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

Chapter: 5 Whole Health Systems' Evidence

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Suggested Citation:"5 Whole Health Systems' Evidence." 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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5

Whole Health Systems’ Evidence

In Chapter 2 the committee stated that “whole health systems are not merely the sum of their parts. There is seamless coordination and provision of services across sectors and interprofessional care teams with a shared goal of helping people and communities achieve whole health.” Accordingly, while it is important to define the evidence supporting the foundational building blocks of whole health, as done in Chapter 3, evidence on system-level transformation is ultimately needed to understand the impact of a whole health approach.

Chapter 4 described five health care delivery models whose program design and philosophy closely align with the committee’s five foundational elements of whole health, showing how other systems have operationalized the delivery of whole health. In this chapter, the committee reviews and summarizes the evidence from U.S. and international systems that have implemented whole health care. The committee sought to identify outcomes related to the effectiveness, implementation, and dissemination of whole health programs. Summarizing the evidence, the committee sought to understand the effect of implementing whole health care, crosscutting themes for implementing and disseminating whole health, challenges with generating systems-level evidence, and the research and learning health systems strategies that are needed to inform the future of whole health.

METHODS

It was beyond the capacity of the committee to conduct a systematic review of systems-level evidence on whole health care. However, the

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

committee did seek to comprehensively identify a globally inclusive and broad sample of bright-spot systems that had both implemented and evaluated a whole health systems approach to care that was consistent with the committee’s definition and mostly inclusive of the five foundational elements described in Chapter 2. Inclusion criteria were purposely broad: implementing a whole health systems approach to care consistent with the committee’s definition; one or more publications reporting the outcomes on effect, implementation, or dissemination of whole health; and the use of some type of comparison group (e.g., randomized control, pre–post comparison, matched comparison, contemporaneous comparison) in the evaluation of effectiveness. Quantitative, qualitative, and epidemiologic studies were included. All outcomes that spoke to an approach’s effectiveness, implementation, or dissemination were included. For example, the effectiveness outcomes considered included mortality, morbidity, patient activation and engagement, cost, care experience, team well-being, and more. Similarly, outcomes that spoke to implementation and dissemination included measures on such domains as the adoption, reach, and maintenance of whole health programs (Gaglio et al., 2013; Glasgow et al., 2019). Bright-spot examples were not included if they did not have an evaluation component that could be objectively assessed in a publication with transparent methods.

The committee used four steps to identify bright-spot systems: it (1) composed a list of whole health systems that committee members knew about; (2) invited panelists to present their whole health work to several open hearing sessions; (3) commissioned a report from Asaf Bitton, executive director of Ariadne Labs, on whole health bright spots; and (4) used a constrained snowball approach from publications identified in the first three steps to find additional whole health bright-spot examples and additional publications on whole health evaluations.

Bitton’s commissioned report identified bright-spot examples by examining key global repositories of case studies.1 These repositories included (1) the World Health Organization’s (WHO’s) People-Centered Integrated Care unit (World Bank and WHO, 2019); (2) the case study repository of the global consortium known as the Primary Health Care Performance Initiative, which includes case studies from WHO, the World Bank, UNICEF, the Global Fund, the Gates Foundation, and others (PHCPI, 2022); (3) important reviews of integrated care case studies done by the World Bank over the last decade; and (4) key state, federal, and academic reviews of integrated care in the United States. The VA Whole Health System, Southcentral Foundation’s Nuka System of Care, and Mary’s Center were purposely excluded from the commissioned report as they had already been

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1 Asaf Bitton’s commissioned paper is available at https://doi.org/10.17226/26854.

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

identified by the committee through invited panel presentations and closed committee discussions. The commissioned paper identified seven innovative models that share important characteristics with the foundational elements of whole health. Six examples were international whole health implementations, and one, the Vermont Blueprint for Health model, was a U.S. implementation. The committee excluded one of the six international programs as it did not have outcomes data on the implementation of the whole health program (Singapore: Regional Health Systems and Agency for Integrated Care Initiatives).

The committee’s parallel process identified six additional systems (not including the Veterans Health Administration [VHA]), all of which were U.S. based. The program design and philosophical approaches for five of these whole health systems are also described in detail in Chapter 4 (VHA, Southcentral Foundation’s Nuka System of Care, Advanced Care for Elderly, Mary’s Center, and the National Intrepid Center of Excellence for Traumatic Brain Injury). The final sample of bright-spot implementations of whole health included in this chapter’s review consists of the following:

U.S.-based systems (bold denotes systems profiled in Chapter 4)

  1. Department of Veterans Affairs Whole Health System
  2. Southcentral Foundation’s Nuka System of Care
  3. Kitsap Mental Health Services Race to Health! program
  4. Advanced Care for Elderly (ACE) Programs2
  5. Mary’s Center
  6. Vermont Blueprint for Health
  7. National Intrepid Center of Excellence (NICoE)
  8. International systems
  9. New Zealand: Canterbury Health Pathways
  10. Australia: South Australia Health in All Policies/Integrated Care Adelaide
  11. Spain: Basque Country Integrated Chronic Care Model
  12. Germany: Gesundes Kinzigtal Model
  13. Costa Rica: EBAIS Community-Based Primary Health Care Model

This chapter reviews what is known about these whole health systems and presents each case summary by providing a brief description on the system and whole health program followed by a summary of the evidence. It is important to recognize that the data sources the committee collated to

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2Chapter 4 details the Program for All-Inclusive Care for the Elderly (PACE) specifically. ACE programs include PACE but also Geriatric Resources for Assessment and Care of Elders (GRACE) and House Calls.

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

develop these case summaries represent a view of these whole health systems at one or more points in time, as reflected by their respective evaluation periods and publication dates noted in the evidence tables. The stability and sustainability of these existing programs is largely unknown. Additionally, the committee identified numerous ongoing evaluations, advances, and new programs that are being implemented and evaluated. This indicates that the field of whole health systems of care is rapidly advancing, and the committee expects a growing body of evidence in the future. Thus, while the summaries that follow will become dated, the lessons learned from their implementation will continue to have relevance.

DEPARTMENT OF VETERANS AFFAIRS WHOLE HEALTH SYSTEM

Given that the Whole Health System (WHS) of the U.S. Department of Veterans Affairs (VA) has been described in detail in the prior four chapters, more specifically in Chapter 4, this section will focus on reviewing the evidence evaluating the use and implementation (Table 5-1a)3 and health and delivery outcomes (Table 5-1b) of the WHS.

The VA initially implemented and evaluated the WHS at 18 pilot sites,4 one from each the geographically distributed Veterans Integrated Services Networks (VISNs). Initial publications spanned the first 18 months of the 3-year pilot program5 and evaluated veterans’ use of WHS services for opioid use and assessed the impact of WHS services on patient-reported outcomes regarding patient experiences, engagement with health care and self-care, quality of life, and overall well-being (Bokhour et al., 2020, 2022).

In a 2020 evaluation, researchers identified a group of veterans with a history of chronic musculoskeletal pain with moderate or severe intensity levels of pain (29 percent of all VA users). Many of these veterans also had co-morbid anxiety, depression, or post-traumatic stress disorder (PTSD) (42 percent of all VA users), chronic conditions for which self-care plays an important role (obesity, cardiovascular disease, and chronic obstructive

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3 All tables can be found at the end of this chapter.

4 The pilot sites were the VA Boston Healthcare System, VA New Jersey Health Care System, Erie (Penn.) VA Medical Center, Beckley VA Medical Center, W.G. (Bill) Hefner VA Medical Center (Salisbury, N.C.), Atlanta VA Health Care System, James A. Haley Veterans’ Hospital (Tampa, Fla.), Tennessee Valley Healthcare System, Aleda E. Lutz VA Medical Center (Saginaw, Mich.), Tomah (Wisc.) VA Medical Center, VA St. Louis Health Care System, Central Arkansas Veteran Healthcare System, South Texas Veteran Health Care System, VA Salt Lake City Health Care System, VA Portland Health Care System, VA Palo Alto Health Care System, Southern Arizona Health Care System, and VA Nebraska-Western Iowa Health Care System.

5 The evaluation, as reported here, included only the first 18 months of the 3-year pilot program in order to meet an early 2020 report deadline set by Congress in the Comprehensive Addiction and Recovery Act.

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

pulmonary disease; 56 percent of all VA users), or both (Bokhour et al., 2020).6

In a more recent evaluation which used data from electronic health records (EHRs), the research team identified veterans who availed themselves of WHS services along with a control population of veterans who did not use WHS services. During the evaluation period, which spanned from the first quarter of fiscal year (FY) 2017 to the third quarter of FY 2019, 1,368,413 unique veterans received care at the 18 pilot sites. Of the total veteran population at the 18 sites, 114,397 were included in an evaluation of opioid utilization, 6,594 of whom had used WHS services for the first time and 107,763 who had only received conventional care. In the patient-reported outcome analysis, the first 3,266 of the veterans who agreed, to participate in the Veterans Health and Life (VHL) survey at baseline and at 6 and 12 months after engaging in WHS services provided self-report data on the impacts that WHS services had on veterans’ perceptions of care; engagement in care; engagement in a life that had meaning and purpose; sense of health and well-being, including functional status and perceived stress; and pain intensity and its effects (Bokhour et al., 2022).7

The EHR provided information on which WHS services the veterans used, and pharmacy records served as the source of data on opioid use. Using EHR data, the researchers identified three types of care:

  • Core whole health, which included personal health planning, peer-led whole health groups, whole health pathway services, whole health coaching, and whole health education groups;
  • Chiropractic care; and
  • Complementary and integrative health, which included acupuncture, therapeutic massage, biofeedback, guided imagery, clinical hypnosis, meditation, yoga, and tai chi/qi gong, all part of the standard VA medical benefits package (Reed et al., 2022).

Outcomes Results

A preliminary WHS assessment published in 2020 found that the percentage of VA health care users with chronic pain who had enrolled in WHS services increased from 10.5 to 30.7 percent over the 18 months of the study (surpassing the outset goal of 30 percent). All 18 pilot sites saw increases in the proportion of veterans with chronic pain enrolling in WHS services (Bokhour et al., 2020). The 2022 study looking at the pilot implementation of WHS found that, collectively, of veterans with chronic pain

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6 After a prepublication version of the report was provided to VA, this paragraph was edited to more accurately describe the research study.

7 After a prepublication version of the report was provided to VA, this paragraph was edited to more accurately describe the research study.

Suggested Citation:"5 Whole Health Systems' Evidence." 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 PTSD, 40 percent used core whole health services and 53 percent used complementary and integrative health (Reed et al., 2022). Use was slightly lower for veterans with chronic pain only, with 28 percent using core whole health services and 40 percent using complementary and integrative health.

In the 2022 evaluation which compared 1,554 veterans who used WHS services to 1,712 who only used conventional care, veterans using WHS services reported greater improvements in the quality of their interactions with VA providers, particularly the interactions that included discussions of personal health goals, and they reported higher levels of engaging in healthy behaviors and participating in health care decisions.8 The researchers also noted that there were “small improvements in overall meaning and purpose in life, especially among the veterans with chronic pain who utilized comprehensive WHS services” (Bokhour et al., 2022, p. 9) as well as slight improvements after 6 months in their self-reported quality of life and well-being compared with veterans who received conventional care.9 Users of WHS services improved more than those who received conventional care according to the Perceived Stress Scale, which measures an individual’s ability to manage the challenges associated with chronic illness (Bokhour et al., 2022). Small improvements in mental and physical health also occurred, although veterans who received conventional care experienced greater improvements in physical health scores than those who used WHS services. Pain scores improved for both groups, but the changes were not clinically meaningful.

Veterans with chronic pain who used WHS services had a larger overall decrease in the average morphine-equivalent dose of opioids than veterans who received conventional care. During the study, opioid use fell among all veterans as a result of national VA efforts to reduce opioid use. Opioid use among veterans classified as either core WHS comprehensive or core WHS intensive users fell by 38 percent (95% confidence interval [CI]: –60.3 to –14.4); those classified as complementary and integrative health intensive users fell by 26 percent (95% CI: –30.9 to –18.4), and the full group of veterans who used any two or more WHS services fell by 23 percent (95% CI: –31.9 to –6.5). Opioid

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8 After a prepublication version of the report was provided to VA, this paragraph was edited to more accurately describe the research study.

