care plan every 6 months.

Home care caregivers are trained to understand and assist patients with day-to-day care needs, including memory support needs and dementia issues. Home care is a supportive senior service that is integrated into the clinical care provided at their clinics (On Lok, 2022). Home care workers can help with light housekeeping, personal care, light meals preparation, feeding, medication reminders, laundry, and escort assistance to medical appointments, as needed, as well as with preparation for van transport to and from PACE center visits or other health care appointments.

Upstream-Focused

The wide array of professionals involved in PACE is a testament that prevention and empowerment are a primary focus of the program (Boult and Wieland, 2010). As discussed above, interprofessional PACE care teams include a wide variety of disciplines in order to meet the medical, behavioral, social, and well-being needs of the participant population. Because all members of the care teams regularly meet to discuss program participants, the model is designed to proactively identify their whole health needs, including upstream factors, and to quickly address them. For example, a driver may notice a problem at an individual’s home (e.g., a pile of unpaid bills or an empty refrigerator) and alert the social worker or home care coordinator to help resolve it. In terms of prevention, physical therapists and activity therapists work to maintain strength, mobility, and function among elderly patients, and they work alongside primary care and other team members to help identify and prevent problems before they arise.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

Equitable and Accountable

PACE is available to anyone who meets the eligibility criteria described above (National PACE Association, 2022a); however, not all programs have the capacity to accept new patients, and programs are not geographically accessible to all. The vast majority of enrollees (90 percent) are dually eligible for Medicaid and Medicare (MACPAC, 2020). Nearly everyone else who participates (9 percent) is Medicaid eligible only, and the remaining 1 percent pay for services privately. Services are covered at no cost to dually eligible or Medicaid-eligible participants. According to the National PACE Association, 67 percent of Medicaid-eligible older adults do not have access to a PACE program. While this population is by definition underserved, the committee was not able to find any demographic information about PACE users and PACE-eligible non-users to see if certain subgroups were over- or underserved. Centers for Medicare & Medicaid Services (CMS) rules state that PACE organizations must not discriminate against any participant in the delivery of required PACE services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, or source of payment (CMS, 2011).

Geographically, PACE programs are not evenly distributed across states. Twenty states have no access to PACE, and among the 30 states that do, access to PACE is inconsistent (National PACE Association, 2020). Nevertheless, the program is growing and is designed to provide high-quality services to underserved older adults. Among participants, the on-site inclusion of a variety of medical and other services enables the care teams to coordinate medical and social needs during patients’ visit, reducing the burden of having multiple visits, which may exclude specific populations. In the past several years, a series of legislative and rule changes granted CMS the authority to develop pilots for PACE programs for individuals under 55 but who otherwise meet the PACE eligibility criteria. This could improve access to the comprehensive and holistic care that PACE offers to younger, but still high-need populations (National PACE Association, 2015).

Regarding accountability, PACE is required to report quality-of-care data to CMS as a condition of its participation in Medicare and Medicaid. PACE organizations are required to develop, implement, maintain, and evaluate an effective data-driven quality assessment and performance improvement program. These programs are to consider the full range of services that PACE offers, although individual organizations should design programs that best meet the needs of their participants and that are not limited to certain services or patient populations. These quality assessments should inform continuous improvements for all PACE services. CMS uses the resulting data to monitor health outcomes and quality improvement efforts as well as to identify gaps or areas in need of improvement, although

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

the committee did not find information in the published literature detailing these efforts (CMS, 2011).

Participants are also active in PACE program governance. Every program has a participant advisory committee which provides advice to the governing body on participant-related concerns. Program participants must make up a majority of the advisory committee, and they select a participant to represent them on the organization governing board (CMS, 2011).

Team Well-Being-Focused

The committee was not able to find any information suggesting that team well-being was part of the PACE model design or implementation.

How Is PACE Illustrative of Whole Health?

PACE is designed to address four of the committee’s five foundational elements of whole health, including providing holistic comprehensive care, addressing upstream factors that influence health, using a people-centered care approach, and having a focus on equity and accountability (Table 4-5). The approach aligns well with whole health aims to achieve patients’ goals for well-being. For the elderly, this often means maintaining independence and function in their homes and communities. That said, based on the available information, it was unclear to the committee if there is a formal structure to understand what matters most to patients in the context of their families and communities although their programs directly address the basic needs and requirements for well-being, including social, emotional, and material supports in partnership with patients and their families. In addition, the committee could not find information that addressed the foundational element of team well-being.

