Achieving Whole Health A New Approach for Veterans and the Nation (2023) / Chapter Skim
Currently Skimming:
4 Whole Health in Practice
4 Whole Health in Practice
Pages 115-156
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, the Nuka-Southcentral Foundation system (an Alaska Native–owned system based in Anchorage, Alaska) , Mary's Center (a community health center based in metropolitan Washington, D.C.)
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For a more detailed look at the evidence that these systems and others address the five foundational elements, see Chapter 5. DEPARTMENT OF VETERANS AFFAIRS WHOLE HEALTH SYSTEM VA has led numerous transformations in health care delivery in the United States.
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It is not diagnosis/disease focused, but rather it emphasizes the whole person and prioritizes their goals and aspirations. Person-centeredness moves beyond the traditional physician-directed approach to one of partnership with the care team that puts veterans in control of their care, focuses on self-care and support, and represents an individualized, lifelong plan that is more proactive than reactive (Marzolf, 2021)
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3. Whole Health Clinical Care is based on the whole health approach for providing care in both CIH and allopathic settings.
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As with the overall WHS approach, the model helps veterans explore connections and facilitate discussion about what is important in their lives and their own health and well-being. It supports people-centeredness by acknowledging the uniqueness of each individual, allowing veterans to identify what matters most to them, and facilitating veteran engagement with their care teams to develop a personal health plan.
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. However, VBA and the VHA -- which oversees VA health care programs, including WHS -- mostly operate separately from each other, with different leadership, system organization, and reporting structures.
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Equitable and Accountable Viewed through an equity lens, while all veterans receiving care at VA are technically eligible to receive WHS, there are variations in access to the services throughout the system. While the committee is not aware of demographic information regarding who does and who does not use WHS services, in February 2020, WHS published a progress report, Whole Health System of Care Evaluation -- A Progress Report on Outcomes of the WHS Pilot at 18 Flagship Sites (Bokhour et al., 2020b)
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. Toward that end, the VA has held cyberseminars focused on promoting health equity in veterans with a Whole Health approach.
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WHOLE HEALTH IN PRACTICE 123 • VA's Life Whole Health mobile app • Videos that support resilience and balance via topics such as guided meditation, chair yoga, acupressure, gratitude, and relaxation techniques • Videos, podcasts, music, and handouts on topics such as recon necting with the mission, value and appreciation, supervisors help ing their employees, staying VA strong, stress management and addressing burnout, social connection and community, spiritual health/spirit and soul, and parenting and other caregiver resources. Urgent and crisis-level employee needs are also addressed by providing ready access to the 24/7 National Suicide Prevention Lifeline, 24/7 Veterans Crisis Line, Physician Support Line, and the Disaster Distress Helpline.
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The committee determined that team well-being is partially addressed because well-being interventions target individual resilience rather than systems-level changes. summarizes how the VA WHS design maps to the committee's five foundational elements of a whole health approach to health care.
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In 1998, SCF began managing primary care, and, in 1999, SCF entered into a co-ownership and co-management agreement with the Alaska Native Tribal Health Consortium (ANTHC) to take over the Alaska Native Medical Center, which is responsible for delivering hospital services to Alaska Native and American Indian people (Southcentral Foundation, 2017a)
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We structure our organization to optimize the skills and contribu tions of our staff. Family Wellness We value the family as the heart of the Native community.
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These teams include primary care physicians or physician assistants, nurses, certified medical assistants, and other clinicians. Since the system's inception, the interprofessional care teams have added behavioral health consultants, nutritionists, HIV consultants, and appointment schedulers (Driscoll et al., 2013)
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SOURCE: Eby, 2007. provide more immediate access to behavioral health services and to create supportive communities (Southcentral Foundation, 2022d)
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The Native Men's Wellness program supports Alaska Native and American Indian men in areas such as employability, cultural connectivity, and healthy living, while the Beauty for Ashes program "uses culturally-grounded approaches to health and healing from trauma, such as relationship building, intergenerational role modeling, and sharing story, to develop knowledge and skills that promote healing and improved social health outcomes" (Southcentral Foundation Nuka System of Care, 2022)
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. SCF regularly reports very high patient satisfaction; a survey of customer-owners found that 98 percent were satisfied with the care they received from SCF, 97 percent reported that they participate in care decisions, and 96 percent said that care was delivered in a manner that respected their culture and traditions (Southcentral Foundation Nuka System of Care, 2020)
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Nuka makes use of integrated care teams to provide care to customer-owners, with each team consisting of a primary care provider, nurse case manager, case management support person, and a certified medical assistant. Other providers, such as nutritionists, behavioral health consultants, and pharmacists are added to the care team as they are needed.
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. However, there is limited discussion of the enabling structures built within the teams to foster resilience of care team members and to facilitate and sustain these changes to care delivery.
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. Mary's Center's service area is large for an urban health center, extending over 30 miles in each direction from its headquarters in Washington, D.C.
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Services are offered at five community health centers and two senior wellness centers. Behavioral health therapy is offered at all clinical sites in addition to 26 public schools, and comprehensive school-based primary care is offered at one public high school and one middle school.
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Because of the behavioral health needs of the population, Mary's Center currently employs more behavioral health providers than medical providers. The organization uses an integrated behavioral health model where therapists are embedded into the primary care team and "warm handoffs" occur between primary care clinicians and behavioral health therapists.