9 Experience with care was measured using CARE (Bikker et al., 2015; Mercer et al., 2004); CollaboRATE (Barr et al., 2014). Satisfaction-with-care questions were adapted from the VHA survey of health experiences of patients; questions about goals were developed internally by VHA. Process questions developed internally were measured using the Patient-Reported Outcomes Information System (PROMIS-10), physical and mental health subscales, and the Perceived Stress Scale (PSS). Engagement with care was measured using the ACE-C and ACE-N (Altarum Consumer Engagement, Commitment and Navigation subscales) (Duke et al., 2015). Meaning and purpose were measured using the LET (Life Engagement Test)(Scheier et al., 2006) and the Institute for Heathcare Improvement’s 100 Million Healthier Lives (Kottke et al., 2016). Well-being was measured using the PROMIS-10 physical and mental health subscales (Hays et al., 2009) and the PSS (Ezzati et al., 2014).

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

use among veterans who used only conventional care services fell by only 11 percent (95% CI: –12.0 to –9.9) (Bokhour et al., 2022).

The pilot evaluation also found that among veterans with PTSD, anxiety, or depression, those who used WHS had an increase in annual outpatient pharmacy costs of 4.3 percent versus an increase of 15.8 percent for veterans with PTSD, anxiety, or depression who did not use WHS (Bokhour et al., 2020). Similarly, annual pharmacy expenditures for veterans who took advantage of comprehensive WHS rose by 4.3 percent, compared with an increase of 15.8 percent for veterans who did not use WHS. The authors noted that there were insufficient data at the time of the evaluation to determine whether WHS reduced costs, the use of more expensive care, emergency department visits, inpatient admissions, or other types of care. Unpublished data cited by the congressionally mandated Creating Options for Veterans’ Expedited Recovery (COVER) Commission found that pharmacy costs for veterans with any condition who used WHS increased 5.3 percent compared with 9.4 percent for the total veteran population (COVER Commission, 2020). This same unpublished dataset showed that using WHS was associated with a cost reduction in all service categories, except pharmacy, ranging from 12 to 24 percent.

A mixed-methods quality improvement evaluation at the San Francisco VA Health Care System found that peer coaching helped participants make incremental progress toward goals and improvements that were described as profound and life changing (Purcell et al., 2021). This 3-month study involved 65 veterans who agreed to participate in telephone surveys before and after participating in a coaching intervention. Survey instruments included demographic questions and multiple validated scales drawn from the VA’s Whole Health Evaluation Toolkit. These scales included the PROMIS-10, which measured overall mental and physical health; the Perceived Stress Scale 4 (PSS-4), which measured perceived stress, and the Perceived Health Competence Scale 2 (PHCS-2), which measured perceptions of competence to manage one’s health (Purcell et al., 2021). In addition, 42 of the subjects participated in a semistructured qualitative interview to identify helpful aspects of the program and solicit suggestions for improvements. There were improvements in 3-month versus baseline PROMIS-10 scores for mental health (12.58 vs. 11.74, p=0.006), stress (5.34 vs. 6.54, p=.003), and health competence (7.88 vs. 6.80, p=.01). Surveyed veterans reported that the veteran-driven nature of the coaching they received worked for them and that they valued the fact that the coaches were largely following the individual veteran’s lead and helped the identify realistic goals. Routine, consistent meetings were important contributors to making progress, as the veterans reported that these meetings motivated them to make changes.

An embedded randomized controlled trial at one site in Salt Lake City randomized 250 veterans with co-occurring opioid misuse and chronic pain

Suggested Citation:"5 Whole Health Systems' Evidence." 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 a Mindfulness-Oriented Recovery Program (MORE) or to group psychotherapy (Garland et al., 2022; Roberts et al., 2022). At 9 months there was a greater reduction in opioid use for the MORE group than for those receiving the supportive psychotherapy (odds ratio of reduction of 2.06: 95% CI, 1.17–3.61; p=.01) (Garland et al., 2022). At 3 months, the MORE group also had greater reductions in emotional distress on the Depression Anxiety Stress Scale (β = –0.263, p=.034) and greater self-regulation of distress (β = 0.335, p=.001) than the supportive psychotherapy (Roberts et al., 2022).

Employee Benefits from WHS Delivery

The preliminary evaluation included efforts to assess how employee involvement in the WHS affected engagement, turnover intention, and burnout (Bokhour et al., 2020).10 The researchers included a question on the 2018 and 2019 All Employee Survey that VA conducts yearly that asked employees to indicate their involvement with their facility’s WHS approach. Employees from the 18 pilot sites who indicated they had a clinical role provided responses to a multipart separate question on WHS. In 2018 and 2019, 20,701 and 21,667 employees at the 18 pilot sites responded (greater than 60 percent response rate), indicating broad representation.

This survey found that employee involvement in WHS varied across the 18 pilot sites, averaging 18 percent but with a high of 87 percent. Primary care, mental health, rehabilitation, and home/community care services had the highest involvement rates. Employees involved in the WHS spoke favorably of their workplaces, leadership, and supervisors, and they reported intrinsic motivation and a lower likelihood of burnout or leaving. Facilities with a greater degree of employee involvement in WHS had higher ratings on hospital performance and higher ratings from veterans on receiving patient-centered care (Bokhour et al., 2020).

A three-site evaluation of the VA’s national Employee Whole Health program found that implementation varied across the three sites (Shah et al., 2022). Factors that facilitated implementation included employee interest and enough staff with the time and expertise to provide complementary

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10 Using items from the All Employee Survey, the researchers created scores for drivers of engagement, a Best Places to Work engagement score, turnover intention, and burnout. These scores were based on the Federal Employee Viewpoint Survey measures for (1) drivers of engagement, representing workplace characteristics with potential to influence engagement conditions and reflect perceptions of leadership behaviors, supervisor behaviors, and self-motivation; (2) best places to work, a weighted score based on responses to questions on job satisfaction, organization satisfaction, and recommending the organization as a place to work; and (3) turnover intention, whether employees were planning to leave their job in the next year. Burnout consisted of two items asking about emotional exhaustion and depersonalization.

Suggested Citation:"5 Whole Health Systems' Evidence." 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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and integrative care for employees. The study investigators noted that the program lacked the infrastructure to evaluate program effectiveness and impact, and they recommended that the VA provide guidance on how to evaluate the program and develop solutions to increase employee participation.

Use and Implementation of the VA WHS

Several studies reported on the use and implementation of the VA WHS program (Table 5-1a). One retrospective analysis of the first 20 months of the flagship implementation found that of 559 veterans referred to WHS services, 73 percent had a service-related disability, 47 percent had nine or more medical needs, 54 percent had mood disorders, and 42 percent had PTSD (Marchand et al., 2020). Compared to VA users overall, those referred to WHS were more likely to be younger, female, of Hispanic ethnicity, a nonwhite race, and service connected. Implementation challenges included having a disproportionate number of referrals from a few clinical services (mainly primary care and WHS programs); poor initial and ongoing treatment engagement, with almost half of referred veterans not initially engaging in the WHS care; and a low average number of sessions attended. Another study conducted semistructured interviews, made observations, and carried out document analysis of 45 staff and clinicians from five design sites and one flagship site (Haun et al., 2021). The researchers concluded that implementation was a complex process but that clinicians and leadership were generally engaged and motivated to deliver WHS. The factors that influenced implementation included a progressive culture, early adopters who integrated whole health in their personal life, recognition of a change in focus of care, leadership support, resources (facilities, hiring, funding), collaboration among interdisciplinary team members, agreed-upon policies and procedures, and standardized measures.

A national organizational survey of 196 VA clinicians and 289 VA sites found that as of 2018, VA sites offered an average of five WHS approaches (range 1–23), with 63 sites offering 10 or more approaches (Farmer et al., 2021). The most frequently offered programs were relaxation techniques, mindfulness, guided imagery, yoga, and meditation. WHS was primarily offered by physical medicine and rehabilitation, primary care, and integrative/whole health clinicians and practices. A recent query of the VA billing system found that a total of 441,891 veterans used 2,930,700 of these services in 2020, representing a slight decrease from the use in 2019 (3,083,806 total visits) (Zeliadt et al., 2022). This correlates with 8.1 percent of all veterans in the VA receiving at least one WHS service. Use was highest among women (14.3 percent), patients with chronic pain (18.1 percent), opioid use disorder

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

(15.6 percent), rheumatoid arthritis (13.3 percent), obesity (12.9 percent), or a mental health condition (12.8 percent) (Zeliadt et al., 2022).

The Whole Health System of Care During the COVID-19 Pandemic

When the COVID-19 pandemic swept across the United States, implementation of the WHS was under way at the first 18 sites, along with a 3-year evaluation of the new system. As part of this evaluation, periodic interviews were to be conducted at the 18 sites to provide an opportunity to gather qualitative data regarding the program from 61 participants across the sites (Dryden et al., 2021). During the pandemic, while in-person WHS services were canceled, many sites shifted to online provision of patient services. The findings from this descriptive study reflect how the pandemic highlighted the need for health care to address patient well-being and how the VA WHS was able to use virtual technology to promote self-care, reduce stress, and support the well-being of veterans. Overall the sites embraced the WHS approach during the pandemic, conducting patient wellness calls and, for patients and employees, promoting complementary and integrative health therapies, self-care, and other concepts to combat stress and support well-being during the pandemic (Groves et al., 2022). VA medical centers converted in-person programs to telehealth offerings. By the end of 2020 nearly one-third of the monthly in-person visit volume was provided through telehealth for therapies including core whole health services, yoga, tai chi/qi gong, meditation, biofeedback, guided imagery, and hypnosis (Zeliadt et al., 2022).

Ongoing Evaluations of the VA WHS

Multiple evaluations of the WHS are currently under way at the VA. A commissioned paper for the committee by Denise Hynes identified 17 funded projects addressing whole health, 51 addressing coaching, and 97 addressing care coordination.11 The committee also identified other publications of evaluation protocols, and the committee expects that findings from the full 3-year evaluation of the flagship implementation will be published in the future as well (Haun et al., 2019; Seal et al., 2020).

SOUTHCENTRAL FOUNDATION’S NUKA SYSTEM OF CARE

The Southcentral Foundation’s (SCF’s) Nuka System of Care (“Nuka”) is an Alaska Native–owned, nonprofit federally qualified health center (FQHC) serving nearly 65,000 Alaska Native and American Indian people

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11 Denise Hynes’ commissioned paper is available at https://doi.org/10.17226/26854.

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

living in Anchorage, Matanuska-Susitna Borough, and 55 rural villages in Alaska. Nuka uses a person-centered, relationship-based, customer-owned system of care to reduce costs and improve outcomes (Gottlieb, 2013; SCF, 2017). In 1998, SCF began managing primary care, which was previously overseen by the Indian Health Service. The following year, SCF entered into a co-ownership and co-management agreement with the Alaska Native Tribal Health Consortium to take over the Alaska Native Medical Center (SCF, 2017).

The goal of the Nuka model is to achieve physical, mental, emotional, and spiritual wellness for its customer-owners. As Chapter 4 explains, based on the information that the committee could find, Nuka’s system design explicitly addresses four of the committee’s five foundational elements of whole health. It provides comprehensive and holistic services, offering primary care, in both outpatient and home settings, as well as dentistry, outpatient behavioral health, residential behavioral health, traditional healing, complementary medicine, and health education. Care is extended to all residents via in-person and telehealth modalities—even reaching remote locations by air or boat. Nuka is people-centered, using a patient-centered medical home approach, and embraces integrated, whole person care through cooperative alliances with services and organizations beyond the practice setting to meet the complete range of needs for the patient population (Martin et al., 2004). It addresses upstream factors and offers a variety of housing, financial, nutrition, and employment programs and services (SCF, 2022), informed in part by information on social determinants of health in the Nuka EHR which allows clinicians to track upstream factors and better understand the context of the customer-owners’ lives.

As an FQHC, Nuka is required to comply with several equity and accountability features in its operations. Care is provided on a sliding fee scale, ensuring guaranteed access to customer-owners who may not have insurance coverage. Additionally, at least 51 percent of its governing board members must be individuals receiving their care in the system, which helps ensure that user input governs the system. Nuka must also complete annual reviews of its catchment area and needs assessments every 3 years to ensure that services are designed to meet the specific needs of its customer-owners. Universal empanelment also helps ensure that clinical teams are accountable to the customer-owners under their care. Regarding team well-being, Nuka has taken steps to improve team functioning, although it is unclear from the published literature if Nuka systematically measures burnout and wellbeing or if it considers evidence-based, systematic approaches to minimizing burnout of clinical teams.