FINDINGS AND CONCLUSIONS

This chapter described health systems and models with design characteristics of the committee’s five foundational elements of whole health (Table 4-6). While Chapter 5 will delve deeper into the evidence of these and other models that align well with the foundational elements, it is difficult to determine the scope and consistency of implementation fidelity of the models. For example, the VHA as a system provides all five foundational elements, but implementation varies from site to site and even within sites. The committee describes Mary’s Center and NICoE as only partially addressing all domains that affect health due to Mary’s Center’s focus on outpatient services and NICoE’s focus on a specific syndrome. PACE limits enrollment by age and insurance by design but is also not available in many

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

TABLE 4-5 Congruence of PACE with the Foundational Elements of Whole Health

Foundational Elements Components that Address the Foundational Elements PACE Indicators
People-centered care approach Achieving a sense of purpose through longitudinal, relationship-based care Table
People/families/communities direct goals of care Table
Care delivered in social and cultural context of people/family/community Table
Holistic comprehensive care Address all domains that affect health—acute care, chronic care, prevention, dental, vision, hearing, promoting healthy behaviors, addressing mental health, integrative medicine, social care, and spiritual care Table
Attend to the entirety of a person/family/community’s state of being Table
Components and team members are integrated and coordinated Table
Addresses upstream factors that influence health Multisectoral, integrated, and coordinated approach to identifying and addressing root causes of poor health Table
Address the structures and conditions of daily life to make them more conducive to whole health Table
Equitable and accountable Whole health systems need to be accountable for the health and well-being of people/families/communities Table
Care needs to be accessible to all Table
Team wellbeing The health of the care delivery team is supported Table

NOTE: Based on the program descriptions, Table indicates that the component is addressed; — indicates that it is partially addressed; a blank space indicates that it is not addressed. The committee determined that PACE care is not accessible to all, given its uneven distribution around the country. Additionally, the committee found no information regarding team wellbeing efforts in PACE programming.

states. The committee recognizes the operational challenges of full implementation as well as the purposeful limitations of some of the programs and does not conclude that one system is superior to another. Additionally, information on patient perspective and experience on access to services is difficult to obtain.

Interestingly, the committee found no programs that embody all five foundational elements fully, but each of the examples highlighted in this chapter offers promising approaches that serve different populations. Variable implementation of foundational elements may be necessary to tailor

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

and deliver whole health that addresses the needs of different communities. Other programs may exist that embody all five elements, but they were not readily found and described in the public domain. Team well-being is the most commonly missing element across the five examples; however, program design features of Mary’s Center address team well-being more comprehensively than the others, employing individual and systems-based approaches. It is possible, though, that the other systems are addressing team well-being more comprehensively than what is documented in the published literature.

TABLE 4-6 Congruence of the Featured Models with the Five Foundational Elements of Whole Health

Foundational Element Components that Address the Foundational Elements VA WHS SCF/Nuka Mary’s Center NICoE PACE
People-centered Self-empowerment, longitudinal, relationship-based Table Table Table Table Table
People/family/community-directed Table Table Table Table Table
Care delivered in social and cultural context Table Table Table Table Table
Holistic and comprehensive Addresses all domains that affect health Table Table Table Table
Attends to the entirety of a person/family/community Table Table Table Table Table
Components and teams are coordinated Table Table Table Table Table
Upstream-focused Identifying and addressing root causes of poor health Table Table Table Table
Addresses the conditions of daily life Table Table Table Table
Equitable and accountable Accountable to people/families/communities Table Table Table Table
Accessible to all Table Table Table Table Table
Team wellbeing Supports the care delivery team Table Table Table

NOTE: Based on the program descriptions, Table indicates that the component is addressed; — indicates that it is partially addressed; a blank space indicates that it is not addressed.

Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
×

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Suggested Citation:"4 Whole Health in Practice." National Academies of Sciences, Engineering, and Medicine. 2023. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press. doi: 10.17226/26854.
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Whole health is physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities. Whole health care is an interprofessional, team-based approach anchored in trusted relationships to promote well-being, prevent disease, and restore health. It aligns with a person's life mission, aspiration, and purpose. It shifts the focus from a reactive disease-oriented medical care system to one that prioritizes disease prevention, health, and well-being. It changes the health care conversation from "What’s wrong with you?" to "What matters to you?"

The Department of Veterans Affairs (VA), the Samueli Foundation, and the Whole Health Institute commissioned the National Academies of Sciences, Engineering, and Medicine to establish a committee to provide guidance on how to fill gaps and create processes to accelerate the transformation to whole health care for veterans, both inside and outside the VA system, and the rest of the U.S. population. The resulting report presents findings and recommendations that provide a roadmap for improving health and well-being for veterans and the nation.

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