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Both of these programs integrate social services, behavioral health services, and clinical services. Equitable and Accountable Mary's Center provides people-centered services by ensuring personalized, equitable access; affordability; and quality.
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. A review of evidence regarding health centers found that those offering services similar to those offered by Mary's Center provided higher quality of care (Martinez et al., 2020)
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How Is Mary's Center Illustrative of Whole Health? Mary's Center provides comprehensive physical and behavioral health care that is well integrated with social and educational services, many of which it provides through an extensive network of community partners (Table 4-3)
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, depression, and mild traumatic brain injury (mTBI) , and it indicated that without greater efforts to enhance the systems of care, the prevalence of these conditions would continue to remain high (Defense Health Board Task Force on Mental Health, 2007)
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The model views each participant as a student, and physician or nurse practitioner admission officers assess each individual's needs fully as well as the impact of the injuries on the student's family. An admissions committee comprising physicians, physician assistants, neuropsychologists, behavioral health, and rehabilitation professionals reviews the application packet and develops an individualized curriculum that takes into account the number of credits required for graduation.
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FIGURE 4-3 The Intrepid Spirit University process map. NOTE: CHCS = Composite Health Care System; pt = patient; AHLTA = Armed Forces Health Longitudinal Technology Applications; TBI = traumatic brain injury; RN = registered nurse; BH = behavioral health; MRI = magnetic resonance imaging; VS = vital signs; BHDP = Behavioral Health Data Portal; RA = research assistant; POC = point of contact; AC = admissions committee; CM = case manager; NP = nurse practitioner; RCC = regional care coordinator; f/u = follow-up.
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. Care teams can also include an audiologist, art therapist, chaplain, licensed clinical social worker, nutrition specialist, occupational therapist, optometrist, physical therapist, recreational therapist, sleep medicine physician, and speech and language pathologists.
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. The researchers postulated that these improvements resulted from comprehensive and coordinated care and the establishment of trust between the participant and the care team.
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Most participants are dually eligible for Medicare and Medicaid, and the program provides all Medicare- and Medicaid-covered services, paying for care via monthly capitation payments from Medicare and Medicaid. The program has grown steadily since 2012, and in 2022 there were 145 PACE programs operating 273 PACE centers in 31 states, serving over 60,000 participants (National PACE Association, 2022b)
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The committee determined that care provided by NICoE is not accessible to all, given the limited locations of available services. The committee was unable to find any information regarding efforts to foster team well-being.
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This is based on the idea that when patients have their medical and long-term care needs taken care of, participants can live to their fullest, at any age and level of ability. PACE makes aging at home possible by • Working with patients and their family to design a personalized care plan • Carefully assessing patient needs and managing every aspect of their health care -- using a high-touch approach designed to make patients feel valued and supported -- by an interdisciplinary team • Providing patients with in-home support, as well as transportation from their homes to their clinics and adult day health centers and to their networks of thousands of local providers • Assisting with the tasks of daily living, such as preparing a meal or doing laundry (On Lok, 2022)
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Because all members of the care teams regularly meet to discuss program participants, the model is designed to proactively identify their whole health needs, including upstream factors, and to quickly address them. For example, a driver may notice a problem at an individual's home (e.g., a pile of unpaid bills or an empty refrigerator)
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Among participants, the on-site inclusion of a variety of medical and other services enables the care teams to coordinate medical and social needs during patients' visit, reducing the burden of having multiple visits, which may exclude specific populations. In the past several years, a series of legislative and rule changes granted CMS the authority to develop pilots for PACE programs for individuals under 55 but who otherwise meet the PACE eligibility criteria.
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How Is PACE Illustrative of Whole Health? PACE is designed to address four of the committee's five foundational elements of whole health, including providing holistic comprehensive care, addressing upstream factors that influence health, using a people-centered care approach, and having a focus on equity and accountability (Table 4-5)
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Interestingly, the committee found no programs that embody all five foundational elements fully, but each of the examples highlighted in this chapter offers promising approaches that serve different populations. Variable implementation of foundational elements may be necessary to tailor
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It is possible, though, that the other systems are addressing team well-being more comprehensively than what is documented in the published literature. TABLE 4-6 Congruence of the Featured Models with the Five Foundational Elements of Whole Health Foundational Components that Address VA SCF/ Mary's NICoE PACE Element the Foundational Elements WHS Nuka Center People- Self-empowerment, centered longitudinal, relationship based People/family/community directed Care delivered in social and cultural context Holistic and Addresses all domains that -- comprehen- affect health sive Attends to the entirety of a person/family/community Components and teams are coordinated Upstream- Identifying and addressing -- focused root causes of poor health Addresses the conditions -- of daily life Equitable and Accountable to people/ -- accountable families/communities Accessible to all Team well- Supports the care delivery -- -- being team NOTE: Based on the program descriptions, indicates that the component is addressed; -- indicates that it is partially addressed; a blank space indicates that it is not addressed.
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2013. Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation.
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2020. Health Center Program Uniform Data System (UDS)
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2011. Southcentral Foundation earns Malcolm Baldridge National Quality Award.
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. Southcentral Foundation Nuka System of Care.
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