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

Evidence Summary

The Nuka System of Care represents a shift from traditional government-managed tribal health care. Three studies reported in five manuscripts compare outcomes in the Nuka system of care with the government-managed care offered prior to 1996 and describe changes in quality and outcomes measures over time using billing, administrative, and EHR data (see Table 5-2) (Blash et al., 2011; Driscoll et al., 2013; Gottlieb, 2013; Johnston et al., 2013; SCF, n.d.). Compared with the prior system of government managed care, the Nuka system substantially improved access to care in 2013 and resulted in an increase in the proportion of people seeing a primary care clinician from 35 to 95 percent, a reduction in wait time to see a primary care clinician from 4 weeks to same-day access, and a reduction in people on the behavioral health waitlist from 1,300 people to none. Concurrently, multiple quality measures improved across multiple time periods, including an increase in the proportion of people with diabetes having gotten an A1c measurement in the year prior, from 78 percent in 2007 to 92 percent in 2009; an increase in childhood immunization rates, from 80 percent in 1998 to 93 percent in 2006; and increased colorectal screening rates, from 49 percent in 2008 to 59 percent in 2009. Health outcomes also improved, with a 42 percent reduction in emergency room use, a 36 percent reduction in hospital days, and a 58 percent reduction in specialist use. Monthly emergency room use overall decreased annually from 2000 to 2006 (p<.001) and then leveled off after 2006. As a result, the proportion of people with one or more emergency room visits in a month decreased from 7.6 percent in 1996 to 5.8 percent in 2009 (p value not reported), and the proportion of people with one or more hospital admissions in a month decreased from 0.9 percent in 1996 to 0.7 percent in 2009 (p<.001). During this time period, staff retention improved from 60 percent in the early 2000s to 83 percent in 2012, suggesting improved team well-being.

A fourth study looked at 90 Alaska Natives and American Indians who participated in a whole health program to address adverse life experiences (Ray et al., 2019). A retrospective analysis of EHR data compared outcomes for program participants with 90 propensity-matched people who participated in other wellness programs. Participation in the whole health program resulted in statistically significant reductions in total system visits (incidence rate ratio 0.64, 95% CI 0.49–0.84) and substance use visits (incidence rate ratio 0.30, 95% CI 0.10–0.93), and a non-statistically significant trend toward reduced emergency room visits (incidence rate ratio 0.60, 95% CI 0.35–1.02) (Ray et al., 2019).

Suggested Citation:"5 Whole Health Systems' Evidence." 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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KITSAP MENTAL HEALTH SERVICES

In January 2013, a community mental health center in Kitsap County, Washington, implemented a program to address concerns about inadequate general medical care and poor self-management for people with mental illness, which was called Race to Health! (Bouchery et al., 2018). The program follows a whole health model and addresses all aspects of a person’s health, including mental health, substance use, and nonpsychiatric health needs. Implementing the program involved redesigning the system’s infrastructure and care delivery model and training staff to address a person’s whole health. Staff were reorganized into multidisciplinary care teams including a psychiatrist, a psychiatric nurse, bachelor’s-level case managers, master’s-level therapists, and co-occurring disorder specialists. Medical assistants supported each care team by collecting medical data, coordinating care between the Kitsap staff and a person’s primary care clinician, coaching people on issues related to nonpsychiatric health needs, and assisting with wellness groups. Resources were invested to expand the EHR system to include data on nonpsychiatric health conditions, medications, and emergency visits. Care teams used data to identify people with health risks in order to engage them in wellness services and to identify people with emergency visits in order to provide them with more intensive care coordination with other social service providers.

Evidence Summary

In a pre–post comparison, 846 people enrolled in the Race to Health! program were compared with a matched observational cohort of 2,643 participants not enrolled in a similar program (see Table 5-3) (Bouchery et al., 2018). Using Medicare claims data, the investigators conducted a difference-of-difference analyses of the first 2.5 years of the program and found a reduction in Medicare expenditures by $266 per month (p<.01) as well as 0.02 fewer hospitalizations per month (p<.01), 0.03 fewer emergency visits per month (p<.01), and 0.13 fewer office visits per month (p<.04).

ADVANCED CARE FOR THE ELDERLY (ACE) PROGRAMS

A series of programs for older adults to help people meet their health care needs in the community instead of going to a nursing home or other care facility have been developed and tested. These programs include the Program of All-Inclusive Care for the Elderly (PACE)(CMS, 2021), the Geriatric Resources for Assessment and Care of Elders (GRACE) program (Counsell et al., 2006), and the House Calls program (Melnick et al., 2016). The PACE program is further detailed in Chapter 4. In these programs,

Suggested Citation:"5 Whole Health Systems' Evidence." 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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comprehensive medical and social care is delivered by an interdisciplinary team of health care providers. Team members often meet daily to discuss the medical and social needs of participants. The advanced care programs are typically intended for older adults who are eligible for nursing home care but can safely live in their home. The programs generally target low-income seniors, and most participants are dual eligible for Medicare and Medicaid. Programs provide all necessary health care services to beneficiaries using a capped financing model (Arku et al., 2022). Comprehensive and holistic services include conventional medical services (primary care, specialty care, hospital care, emergency services, prescription drugs, laboratory and radiology services, physical therapy, occupational therapy), complementary and integrative medicine (recreational therapy), and programs aimed at upstream factors (adult day care, home care, meals, nursing home care, nutritional counseling, social services, transportation). Programs additionally may include in-home assessments, the use of specific care protocols for the evaluation and management of common conditions, the use of an integrated electronic medical record and care management tracking tools, and integration with pharmacy, mental health, home health, and community-based and inpatient geriatric care services (Counsell et al., 2007).

Evidence Summary

A randomized controlled trial, a case-control study, an observation cohort, and a scoping review provide key evidence on the GRACE, House Calls, and PACE programs (see Table 5-4). The first study was a randomized controlled trial that compared 474 low-income seniors randomized to receive home-based care in a GRACE program in Indiana versus 477 low-income seniors who continued to received usual care (Counsell et al., 2006, 2007, 2009). Overall, the 2-year emergency room visit rate per 1,000 was lower in the intervention than in the control group (1445 [n=474] vs. 1748 [n=477], p=.03), but hospitalization rates were not different. However, in a predefined high-risk group of seniors, both emergency room visits (848 [n=106] vs. 1,314 [n=105]; p=.03) and hospital admission rates (396 [n=106] vs. 705 [n=105]; p=.03) were lower for the intervention group in the second year of the program. Four of eight SF-36 scales improved more for the seniors in the GRACE program than with those given usual care [general health (0.2 vs. -2.3, p=.045), vitality (2.6 vs. -2.6, p<.001), social functioning (3.0 vs. -2.3, p=.008), and mental health (3.6 vs. –0.3, p=.001)]. The mean 2-year total costs were not significantly different for the study overall group and for high-risk seniors, but the costs were higher in the low-risk seniors randomized to receive the GRACE program compared with usual care ($13,307 vs. $9,654; p=.01). A second study used a case-control design to compare 179 senior veterans discharged from acute

Suggested Citation:"5 Whole Health Systems' Evidence." 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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hospitalization who received a veteran-centric care plan and support from a GRACE team versus 77 matched hospitalized veterans who received usual care at discharge between 2010 and 2011 (Schubert et al., 2016a). Veterans who received GRACE care after discharge had 28.5 percent fewer bed days in the hospital in the following year than veterans receiving usual care (p=.01). There were non-statistically significant trends towards a reduction in emergency visits (7.1 percent, p=.59), 30-day readmissions (14.8 percent, p=.19), and total hospitalizations (p=.14) as well.

An observational cohort analysis followed 7,925 high-risk, high-cost patients enrolled in the California House Calls program after hospital admission between 2009 and 2013 (Melnick et al., 2016). Comparing 6 months before enrollment, 6 months after enrollment, and 6 months after disenrollment, there were sustained reductions in emergency visits per person (0.46 vs. 0.21 vs. 0.08), hospital days per 1,000 people (680 vs. 286 vs. 100), and health care spending ($1,768–2,673 vs. $965–1,362 vs. $326–453).

A scoping review of the PACE program funded by the Centers for Medicare & Medicaid Services identified six studies with 4,826 people who received PACE care and 7,920 people in comparison groups (Arku et al., 2022). All studies compared people receiving care through other non-PACE Medicare programs (e.g., Wisconsin Partnership Program, Medicaid long-term care, Visiting Nurse Service, Veteran’s Affairs, or nursing home care). The review found mixed results. Two of three studies found that PACE participants had worse or declining activities of daily living, while the third showed improvement. Two of three studies found PACE participants to have had less hospital use, but the third showed no difference. Both studies that measured use of service found an increased use of community-based services and adult day center visits. One study that evaluated pain, discomfort, or depression found no difference in outcomes. One of three studies showed increased mortality with PACE participation, another showed no difference, and the third showed longer survival with PACE.

MARY’S CENTER

As described in Chapter 4, Mary’s Center, established in 1988 and recognized as an FQHC in 2005, primarily serves women and children, immigrants, low-income individuals, and uninsured or underinsured individuals across Washington, D.C., and Maryland. Mary’s Center emphasizes wraparound services for clients, such as English as a second language, job training, and behavioral health services, and it has a unique partnership with Briya schools to provide educational opportunities (Mary’s Center, n.d.). Mary’s Center serves over 55,000 individuals across five community health centers and two senior wellness centers. The center also provides integrated

Suggested Citation:"5 Whole Health Systems' Evidence." 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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behavioral health in each center and in area public schools, and it deploys mobile units and pods to extend dental, imaging, HIV, sexual health, and COVID-19-related services (Galvez et al., 2019; Martinez et al., 2020). Mary’s Center refers to those individuals it serves as “participants,” encouraging and endorsing active participation in one’s own care and recognizing that the term “patient” inadequately characterizes program participants. Program participants coming from roughly 50 different countries partner with employees who come from 40 countries and speak over 35 languages.

Mary’s Center ensures that it has direct input from its participants by having a patient-majority board of directors (a requirement of its FQHC certification), a monthly community engagement council meeting, and an external company to continuously survey patients on their experiences. Mary’s Center grounds its model in the philosophy that overall wellness depends on social and economic well-being as well as on comprehensive primary care that includes oral health and behavioral health. The model includes an integrated behavioral health approach with therapists embedded into the primary care team and regular interaction across team members plus those from on-site social services, nutrition, and health education team members. The center incorporates social determinant assessment into patient care, using the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool in every participant’s EHR records to guide staff on what services are necessary for each participant and to guide care coordination and case management to assist patients in obtaining food, clothing, housing, and direct cash assistance (PRAPARE, 2022). Key partnerships with hundreds of community-based organizations provide additional resources, such as legal services and housing, as well as 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 has staff dedicated to helping its participants access benefits and entitlements, including insurance, and it participates in the 340B drug pricing program12 that provides uninsured or underinsured patients medications at a discount (HRSA, 2022).

Evidence Summary

The Urban Institute conducted an evaluation of Mary’s Center to highlight lessons learned for community health centers, medical providers, health policy makers, and others interested in addressing the social determinants of health (Galvez et al., 2019). The evaluation reviewed care for

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

Suggested Citation:"5 Whole Health Systems' Evidence." 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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55,000 people between 2009 and 2017. The Urban Institute research team collected staff, participant, and community perspectives on Mary’s Center’s history, approach, and outcomes. Data sources included a document review, online survey of over 300 Mary’s Center staff members (representing about half of all staff), and interviews or focus groups with 16 staff, 35 current and former participants, and 14 community partners(Galvez et al., 2019).

Mary’s Center is organized around primary care services, and 61 percent of people use Mary’s Center exclusively for primary care (see Table 5-5). However, there is a high level of engagement with wraparound services, and 24 percent of people receive primary care plus one or more services, while 15 percent of people receive wraparound services only. Overall, 74 percent of encounters are for primary care, 4 percent for social services, 13 percent for dental, and 10 percent for behavioral health.

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 (Galvez et al., 2019). Compared with other FQHCs, Mary’s Center ranked in the top 25 percent of FQHCs for cervical screening, child immunizations, cholesterol treatment, adolescent weight screening/follow-up, depression screening, and asthma treatment (Galvez et al., 2019). Among participants in teen after-school programs, 99 percent graduated from high school, avoided pregnancy, and attended college. The participants of the home visiting program reported “virtually no” cases of abuse or neglect after enrollment.

VERMONT BLUEPRINT FOR HEALTH

Established in 2006, the Vermont Blueprint for Health is intended to design, implement, and evaluate community-led strategies for improving health and well-being. Through the provisions of a statutory framework act in 2010, the mission of Blueprint for Health was broadened to include integrating systems of health care, improving overall population health, and improving health care cost control through prevention, care coordination, and health maintenance (Vermont Blueprint for Health, 2022). There is a central administrative core at the state level with an executive director and central office, but most of the work happens at the hospital or health service area (HSA), where administrative entities exist in each of these 13 regions to receive payments, hire and maintain community health teams, and coordinate quality improvement initiatives.

A foundation of the Blueprint model is advanced team-based primary medical homes as a locus for comprehensive and holistic care. Medical homes are aligned with National Committee for Quality Assurance patient-centered medical home (PCMH) standards and work toward continuous

Suggested Citation:"5 Whole Health Systems' Evidence." 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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quality improvement through ongoing engagement with a quality improvement facilitator at each HSA (Crabtree et al., 2010; Jaen et al., 2010; Nutting et al., 2009, 2011). Practices participating in this model receive augmented monthly payments of between $2 and $4 per person per month to implement the model (Jones et al., 2016). There are also performance payments and bonuses based on health care use and quality measure attainment. Improving patient experience and self-management approaches through enhanced medical visits and the use of community-based support resources has accentuated the focus on people-centered care. Over the last few years, the state made payment system changes aimed at moving primary care practices away from fee-for-service and toward prospective risk-adjusted payments. A statewide all-payer accountable care organization (ACO) sustains initial implementation of elements of this model, provides incentives for attainment of population health goals, and reduces cost growth (NORC, 2021).

Augmenting the move toward advanced primary care, each HSA established community health teams to support broader provision of work on upstream factors that drive community health. Community health teams support practices to identify and address the root causes of health issues through behavioral health integration and screening for the social determinants of health. The teams spend considerable effort at the HSA level to connect patients with effective community interventions, support people in managing their chronic conditions, and catalyze community-wide well-being initiatives. Community health teams include community health workers, dietitians, care coordinators, panel managers, behavioral health managers, and nurses. In addition, the community health teams are integrated into teams with a broader mandate which are intended to provide whole health service, including home-based services, food security initiatives, housing resources, and connections with other state and local agencies. HSAs receive funding from commercial and state insurance to staff these community health teams at between $2 and $3 per person per month. Given the significant and community-identified challenges around substance use disorders and access to women’s and reproductive health, Vermont Blueprint for Health has increased its emphasis on providing care in these areas (Bitton, 2022).

Community health dashboards exist for each of the HSAs and offer baseline and iterative data on population demographics as well as on the performance of the community-led strategies, providing equity and accountability. These profiles are based on data from Vermont’s all-payer claims database and other reporting systems as well as on data from commercial Medicaid and Medicare payers. Finally, through a Center for Medicare and Medicaid Innovation program, Vermont has now added a statewide all-payer ACO model to catalyze further payment and delivery transformation

Suggested Citation:"5 Whole Health Systems' Evidence." 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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with the hope of improving health and reducing spending. This program provides the flexibility for Vermont to implement an all-payer approach that moves away from fee-for-service payment toward global spending targets and prospective payment in service of whole health goals (Bitton, 2022).

Evidence Summary

A 6-year, sequential, cross-sectional analysis from 2008 to 2013 compared the annual cost, usage, and quality outcomes for people attributed to 123 practices participating in the program versus a comparison population from each year attributed to nonparticipating practices (Jones et al., 2016). After the second year, people seen in participating practices had significantly higher rates of adolescent well-care visits, breast cancer screening, cervical cancer screening, appropriate testing for pharyngitis, and, for people with diabetes, eye exams, A1c testing, lipid testing, and nephropathy screening. The rates for imaging for low back pain, treatment of upper respiratory infection, and well-child visits were not significantly different (see Table 5-6). A financial analysis using a difference-in-difference approach revealed statistically significant reductions of approximately $482 in total medical expenditures per person for model participants, with the savings driven primarily by decreases in inpatient spending (Jones et al., 2016). As was intended, Medicaid beneficiaries had a statistically significant higher rate of spending on social, dental, and community-based support services (Jones et al., 2016). Overall expenditures over a 2-year period fell by $104.4 million, driven largely by reduced spending for inpatient care, and total expenditure decreased by $5.8 million for every $1 million spent on the program.

NATIONAL INTREPID CENTER OF EXCELLENCE

The U.S. Armed Forces is the world’s third largest military and has deployed 2.8 million troops since September 11, 2001, for operations Enduring Freedom, Iraqi Freedom, and New Dawn (DeGraba et al., 2020). This extensive troop deployment has led to an unmet need within the military and civilian health delivery systems to help veterans with traumatic brain injury (TBI) and comorbid psychological health conditions (Inoue et al., 2022). The Department of Defense established the National Intrepid Center of Excellence (NICoE) in 2010 to meet the needs of service members of all branches, including the National Guard and reserves (DeGraba et al., 2020). NICoE treats service members with comorbid TBI and psychological health conditions that have not responded to previous treatment or for whom extensive treatment options are not available at their home stations. The program is further detailed in Chapter 4.

Suggested Citation:"5 Whole Health Systems' Evidence." 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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NICoE is an interdisciplinary intensive outpatient program. It combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness (Singman, 2021). Those who are referred to the program have a robust intake evaluation from the interdisciplinary team, including a head-to-toe evaluation and state-of-the-art screenings and imaging (Foote and Schwartz, 2012). After a period of comprehensive care, NICoE then works to successfully transition the service member back to their home station. A discharge summary with all evaluations, treatments, treatment plans, and goals is provided to the patient and clinician (Ayer et al., 2015). Care at NICoE differs from conventional care in that it includes alternative treatment options, such as group counseling, psychoeducation, yoga, tai chi, and canine programs (DeGraba et al., 2020).

Evidence Summary

In 2013 researchers fielded surveys and conducted site visits and interviews with 184 clinicians and 311 former NICoE patients from the Bethesda, Maryland center (Table 5-7). Respondents reported that NICoE treats the most severe cases and that a disproportionately large number of those referred are active service members, especially Navy SEALs and other special forces, who require more discretion and deploy more frequently (Ayer et al., 2015). Patients expressed low levels of satisfaction with their usual source of care prior to referral to NICoE due to long wait times for appointments, staff shortages, and having no access to complementary and alternative medicine treatment modalities. Patients expressed positive opinions about the value of care, the facility’s care model, and the involvement of family members in care. Referring clinicians from smaller rural sites, who provided usual care, viewed NICoE as an extremely valuable resource, although many other usual-care clinicians did not perceive a significant difference between the type of services offered at home stations and NICoE. Usual-care clinicians gave positive feedback on discharge planning process but noted some gaps in communication about patient progress while treatment was being delivered.

In a prospectively planned pretest–posttest analysis of people referred to the program from 2011 to 2019, 91 percent of people consented to include their data in the analysis (Table 5-7) (DeGraba et al., 2020). There were statistically significant and clinically meaningful improvements in differences across seven symptom inventories administered to all participants. Benefits were maintained for all but one outcome measure at 1, 3, and 6 months after discharge from the program. The symptom inventories included the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Military (PCL-M), Satisfaction With Life Scale (SWLS), Patient

Suggested Citation:"5 Whole Health Systems' Evidence." 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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Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6).

NEW ZEALAND’S CANTERBURY HEALTH PATHWAYS

The Canterbury, New Zealand, district health board plans and provides services using a whole health system approach in partnership with health service providers, communities, and the wider New Zealand governmental agencies. It aligns itself with a clinical care network, a charitable trust, and an alliance of district health boards across the South Island of New Zealand. Its mission is to create and improve a health system and community of people taking greater responsibility for their own health, staying well in their homes and community, and receiving timely care.13

Canterbury’s journey toward integrated care began in 2007 after it had experienced bottlenecks in acute inpatient and emergency department care (Timmins and Ham, 2013; World Bank and WHO, 2019). Primary care physicians and general practitioners were a main early focus of this work, which used new agreed-upon clinical standards and referral pathways as well as district-level support outside of practices. These new services were built around a contracting alliance for standard care protocols as opposed to the previous fee-for-service visit billing. Canterbury is well known for HealthPathways, a set of approaches based on consensus-based agreements about best practices for person-centered and comprehensive care created among general practitioners, specialists, and hospital providers (Timmins and Ham, 2013). Initially developed as a focused project to reduce referral waiting time, HealthPathways has grown to be the centerpiece of an integrated approach to health which includes resources and practitioners outside of conventional medical care and inclusive of other realms where health is created (Figure 5-1).

The HealthPathways approaches are a centerpiece of comprehensive and holistic care in the system. Consumer, patient, and community perspectives informed their development and management, and these, along with a clear vision concerning improved self-management of health, make them a paragon of people-centered care. Furthermore, after the creation of the agreements and pathways below, much effort was given to enumerating and supporting team well-being across the care continuum. The pathways have increasingly but not substantially started to focus on upstream factors by including a whole-of-government approach aligned with the national health strategy. Their greater focus on equity is apparent, especially for Māori and Asian populations, though much work remains to be done.

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13 Additional information is available at https://www.cdhb.health.nz/about-us/vision-mission-values/ (accessed December 13, 2022).

Suggested Citation:"5 Whole Health Systems' Evidence." 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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Image
FIGURE 5-1 Pictogram of health care system in Canterbury.
SOURCE: Timmins and Ham, 2013.
Suggested Citation:"5 Whole Health Systems' Evidence." 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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Evidence Summary

Several observational studies compared the performance of the New Zealand Canterbury system with other regions of New Zealand between 2008 and 2017 (see Table 5-8) (Gullery and Hamilton, 2015; McGeoch et al., 2019; World Bank and WHO, 2019). These studies report that there are between 15,000 and 35,000 people referred to the program per year. Between 2008 to 2014 the acute demand management system resulted in a 30 percent lower annual hospitalization rate in Canterbury than in New Zealand as a whole, and the timely discharge to rehabilitative services resulted in a 14 percent reduction in long hospital stays (over 24 days) for people over 75 years old. Compared with before the program started, there was a reduction in the surgical waitlist, as more people were able to access needed care. Additionally, more people over the age of 75 years were able to age in their home, resulting in a reduction in the proportion of people living in care homes from 16 to 12 percent between 2006 and 2013 (Gullery and Hamilton, 2015). Benefits were partially attributable to improved primary care workups and an increased speed of diagnosis by using HealthPathways (Timmins and Ham, 2013), and HealthPathways has now been deployed to more than 23 systems across Australia and New Zealand, highlighting the program’s success and perceived value (Gullery and Hamilton, 2015).

AUSTRALIA: SOUTH AUSTRALIA HEALTH IN ALL POLICIES/INTEGRATED CARE ADELAIDE

South Australia is an Australian state with a population of 1.6 million people predominantly living in and around Adelaide. It has a relatively high life expectancy and health outcomes, though notable inequities exist especially among its Aboriginal and Torres Strait Islander populations. Based on previous work done at both the WHO and the European Union on the concept of Health in All Policies (HiAP), the South Australian government adopted an HiAP model that built on its history of public policy experimentation and innovation (Baum et al., 2019). In 2007 the Department of Health and Ageing established a dedicated department and sequentially created a set of HiAP processes (Baum et al., 2019). Links were made between the executive premier’s office and the Department of Health and Ageing in order to coordinate intersectoral processes and policies (Government of South Australia and WHO, 2017). Key steps in establishing this HiAP approach were endorsement at the executive level followed by a set of agreements staking out shared responsibilities and collaborations and the creation of the cabinet-level task force on key priorities (Government of South Australia and WHO, 2017).

Suggested Citation:"5 Whole Health Systems' Evidence." 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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In 2011 the South Australian Public Health Act offered new governance mechanisms and legislative pathways for the HiAP unit to create additional levers and formalize cross-sector collaboration around upstream factors that affect health (Williams and Galicki, 2017). Further work established performance and accountability mechanisms for this work and assigned them to the chief executive branch. The HiAP office was staffed using relatively small amounts of funding totaling less than $1 million per year (Baum et al., 2019). The office’s areas of focus included upstream factors to address social determinants of health within and outside of the formal health care sectors. In addition, communities of practice were established along with policy impact evaluation capacities (Government of South Australia and WHO, 2017). Work conducted by the HiAP office included establishing improved licensing mechanisms for Aboriginal drivers in order to offer wider driving training and reduce the unlicensed driving that had been associated with higher road accidents (Government of South Australia and WHO, 2017). Other projects included working with business communities on sustainable regional community development with mining entities and establishing broader investments in healthy park systems for outdoor recreation with the environmental department. Later areas of focus included access to more nutritious food for children along with new approaches to incorporating health and well-being planning into urban environments (Williams and Galicki, 2017). This iterative approach to intersectoral policy making that incorporated a health lens but was not bound to a health care approach resulted in a number of clearly documented policy changes across a variety of sectors (Baum et al., 2019).

In parallel, the South Australian government invested in integrated care services by adopting best practices from inside and outside of Australia and by creating an independent government agency in 2020 known as Wellbeing SA to lead cross-government and cross-sector strategies concerning health and prevention. In some ways this agency grew out of the HiAP approach, but it also represented further integration with established health care systems and a focus on partnering, prioritizing, and delivering evidence-based approaches to improve the integration of community-based health care and improve overall population health (Wellbeing SA, 2022). Currently, its specific areas of action are in mental health and suicide prevention, integrated care for chronic disease, and maternal health. Integrated approaches for comprehensive and holistic care include adapting the HealthPathways models from New Zealand to the South Australian context and creating advanced primary care practice capacity and networks (known as health care homes) to provide better coordinated, more supportive people-centered care. Finally care integration is promoted through care connection models to improve coordination across the continuum of care and through home

Suggested Citation:"5 Whole Health Systems' Evidence." 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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hospital models to deliver acute care services at home instead of in the hospital.

Evidence Summary

The evaluation of the South Australian model has focused more on the outcomes for HiAP than on the integrated health care services (see Table 5-9). A mixed-methods evaluation consisting of qualitative analysis, quantitative analysis, policy analysis, and survey instruments was conducted between 2012 and 2016 with the results reported in three publications (Baum et al., 2019; van Eyk et al., 2017; Williams and Galicki, 2017). Data sources included 918 public servant interviews, 5 document reviews, 144 key informant interviews, and 2 workshops. Investigators reported an increase in public servants’ awareness of the health impacts of their agencies’ policies. Of participants, 55 percent reported that they better understand the link between their department and social determinants, and 53 percent agreed that collaborations between policy and health increased their understanding of equity. However, participants said that the initial intentions to address equity were only partially enacted and that little was done to reduce inequities due to government narrowing its priorities to economic goals. Using a program logic model to identify and organize the data against the three most relevant components of the model that link to the anticipated program outcomes, the authors report likely improved overall population health (Baum et al., 2019). Other governmental reports also came to similar conclusions (Williams and Galicki, 2017).

SPAIN’S BASQUE COUNTRY INTEGRATED CHRONIC CARE MODEL

The Basque Country is an autonomous community in Northern Spain with a population of approximately 2.2 million people. Health organization and planning powers rest with the Ministry of Health, while the provision of public health care services is the responsibility of the Basque Health Service known as Osakidetza. In 2010 the health system created an integrated care strategy to manage the challenge of rising chronic diseases, focusing on five areas: (1) a population health approach that used risk stratification methods to identify targeted patients with chronic conditions; (2) prevention and health promotion efforts aimed at addressing risk factors for these common prioritized chronic conditions such as heart failure, diabetes, and chronic obstructive pulmonary disease; (3) an emphasis on self-management approaches to achieve better self-care in the community using a patient autonomy framework as well as patient networks of people who shared conditions in common; (4) integrated EHRs, along with

Suggested Citation:"5 Whole Health Systems' Evidence." 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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standardized care pathways, referral mechanisms, and connections to social care, accentuating both continuity and coordination of care; and (5) electronic visits and e-prescriptions, which allowed more connection to patients in the community and research on care innovations to occur (Rosete and Nuno-Solinis, 2016).

By the end of the first phase of integration, a total of 13 integrated health organizations had been built across the Basque Country. The integration efforts focused primarily on making people-centered care more available throughout the Basque Country, and they used novel organizational and funding mechanisms to provide a wider array of comprehensive and holistic care, particularly for patients with complex needs. Complex care management and the transitions of care strategies were emphasized, and more comprehensive approaches were taken inside and around primary care settings to improve the continuity and coordination of care in the five areas identified above. Both centralized and local approaches were used iteratively in recurrent cycles of quality improvement (Polanco et al., 2015).

Evidence Summary

Three studies in five publications describe the outcomes of implementing the integrated care model (see Table 5-10). The first was a case study of the Bidasoa Integrated Health Organization (Polanco et al., 2015; Rosete and Nuno-Solinis, 2016). In this evaluation, 80 to 122 clinicians were surveyed annually between 2010 and 2013, and organizational quality metrics were compared pre- and post-implementation (2014 vs. 2011). Clinicians reported improvements over time in the organization of health systems, the health care model, self-management, clinical decision support, information systems, shared goals, the patient-centered approach, mutual knowledge, trust, strategic guidelines, and shared and supportive leadership. However, they did not report improvements in community health. Clinical quality measures showed that over 4 years, hospital admissions fell by 7 percent, and hospital readmissions decreased by 24 percent. Specifically, there was a 16 percent reduction in adverse event admissions, 10 percent reduction in ambulatory care sensitive admissions, and a decrease in mental health hospital readmissions within 30 days from 16 to 7 percent (Polanco et al., 2015; Rosete and Nuno-Solinis, 2016). These improvements were even more pronounced in patients with chronic or multiple complex conditions, with a 38 percent reduction in hospital use and a 31 percent reduction in adverse event admissions.

A second evaluation used a quasi-experimental design and compared 200 patients with complex needs, age 65 years and older, with two or more chronic conditions who were registered in four health systems that implemented the Carewell program with matched patients in two health systems that had not implemented the program (Mateo-Abad et al., 2020). Patients

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

from the Carewell health systems had fewer emergency room visits (0.3 vs. 1.3 percent, p<.001), more primary care visits (12.2 vs. 9.6, p=.041), and more phone meetings (6.7 vs. 3.6, p=.002). There were also non-statistically significant trends toward reductions in weight, glucose, and blood pressure.

During the COVID-19 pandemic, interviews with 20 system stakeholders indicated that health integration processes that have been in place for nearly a decade resulted in improved resilience and flexibility of the health care system in the face of health shocks (Izagirre-Olaizola et al., 2021). The integration of primary care into the program was key for success, but primary care needed even more resources than it had been allocated. Telehealth allowed for more care delivery. Despite growing social needs, social care remained poorly integrated into the model.

GERMANY’S GESUNDES KINZIGTAL MODEL

Gesundes Kinzigtal is a health care management company in the Southwest German Black Forest area that was launched in 2005 to care for members in its region. The company is structured as a cooperative agreement among a large physician network called MQNK, a health management and services company called OptiMedis AG, and two large statutory health insurers in the region (Hildebrandt et al., 2010). The Kinzigtal model focuses on integrating health and social services through a novel private partnership to improve patient experience and population health outcomes and to reduce the overall cost of care. The Kinzigtal entity allows the two insurers and the health care management company to establish contracted shared savings initiatives to provide incentives to better manage care, improve cross-sector integration, and reward improved outcomes instead of usage volume (Marill, 2020).

A majority of doctors in the area and about one-third of eligible patients participate in the program (Marill, 2020). Cost benchmarks which include all national age and health-adjusted costs help mitigate the risk of selecting healthier patients into the program. The success of the program has allowed investments in non–health care infrastructure to promote comprehensive and holistic care such as gyms, health academies where patients engage in education classes, and group sessions for amplifying the ability of people to manage common chronic conditions together outside of the medical arena. The doctor network has incentives to stay involved, such as the doctors’ two-thirds stake in the company. Physicians have used the savings to build extra time into their schedule to engage in broader conversations around shared decision making as well as to hire other health professionals such as nurses, physiotherapists, and social workers to help patients achieve their self-management goals (Marill, 2020). In fact, team well-being has been

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

an important emphasis of the initiative. However, its voluntary basis and position in a relatively wealthy region of Germany means that a focus on community equity has not been the mainstay of the program. Furthermore, while there is connection to integrated social services, there has been less emphasis on addressing upstream factors through intersectoral approaches aligned with government or other areas, although health behavior and mental health needs are an important part of the program.

Evidence Summary

Five key publications review the use of the Gesundes Kinzigtal program and its impact on quality, hospitalizations, and cost (see Table 5-11). An early evaluation on the use of the program reported that in 2010 about 31,000 of the 60,000 residents of Kinzigtal participated in one of the Gesundes Kinzigtal insurance programs and 6,870 residents had enrolled in the integrated care model (Hildebrandt et al., 2010). The numbers of members who enrolled by program included heart failure (67), lifestyle intervention (122), smoking cessation (128), active health for elderly (511), therapy for personal crisis (126), prevention osteoporosis (455), social case management (78), diabetes (830), coronary artery disease (288), breast cancer (18), asthma (100), chronic obstructive pulmonary disease (154), patient university (1,070), and nursing home medical care (124). Despite success in this region, there was poor dissemination to other regions in Germany until 2017 when the program was extended to two low-income neighborhoods in Hamburg which have a large immigrant population, a high rate of chronic disease, and low health literacy (Marill, 2020).

Two independent analyses compared outcomes for people in the Gesundes Kinzigtal program with people in other regions of Germany who were insured by the same insurer but not in the integrated care model (Schubert et al., 2016b, 2021). The first study, which reported on results between 2004 and 2011, found greater improvements in two of five indicators of overuse (long-term NSAID use and inappropriate medications for vascular dementia) and greater improvements in 2 of 10 indicators of underuse (antiplatelet drugs for heart disease and diabetes patients with eye exams) (Schubert et al., 2016b). Additionally, from 2007 to 2011 people in the integrated care program had a lower risk of osteoporotic fracture (hazard ratio [HR] 0.81; 95% CI: 0.74–0.89; p < .001) and a lower risk of death (HR 0.94; 95% CI: 0.90–0.99; p < .019) than the comparison group, but no difference in preventable hospitalizations. The second 10-year evaluation, carried out between 2006 and 2015, found that out of 101 quality indicators there was no difference seen for 88 indicators, positive differences seen for 6 indicators, and negative differences seen for 7 indicators for people in the integrated care model versus those not in the program (Schubert et

Suggested Citation:"5 Whole Health Systems' Evidence." 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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al., 2021). The authors concluded that, overall, there was neither a positive nor negative trend in health care indicators seen over time compared with the control group. However, in the setting of notable shared savings and reduced cost, the fact that there was no decrease in quality compared with more expensive usual care may be significant.

A case study describing the successes of the program reported a net savings of almost $20 million from 2007 to 2018, decreased avoidable hospitalization rates, and increased life expectancy (Marill, 2020). However, the magnitude of benefit and statistical significance were not reported, and the original studies referenced were in German and were not verified. In 2013 and 2015, over 3,000 integrated care model program members were surveyed about their experiences, with about one-quarter completing the survey (Siegel and Niebling, 2018). Over 90 percent of surveyed participants said they would likely or would definitely recommend this model to others. From 2013 to 2015 patient satisfaction and quality of life (measured by EQ-5D) were both very high but did not change over the 2-year period. The proportion of respondents who felt they lived an overall healthier life did increase over the 2 years from 25.6 30.7 percent (p=.020), consistent with a model focus on patient activation and motivation for better self-care (Siegel and Niebling, 2018).

COSTA RICA’S EBAIS COMMUNITY-BASED PRIMARY CARE MODEL

Costa Rica is an upper-middle-income country in Central America with a population of approximately 5.1 million people. In 1994 the Equipo Básico de Atención Integral de Salud (EBAIS) model was started (VanderZanden et al., 2021). This approach builds multidisciplinary care teams assigned to a geographically empaneled group of people in each area across the country. Each team includes a doctor, a nurse, a technical assistant who acts as a community health worker, a medical clerk, and a pharmacist who provide comprehensive acute, chronic, and preventive care, both at a clinic and in homes within the community. The average team cares for approximately 4,500 patients and is located within a health area that serves between 30,000 and 100,000 people (Pesec et al., 2017). EBAIS teams conduct regular proactive population outreach, visiting each household at least once a year to conduct social, demographic, and other health needs surveys as well as to register patients and their families in a geolocated electronic health record that is available on mobile platforms in a secure manner (VanderZanden et al., 2021). This integrated health record is used to help track and improve the care journey for patients as they access people-centered care across each different layer of the health care system. In addition, the integrated record stores both health care and social information, often

Suggested Citation:"5 Whole Health Systems' Evidence." 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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enabling teams to be able to jointly address both health care and upstream factors in their visits either at home or in the clinic (PHCPI, 2022).

EBAIS teams also regularly conduct health education and integrated social referrals with other social agencies, enabling the patients and communities to have a single point of contact for most of their health and social needs. The model, which has been continually improved over the past three decades, is able to provide comprehensive and holistic care for the entire population, including previously marginalized members of Indigenous communities who live in rural areas and undocumented migrants who live primarily in your urban areas (Bitton et al., 2019).

Evidence Summary

Outcomes regarding effectiveness, efficiency, and patient experience have generally been positive (see Table 5-12). A report from the Commonwealth Fund followed national trends in Costa Rica from 1994 to 2019 (VanderZanden et al., 2021). The report compared change over time in Costa Rica versus other countries. Since being implemented more than three decades age, there have been clear improvements in access to care. In 2019, it was found that there were 1,053 EBAIS teams and 106 support teams, which provided more advanced behavioral health and social services care. More than 94 percent of the population in Costa Rica was empaneled and on average there was one EBAIS team per 4,660 citizens. These EBAIS teams provided 80 percent of care for health needs (Pesec et al., 2017). Between 1990 and 2010, deaths from communicable disease decreased from 65 per 100,000 to 4.2 per 100,000. There was an 8 percent reduction in infant mortality and 2 percent reduction in adult mortality. In 2016, health care spending was 7.6 percent of gross domestic product, substantially lower than the world average of 10 percent. To address equity, the first EBAIS teams were established in regions with poorer access to care and throughout the program, nearly one-third of funds go to the poorest 20 percent of the population. As a result, health equity in Costa Rica rivals that of the top performing countries in the world, and chronic disease outcome measures show high levels of control (Bitton, 2022).

Multiple literature reviews and summaries have compared Costa Rica’s national trends with other countries and have verified these findings (Gawande, 2021; Pesec et al., 2017; PHCPI, 2018; Spigel et al., 2020; Unger et al., 2008). These reviews have confirmed that Costa Rica has the third-highest life expectancy in the Americas; that there has been a 25-year decline in maternal mortality (current rate 25/100,000 live births), infant mortality (current rate 8.5 per 1,000 live births), and mortality among children under 5 years (9.7 per 1,000 live births); and that Costa Rica spends less on health care per capita than the world average ($970 USD per person

Suggested Citation:"5 Whole Health Systems' Evidence." 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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per year). Compared with the United States, the middle-aged death rate (adjusted for health and social factors) is 30 percent lower in Costa Rica (Gawande, 2021).

FINDINGS AND CONCLUSIONS

In the chapter the committee identified and reviewed system-level evidence from 12 promising whole health care approaches. It is clear from this review that whole health systems are greater than the sum of their parts, requiring a holistic vision rather than the mere addition of multiple isolated interventions. It is also evident that efforts to develop, refine, and iterate whole health systems in the United States and internationally are nascent. Despite the early nature of the field, the committee did find substantially more examples of whole health care and published evidence about outcomes than expected. While different studies in the published literature measured different outcomes and no single whole health approach demonstrated, or even measured, all the benefits listed below, the committee found evidence across the 12 approaches that whole health care had multiple benefits, including

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

Across this evidence several common themes emerged:

  1. While whole health systems share many foundational elements, how these elements are designed is, out of necessity, tailored to the local environment and resources as well as to the preferences and needs of the people served.
  2. At the core of a whole health system is a clear and identified approach to strengthening primary care (and primary health care) that includes comprehensive, team-based advanced primary care that is integrated with public, behavioral, and mental health care
Suggested Citation:"5 Whole Health Systems' Evidence." 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. to be people-, family- and community-centered and to value and support the whole person.
  2. The unit of change, when it comes to developing a whole health system, should be the region served. Whole health systems, by design, aim to break down the walls that exist between medical care, mental health, public health, community programs, and social services across a region and not just for the people who seek care.
  3. Whole health systems require robust and sustained financing mechanisms that pool risk so that a system can support integrated care that is often, but not always, publicly financed.
  4. Many whole health systems need a more thoughtful and calculated equity strategy and approach that incorporates addressing upstream factors as drivers of inequitable and unacceptable poor outcomes.
  5. Team well-being, especially in the wake of the high burnout rate resulting from the COVID-19 pandemic, is an oft-neglected foundational element of whole health systems.
  6. Systematic evaluations of how whole health care is implemented are scarce, often limited in the methods used and outcomes studied, and rarely longitudinal, which makes it challenging for systems to evolve and learn.

What is clear from this chapter is that there is a need for more evidence about whole health care. Because the scale and spread of effective whole health care approaches will take fundamental and seismic changes to the structures, processes, and goals of how the nation thinks about and cares for people, it will be essential for public and private systems fielding a whole health approach to evaluate how they implement whole health care and its outcomes, continually learn from and adapt its approach, and broadly share findings so that all can benefit from the new knowledge. Several gaps will need to be addressed to accomplish this goal. First, there is an absence of common measures around which to evaluate the evidence of achievement of whole health and whole health care. Conventional biomedical measures of success—or even of cost—fail to capture the important elements of whole health care and what it can achieve. More research will be needed to identify and develop more appropriate measures of success.

Second, more funding will be needed to study how best to deliver care or implementation science. This funding can be applied to studying whole health care approaches. The National Institutes of Health (NIH) are provided with more than $45 billion annually to develop new cures for disease, the Centers for Disease Control and Prevention receive more than $8.25 billion to study public health, and the Food and Drug Administration is funded over $6 billion to study drug safety. While NIH’s implementation

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

science program has some direct applicability, and public health and drug safety are needed for whole health care, the only public agency with a mission focused on how care is delivered is the Agency for Healthcare Research and Quality, which receives only $500 million in annual funding. Without rebalancing these funding priorities, at least to some degree, collective knowledge about how to best deliver care and implement change will be limited.

Third, studying how care is delivered is difficult. Traditional study designs that limit the risks of bias, like randomized controlled trials, are difficult to apply to transforming health systems, particularly given the need for whole health to include multiple sectors such as health care, public health, community programs, and social services. A range of research methods and disciplines, on a large scale, with coordinated efforts will be needed to measure the outcomes of whole health care transformations.

Finally, little has been written to date about designing a whole health system for sustainability. This will necessarily require the development of measures of costs of implementing whole health systems and their impact on overall health system costs. There is a growing body of evidence suggesting that sustainability must not be an afterthought; from the start, whole health systems need to be designed to endure with the ability to adapt and evolve over time. It is abundantly clear from the above case studies that whole health systems, once implemented, must constantly evolve to meet the continually changing needs of the people, communities, and families they serve, and to respond to an ever-changing environment. More thinking, knowledge generation, and research is needed to consider how best to design and support whole health systems to be able to adapt, as this will be inevitable.

Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×

EVIDENCE SUMMARY TABLES

TABLE 5-1a The Veterans Health Administration—Use and Implementation of Whole Health Services

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
VHA early implementation and utilization—patient experience

(Marchand et al., 2020)
A large VHA Whole Health flagship site with a 121-bed tertiary care center and outpatient clinics Retrospective observational cohort analysis of EHR and referral data conducted during the first 20 months of Whole Health implementation (2018–2019) First 559 veterans referred to VHA Whole Health program which includes a pathway to engage veterans in care, partnership from peers, and well-being programs Veterans receiving usual primary care Of those referred:
73% had a service-related disability
47% had 9 or more medical needs
54% had mood disorders
42% had PTSD

Those referred were more likely to be younger, female, members of underrepresented minorities, and service connected

Implementation challenges included: Disproportionate numbers of referrals from a few clinical services—primary care and Whole Health programs
Poor initial and ongoing treatment engagement, with almost half of referred veterans not initially engaging
The average number of sessions attended was also low
Selection bias from early adopters and referrals to Whole Health program

Limited generalizability to other VHA Whole Health flagship sites or other health systems
Suggested Citation:"5 Whole Health Systems' Evidence." 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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VHA early implementation—staff experience

(Haun et al., 2021)
VHA Whole Health model implementation in 18 design sites and 18 flagship sites Cross-sectional semistructured interviews, observations, and document analysis based on Consolidated Framework for Implementation of Research Constructs (2018) 45 staff and clinicians from 5 design sites and 1 flagship site who are providing Whole Health in the VHA None Implementation was a complex process, but clinicians and leadership were engaged and motivated and steps were taken to engage veterans

Facilities varied in the degree to which Whole Health was implemented. Factors identified that influenced implementation including:
Progressive culture, including early adopters who integrated Whole Health in their personal life
Recognition of a change in focus of care
Leadership support
Resources (facilities, hiring, funding)
Collaboration among interdisciplinary team members
Agreed upon policies and procedures
Standardized measures
Pilot study with potentially limited generalizability

Selection bias from sites sampled on a volunteer basis and interviewees through purposive and snowball sampling
Whole health use and interest across veterans with co-occurring chronic pain and PTSD

(Reed et al., 2022)
18 VHA Whole Health medical center flagship sites Retrospective observational cohort study (2019–2020) 1,698 veterans with co-occurring chronic pain and PTSD 4,170 veterans with chronic musculoskeletal pain only Of veterans with chronic pain and PTSD 40% used core whole health services 53% used complementary and integrative health

Of veterans with chronic pain only
28% used core whole health services
40% used complementary and integrative health
Inclusion of all veterans with diagnoses limits risk for bias
Suggested Citation:"5 Whole Health Systems' Evidence." 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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Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Whole health efforts during the pandemic

(Dryden et al., 2021)
Whole health system leaders Semi-structured interviews (2020) 61 leaders at 18 VHA medical centers None Sites embraced whole health approach during pandemic conducting patient wellness calls, and, for patients and employees, promoting complementary and integrative health therapies, self-care, and concepts to combat stress and support well-being Report on intentions and not actual use of programs

Observations at one time early in pandemic
Patient-centered behavioral services for women veterans with mental health conditions

(Pebole et al., 2021)
Female veterans using VHA mental health care services Convenience sample survey (2018–2019) 107 female veterans None Over 50% endorsed relationships, physical activity, pain management, sleep/nightmares, spiritual/moral pain, or anger as top wellness priorities

Preferred site to receive services: Main VA facility: integrative medicine (50%), pain (61%), sleep (60%), anger (60%), sexual health (57%)
Community facility: physical activity (52%)
Remote-based options lowest endorsed
Number of surveys distributed, characteristics of nonrespondents, and the response rate were not reported

Geographic focus on one city
Complementary and integrative approaches offered at VHA VA medical centers and community-based outpatient clinics National organizational survey (2017–2018) 196 clinicians from 289 VHA sites participated

63–91% response rate depending on region
None Sites offered an average of five approaches (range 1–23), and 63 sites offered 10 or more approaches

Relaxation techniques, mindfulness, guided imagery, yoga, and meditation were most frequently offered
Self-reported availability of programs
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
(Farmer et al., 2021; Whitehead and Kligler, 2020) Mostly offered in physical medicine and rehabilitation, primary care, and integrative/whole health programs

TABLE 5-1b The Veterans Health Administration—Outcomes of Whole Health Services

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Evaluating the impact of VHA’s implementation of the Whole Health System of Care on the flagship sites

(Bokhour et al., 2022)
114,397 veterans with chronic pain at 18 VHA Whole Health medical center flagship sites Retrospective observational cohort study (2017–2019) 6,594 veterans who initiated whole health services

3,266 veterans completed a baseline and 6-month survey
107,763 veterans who did not use whole health services Decrease in opioid dose in 18 months
11% (95% CI: –12.0 to –9.9) for conventional care
23% (95% CI: –31.9 to –6.5) for use of 2 Whole Health services
26% (95% CI: –30.9 to –18.4) for use of intensive complementary and integrative health
38% (95% CI: –60.3 to –14.4) for use of intensive core Whole Health

Survey respondents reported greater improvements in perceptions of care, engagement in health care, self-care, life meaning and purpose, pain, and perceived stress
Selection bias from willingness/interest in being referred to whole health program
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Mindfulness-Oriented Recovery Enhancement (MORE)

(Garland et al., 2022; Roberts et al., 2022)
250 primary care patients with co-occurring opioid misuse and chronic pain in Salt Lake City Utah Randomized controlled trial (2016–2020) 129 veterans received training in mindfulness, reappraisal, and savoring positive experiences

8 weekly, 2-hour, group mindfulness sessions
121 veterans received supportive group psychotherapy Odds ratio for reduction in opioid use at 9 months for mindfulness-oriented recovery enhancement group compared with the supportive psychotherapy group was 2.06 (95% CI, 1.17–3.61; p=.01)

At 3 months, compared with the support group, the MORE group had
Greater reductions in emotional distress on the Depression Anxiety Stress Scale (β = –0.263, p=.034)
Greater self-regulation of distress (β = 0.335, p=.001)
RCT lowers risk of bias

Unknown whether observed reduction in opioid use translates to health outcomes
Health Coaching and Quality of Life

(Purcell et al., 2021)
88 veterans enrolled in the VHA Whole Health Coaching Program in Northern California Mixed-methods pre–post quality-improvementevaluation of surveys (n=65) and interviews (n=42) (2019) Structured program to support veterans in making healthy behavior changes None Improvements in 3-month vs baseline PROMIS-10, PSS-4, and PHCS-2 scores for:
Mental health (12.58 vs 11.74, p=.006) Stress (5.34 vs 6.54, p=.003)
Health competence (7.88 vs 6.80, p=.01)
Selection bias from willingness/interest in program. No comparators
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-2 The Nuka System of Care (Southcentral Foundation)

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
The Nuka System of Care: improving health through ownership and relationships

(Blash et al., 2011; Gottlieb, 2013; SCF, 2017)
Over 60,000 Alaska Natives and American Indians in Anchorage Alaska Observational cohort analysis of annual satisfaction surveys and quality measures (1996–2013)


In 1999…Shift to customer ownership to design, implement, and control health care
Prior system of government managed tribal health care

Change over time
Compared with prior government managed care, access
Increase in people with a primary care provider from 35% to 95%
Improved access from 4-week wait to same day access
Reduction in people on behavioral health waitlist from 1,300 to 0

Quality
Improved diabetes monitoring from 78% with A1c in 2007 vs. 92% in 2009
Improved childhood immunization rates from 80% in 1998 to 93% in 2006
Increased colorectal screening rates from 49% in 2008 to 59% in 2009
42% reduction in emergency room use
36% reduction in hospital days
58% reduction in specialist use
Limited description of methods for data

Statistical significance not reported

Time periods for data comparisons sometimes unclear

Citations to primary sources are non-functional links
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias



In 1999…Shift to customer ownership to design, implement, and control health care
Team well-being
Improved staff retention from 60% in the early 2000s to 83% at publication


Limited description of methods for data

Statistical significance not reported

Time periods for data comparisons sometimes unclear

Citations to primary sources are non-functional links
Process and outcomes of patient-centered medical care

(Driscoll et al., 2013)
Up to 48,043 Alaska Natives and American Indians in Anchorage Alaska Time-series analyses of emergency care use from medical record data (1996–2010) Built relationship with community Invested in primary care
Provided prepaid services
Team-based care
Patients matched to comprehensive care team
Open access
Change over time Monthly emergency room use overall decreased from 2000 to 2006 and leveled off from 2006 to 2010 (p<.001)
Bimonthly emergency room use for asthma decreased from 1998 to 2005 and then leveled off from 2005 to 2010 (p<.001)
Pre–post with no external comparison
Suggested Citation:"5 Whole Health Systems' Evidence." 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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Tribal implementation of a patient-centered medical home model

(Johnston et al., 2013)
Up to 47,464 Alaska Natives and American Indians in Anchorage Alaska Time-series analyses of hospitalizations from medical record data (1996–2009) Change over time Proportion of people with one or more emergency room visit in a month decreased from 7.6% in 1996 to 5.8% in 2009 (p value not reported)

Proportion of people with one or more hospital admission in a month decreased from 0.9% in 1996 to 0.7% in 2009 (p<.001)
Pre–post with no external comparison
Program to address adverse life experiences

(Ray et al., 2019)
90 Alaska Natives and American Indians who completed the intervention Propensity score-matched cohort analysis using retrospective electronic health record data (2012–2017) 90 propensity matched people who participated in other emotional wellness programs 36% reduction in total system visits (incidence rate ratio 0.64, 95% CI 0.49–0.84) 70% reduction in substance use visits (incidence rate ratio 0.30, 95% CI 0.10–0.93)
40% reduction in ED visits (incidence rate ratio 0.60, 95% CI 0.35–1.02)
Propensity matching lowers risk of bias

TABLE 5-3 Kitsap Mental Health Services Race to Health! Program

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Implementing a whole health model in a community mental health center

(Bouchery et al., 2018)
Medicare clients at Kitsap Mental Health in Washington Pre–post comparison of matched observational cohort (2009–2015) 846 people enrolled in the Race to Health! Program, an interdisciplinary team to address mental health, substance use, and nonpsychiatric needs Matched cohort of 2,643 veterans Difference of difference for first 2.5 years favored intervention group:
Reduced Medicare expenditures by $266 per month (p<.01)
0.02 fewer hospitalizations per month (p<.01)
0.03 fewer emergency visits per month (p<.01)
0.13 fewer office visits per month (p<.04)
Selection bias from willingness/interest in program
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-4 Advanced Care for Elderly (ACE) Programs

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Geriatric care management for low-income seniors: a randomized controlled trial

(Counsell et al., 2007, 2009)
6 community health centers in Indiana Randomized controlled trial (2002–2004) 474 seniors received home-based care by a nurse practitioner, social worker, primary care clinician, and interdisciplinary team using 12 care protocols for common geriatric conditions 477 low-income seniors received usual care Overall, 2-year ED visit rate per 1,000 was lower in the intervention group (1,445 [n=474] vs. 1,748 [n=477], p=.03), but hospitalization rates were not different

In a predefined high-risk group, ED visits (848 [n=106] vs. 1,314 [n=105]; p=.03) and hospital admission rates (396 [n=106] vs. 705 [n=105]; p=.03) were lower for intervention patients in the second year

4 of 8 SF-36 scales improved more compared with usual care: General health (0.2 vs. −2.3, p=.045) Vitality (2.6 vs. −2.6, p<.001) Social functioning (3.0 vs. −2.3, p=.008) Mental health (3.6 vs. −0.3, p=.001)

Mean 2-year total costs were not significantly different between intervention vs. usual care for overall group ($14,348 vs. $11,834; p=.20) and high-risk group ($17,713 vs. $18,776; p =.38)

Mean 2-year total costs were higher in the low-risk group ($13,307 vs. $9,654; p=.01).
Randomized design limits bias
Suggested Citation:"5 Whole Health Systems' Evidence." 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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Implementing GRACE team care in a Veterans Affairs medical center (Schubert et al., 2016a) 5 Veterans Association medical centers (VAMCs) in Indiana Case–control study (2010–2011) 179 senior veterans discharged home from acute hospitalization from 4 VAMC clinics received a veteran-centric care plan 77 hospitalized veterans from a fifth VAMC clinic Enrollment in GRACE was associated with:
7.1% fewer emergency visits (p=.59)
14.8% fewer 30-day readmissions (p=.19)
37.9% fewer total hospitalizations (p=.14)
28.5% fewer total bed days of care (p=.01)
Only outcome of total bed days of care is statistically significant
House Calls: California program For homebound patients

(Melnick et al., 2016)
7,925 high-risk, high-cost postacute patients enrolled in program following hospitalization Observational cohort analysis (2009–2013) Interdisciplinary teams develop a care plan, monitor patient, maintain contact with clinicians, and meet weekly to review progress None Comparing 6 months before enrollment, 6 months after enrollment, and 6 months after disenrollment:
Fewer emergency visits per person (0.46 vs. 0.21 vs. 0.08)
Fewer hospital days per 1,000 people (680 vs. 286 vs. 100)
Lower health care spending ($1,768–2,673 vs. $965–$1,362 vs. $326–$453)
Minimal methods presented

No tests of statistical significance No comparison group
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Scoping review of Program of All-Inclusive Care for the Elderly (PACE) versus other care programs

(Arku et al., 2022)
6 studies with a total of 12,746 adults participating in a care program Scoping review included studies used cross sectional as well as retrospective and prospective cohort designs (2002–2013) PACE provides comprehensive health and social services to community-dwelling older adults Participants in other caregiving programs including Wisconsin Partnership Program, Medicaid long-term care, Visiting Nurse Service, Veterans Affairs, nursing home, aged and disabled waiver program Studies comparing PACE to other programs have mixed results
2/3 studies showed PACE participants had worse or declining activities of daily living, 1/3 showed improvement
2/3 studies showed PACE participants had less hospital use, 1/3 showed no difference
2/2 studies showed increased use of community-based services utilization and adult day center visits
1/1 study showed no difference in pain, discomfort, or depression
1/3 studies showed increased mortality with PACE participation, 1/3 showed no difference, 1/3 showed longer survival with PACE
The 6 included studies were more descriptive limiting assessment for risk of bias

Selection bias from who enrolled in PACE versus other programs

No studies reported on missing data
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-5 Mary’s Center

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Mary’s Center’s Social Change Model

(Galvez et al., 2019)
Federally qualified health center serving 55,000 people in Washington D.C., high proportion immigrants, women, low-income, uninsured or underinsured Case study reporting use of services (2016) Social Change Model adds wraparound services to conventional care such as job training, behavioral health services, trauma informed care, educational services, pediatric dental suite, telehealth, home visitation services Contemporaneous comparison of other FQHCs 61% of patients use Mary’s Center exclusively for primary care
Encounters were for primary care (74%), social services (4%), dental (13%), and behavioral health (10%)
Receive primary care only (61%), primary care plus one service (24%), and non-primary care services only (15%)
Ranked in top 25% of FQHCs for cervical screening, child immunizations, cholesterol treatment, adolescent weight screening/follow up, depression screening, asthma treatment
99% of participants in teen after school programs graduated from high school, avoided pregnancy, attended college
Home visiting program reported “virtually no” cases of abuse or neglect after enrollment
Job training programs placed graduates in employment
Not a primary research report

Limited methods description

Retrospective analysis Contemporaneous comparison
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-6 Vermont Blueprint for Health

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Vermont’s Community-Oriented All-Payer Medical Home Model

(Jones et al., 2016)
Residents in Vermont who were seen for care Sequential cross-sectional analysis, difference of difference comparing post year 2 vs. preintervention (2008–2013) Residents seen in 123 participating patient-centered medical homes supported by community health teams and payment reforms Residents seen in nonparticipating practices Quality
In post-year 2, participants had significantly higher rates of adolescent well-care visits, breast cancer screening, cervical cancer screening, appropriate testing for pharyngitis, and for people with diabetes eye exams, A1c testing, lipid testing and nephropathy screening
Rates for imaging for low back pain, treatment of upper respiratory infection, and well-child visits were not significantly different

Cost
Total expenditures –$482 (95% CI, –$573 to –$391)
Primarily driven by lower inpatient (–$218; p<.001) and outpatient hospital costs (–$154; p<.001)
$5.8 million decrease in expenditures for every $1 million spent on program
Supported practices actively engaged in measuring and improving outcome measures
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-7 National Intrepid Center of Excellence (NICoE) for Traumatic Brain Injury

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Care transitions to and from the National Intrepid Center of Excellence (NICoE) for service members with traumatic brain injury (TBI)

(Ayer et al., 2015)
184 referring clinicians and 311 former NICoE patients from the NICoE center in Bethesda, MD., were surveyed with a 20–30% response rate Surveys, site visits, and interviews to examine transitions of care between NICoE, usual care clinicians, and service members receiving care (2010) NICoE provides interdisciplinary diagnostic evaluations, short-term treatment, and treatment planning for comorbid traumatic brain injury and psychological health conditions to mitigate barriers for treatment None Patients most commonly referred if their traumatic brain injury or psychological health problems were complex and severe or their symptoms were not improving
Usual-care clinicians at smaller, more rural sites viewed NICoE as extremely valuable while clinicians at larger facilities perceived it as duplicative
Usual-care clinicians expressed a desire to have more information from NICoE about eligibility criteria and services available to help with future referrals
Some usual-care clinicians noted gaps in communication about patient progress
Patients expressed low levels of satisfaction with their usual source of care prior to referral to NICoE due to long wait times for appointments, staff shortages and no access to complementary and alternative medicine treatment modalities
Patients expressed positive opinions about the value of care, the facility’s care model, and the involvement of family members in care
Many usual-care clinicians did not perceive a significant difference between the type of services offered at home stations and NICoE
Usual-care clinicians gave positive feedback on the discharge planning process There was some duplication of diagnostic services
Selection bias from those clinicians and patients agreeing to participate in evaluation and responding to the survey
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Efficacy of an interdisciplinary intensive outpatient program in treating combat-related traumatic brain injury and psychological health conditions

(DeGraba et al., 2020)
1,456 service members with residual symptoms from traumatic brain injury and comorbid psychological health conditions referred to NICoE in Bethesda, Md. Prospectively planned pretest–post-test analysis of people referred to the program from 2011 to 2019, with 91% consenting to participate NICoE provides 4-week interdisciplinary diagnostic evaluations, short-term treatment, and treatment planning for comorbid traumatic brain injury and psychological health conditions to mitigate barriers for treatment Baseline Statistically significant improvements seen for all seven assessments:
Neurobehavioral Symptom Inventory (NSI)
PTSD Checklist-Military (PCL-M)
Satisfaction With Life Scale (SWLS)
Patient Health Questionnaire-9 (PHQ-9)
Generalized Anxiety Disorder-7 (GAD-7)
Epworth Sleepiness Scale (ESS)
Headache Impact Test-6 (HIT-6)
Pre–post study design and lack of comparison group has a risk of regression to the mean and a risk of a response bias

TABLE 5-8 Canterbury HealthPathways (New Zealand)

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Integrated community system to reduce acute hospital demand

(Gullery and Hamilton, 2015; McGeoch et al., 2019)
Acute medical hospitalization rate per 100,000 people in New Zealand Prospective observational cohort analysis of national health trends (2008–2017) Implemented in 2000
Acute demand management system of supported primary care teams provide in home care to prevent hospitalization
Other regions of New Zealand 15,000 to 35,000 referrals per year Annually from 2008 to 2014, a 30% lower hospitalization rate in Canterbury compared with New Zealand as a whole 14% reduction in long hospital stays (over 24 days) for people over 75 years of age
Reduction in proportion of people over 75 years of age living in care homes from 16% to 12% from 2006 to 2013 Reduced surgical wait list from
Limited methods presented in reports

Reports focused more on describing the model than evaluating the model
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Community rehabilitation enable-ment and support teams
24-hour general practice
Localized clinical guidance website and shared electronic medical record
Evaluation focused on acute services and hospitalization usage

TABLE 5-9 Health In all Policy Initiative (Australia)

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
South Australian Health in All Policies initiative

(Baum et al., 2019; van Eyk et al., 2017; Williams and Galicki, 2017)
918 public servant interviews, 5 document reviews, 144 key informant interviews, 2 workshops Mixed-methods case study (2012–2016) Collaboration across sectors to develop policies on factors that influence health such as environment, food, and social determinants implemented in 2007. Serve 1.6 million people in South Australia with a high proportion being Aboriginal/Torres Strait Islanders None Increased public servants’ awareness of the health impacts of their agencies’ policies
55% reported understanding the link between their department and social determinants
53% agreeing that collaborations increased their understanding of equity

Health in All Policies addressed education, employment, regional planning, healthy weight, Aboriginal driving

Participants said that the initial intentions to address equity were only partially enacted and little was done to reduce inequities due to government narrowing its priorities to economic goals
Quantitative data on number of policies developed and influenced and the impact of programs and policies not presented

Difficult to assess participation rate in interviews and workshops
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-10 Basque Region Integrated Care Model (Spain)

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Building integrated care systems

(Polanco et al., 2015; Rosete and Nuno-Solinis, 2016)
Autonomous country in northern Spain with population of 2.2 million people Case study of Bidasoa Integrated Health Organization, including 80–122 clinicians surveyed annually (2010–2013) and comparison of quality metrics for the health organization between 2014 and 2011 Integrated care model includes risk stratification of entire population, coordination between primary and specialty care (care pathways and common goals), common electronic medical record, continuity of care, prevention, patient responsibility and autonomy, patient-centered care Change over time Clinician respondents reported improvements over time in organization of health system, health care model, self-management, clinical decision support, information systems, shared goals, patient-centered approach, mutual knowledge, trust, strategic guidelines, and shared and supportive leadership; but no improvement in community health

From 2011 to 2014 clinical quality metrics showed a 7% reduction in hospital use, 24% reduction in hospital readmission, 16% reduction in adverse-event admissions, 10% reduction in ambulatory care sensitive conditions, and decrease in mental health hospital readmissions within 30 days from 16% to 7%

For people with multi-morbidity there was a 38% reduction in hospital use and 31% reduction in adverse event admissions
Some assessment instruments take 5–6 hours for team to complete

Data not reported on response rate, characteristics of participants, or continuity of respondents over time

Quality measures only report pre–post changes
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Impact of the CareWell integrated care model for older patients with multimorbidity

(Mateo-Abad et al., 2020; Rosete and Nuno-Solinis, 2016)
200 patients with complex needs who were >65 years old with two or more chronic conditions registered in 6 health systems in Basque Region Quasi-experimental design (2015–2016) Patients from 4 health systems that implemented the CareWell program which includes risk identification, therapeutic plan definition, patient stabilization at home by multidisciplinary team, integrated care during hospitalization, coordinated discharge Patients registered in two health systems who had not implemented CareWell program Compared with usual care, Carewell patients had
Fewer emergency room visits (0.3% vs. 1.3%, p<.001)
More primary care visits (12.2 vs. 9.6, p=.041) and phone meetings (6.7 vs. 3.6, p=.002)
Non-statistically significant trends towards reductions in weight, glucose, blood pressure
Health systems not randomized, but intervention and control patients had similar characteristics
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Integration of health care in the Basque Country during COVID-19

(Izagirre-Olaizola et al., 2021)
20 system stakeholders in the Basque model Case study of qualitative interviews to assess the integrated care model during COVID-19 (2020) Basque integrated care model implementation None Themes that emerged included:
Integration of primary care into program was critical for success
Primary care needs more resources
Social care was poorly integrated into the model
Telehealth has allowed for more care delivery and uptake/implementation
Small sample size

Interview participant recruitment not described

TABLE 5-11 Gesundes Kinzigtal Model (Germany)

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
From rural Germany, integrated care grows into a global model

(Hildebrandt et al., 2010)
Residents of Kinzigtal River Valley, Germany, who participate in KG model Observational analysis (2006–2015) None In 2010, of the 60,000 residents of Kinzigtal, 31,000 were insured by AOK BW or LKK BW, and 6,870 enrolled in the integrated care model

Number of members enrolled in each program: heart failure (67), lifestyle intervention (122), smoking cessation (128), active health for elderly (511), therapy for personal crisis (126), prevention osteoporosis (455), social case management (78), diabetes (830), coronary artery disease (288), breast cancer (18), asthma (100), chronic obstructive pulmonary disease (154), patient university (1070), and nursing home medical care (124)
No comparison group
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Population-based integrated care model operated via shared savings contract includes integrated coordinated care teams, shared decision making, patient engagement through education and classes, and team support from nurses, dieticians, physiotherapists, nutrition counseling, social workers Poor dissemination to other regions in Germany until 2017 when extended to two low-income neighborhoods in Hamburg that have a large immigrant population, a high rate of chronic disease, and low health literacy
From rural Germany, integrated care grows into a global model

(Marill, 2020)
Residents of Kinzigtal River Valley, Germany, who participate in KG model Time trend analysis (2007–2017) Pre–post comparison Net savings observed of almost $20 million from 2007 to 2018 Decreasing avoidable hospitalization Increased life expectancy Primary research studies in German

Some values and statistical significance not available in English
Evaluation of the population-based Integrated Health Care System Gesundes Kinzigtal (IHGK)

(Schubert et al., 2016b)
Residents of Kinzigtal River Valley, Germany, who participate in KG model Longitudinal cohort study (2004–2011) Patients insured by same insurer in other regions of Germany without the integrated care model Greater improvements in 2 of 5 indicators of overuse (long-term NSAID use and inappropriate medications for vascular dementia)
Greater improvements in 2 of 10 indicators of underuse (antiplatelet drugs for heart disease and diabetes patients with eye exams)
Primary research studies in German

Baseline Kinzigtal population may be healthier (longer life expectancy, younger, lower morbidity, less multi-medications)
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias
10-year evaluation of the population-based integrated health care system

(Schubert et al., 2021)

Individual patient satisfaction in Gesundes Kinzigtal: Interim results of a trend study

(Siegel and Niebling, 2018)
Residents of Kinzigtal River Valley, Germany, who participate in KG model

3,034 members in 2013 and 3,471 members in 2015 were invited to complete a postal survey
Longitudinal cohort study (2006–2015)

Cross-sectional survey (2013 and 2015)
Patients insured by same insurer in other regions of Germany without the integrated care model

None
From 2007 to 2011, compared with the control group
Lower risk of osteoporotic fracture (HR 0.81; 95% CI: 0.74–0.89; p<.001)
Lower risk of death (HR 0.94; 95% CI: 0.90–0.99; p<.019)
No difference in preventable hospitalizations

From 101 quality indicators
No difference seen for 88 indicators
Positive differences seen for 6 indicators
Negative differences seen for 7 indicators
Overall, no positive or negative trend in health care indicators seen over time compared to control

In setting of notable shared savings and reduced cost, no decrease in quality compared with more expensive usual care may be significant

Survey response rate 23.4% in 2013 and 24.9% in 2015
Patient satisfaction and mean EQ-5D unchanged
Proportion of participants who felt they lived overall healthier life increased from 25.6% to 30.7% (p=.020)
Primary research studies in German

Baseline Kinzigtal population may be healthier (longer life expectancy, younger, lower morbidity, less multi-medications)

Full article only in German

Unclear how members selected to complete survey

Risk of response bias
Suggested Citation:"5 Whole Health Systems' Evidence." 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 5-12 EBAIS (Equipo Básico de Atención Integral de Salud) Community-Based Primary Health Care Model (Costa Rica)

Study Population Study Design Intervention Comparator Outcomes Risk of Bias
What does community-oriented primary health care look like?

(VanderZanden et al., 2021)
4.8 million Costa Ricans covered under model Prospective observational cohort analysis of national health trends (1994–2019)


Integrated health care team includes public health services and primary health care delivery, multidisciplinary EBAIS teams, geographic empanelment, measurement and feedback, digital technology
Change over time

Other countries
EBAIS teams provide 80% of care for health needs

By 2019
More than 94% population empaneled There were 1,053 EBAIS teams and 106 support teams (provide more advanced behavioral health and social services) Average one EBAIS team per 4,660 citizens

First EBAIS teams established in regions with poorer access to care

Quality
Deaths from communicable disease decreased from 65 per 100,000 in 1990 to 4.2 per 100,000 in 2010
10 years after implementation, there was an 8% reduction in infant mortality and 2% reduction in adult mortality

Cost
In 2016, health care spending was 7.6% of gross domestic product vs the world average of 10%
To improve equity, nearly one-third of funds go to the poorest 20% of the population
Many primary data sources in Spanish

Temporal comparisons with no external comparison

Cost comparison without adjustments
Suggested Citation:"5 Whole Health Systems' Evidence." 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.
×
Study Population Study Design Intervention Comparator Outcomes Risk of Bias
Primary health care that works: The Costa Rican experience

(Pesec et al., 2017; PHCPI, 2018; Spigel et al., 2020; Unger et al., 2008)
94% of 4.8 million Costa Ricans covered under model Literature review of 280 articles comparing change in care (1994–2016) Change over time

Other countries
Quality
Third-highest life expectancy in the Americas
25-year decline in (current rate): Maternal mortality (25/100,000 live births)
Infant mortality (8.5/1,000 live births)
Under 5 mortality (9.7/1,000 live births)

Cost
Costa Rica spends less on health care than world average per capita ($970)
Many primary data sources in Spanish

Life expectancy comparison without adjustment

Temporal comparisons with no external comparison

NOTES: AOK BW = AOK Baden-Württemberg; EBAIS = Equipo Básico de Atención Integral de Salud; ED = emergency department; EHR = electronic health record; FQHC = federally qualified health center; KG = Gesundes Kinzigtal; LKK BW = LKK Baden-Württemberg; PTSD = post-traumatic stress disorder; RCT = randomized controlled trial; VHA = Veterans Health Ad.

Suggested Citation:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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:"5 Whole Health Systems' Evidence." 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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Next: 6 Scaling and Spreading Whole Health »
Achieving Whole Health: A New Approach for Veterans and the Nation Get This Book
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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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