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5 Whole Health Systems' Evidence
Pages 157-218

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From page 157...
... 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.
From page 158...
... 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 1 Asaf Bitton's commissioned paper is available at https://doi.org/10.17226/26854.
From page 159...
... Spain: Basque Country Integrated Chronic Care Model 12. Germany: Gesundes Kinzigtal Model 13.
From page 160...
... 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.
From page 161...
... 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 acupunc ture, 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)
From page 162...
... 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.
From page 163...
... 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
From page 164...
... 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.
From page 165...
... 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.
From page 166...
... 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)
From page 167...
... 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.
From page 168...
... . 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.
From page 169...
... 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.
From page 170...
... . 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 communitybased and inpatient geriatric care services (Counsell et al., 2007)
From page 171...
... . Mary's Center serves over 55,000 individuals across five community health centers and two senior wellness centers.
From page 172...
... 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)
From page 173...
... 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)
From page 174...
... 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)
From page 175...
... 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)
From page 176...
... 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.
From page 177...
... 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)
From page 178...
... 178 FIGURE 5-1  Pictogram of health care system in Canterbury. SOURCE: Timmins and Ham, 2013.
From page 179...
... . 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.
From page 180...
... . 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.
From page 181...
... 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)
From page 182...
... . Evidence Summary Three studies in five publications describe the outcomes of implementing the integrated care model (see Table 5-10)
From page 183...
... 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)
From page 184...
... . 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)
From page 185...
... 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)
From page 186...
... . 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)
From page 187...
... 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.
From page 188...
... 4. Whole health systems require robust and sustained financing mech anisms that pool risk so that a system can support integrated care that is often, but not always, publicly financed.
From page 189...
... 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.
From page 190...
... 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
From page 191...
... Collaboration among interdisciplinary team members Agreed upon policies and procedures Standardized measures Whole health 18 VHA Whole Retrospective 1,698 veterans 4,170 vet- Of veterans with chronic pain and PTSD Inclusion of all use and Health medical observational with co-occurring erans with 40% used core whole health services veterans with interest across center flagship cohort study chronic pain and chronic mus- 53% used complementary and integrative diagnoses limits veterans with sites (2019–2020) PTSD culoskeletal health risk for bias co-occurring pain only chronic pain Of veterans with chronic pain only and PTSD 28% used core whole health services 40% used complementary and integrative (Reed et al., health 2022)
From page 192...
... TABLE 5-1a  Continued 192 Study Population Study Design Intervention Comparator Outcomes Risk of Bias Whole health Whole health Semi-struc- 61 leaders at 18 None Sites embraced whole health approach Report on intenefforts during system leaders tured inter- VHA medical during pandemic conducting patient tions and not the pandemic views (2020) centers wellness calls, and, for patients and actual use of employees, promoting complementary and programs (Dryden et al., integrative health therapies, self-care, and 2021)
From page 193...
... for conven- from willingVHA's imple- chronic pain at cohort study whole health did not use tional care ness/interest in mentation of 18 VHA Whole (2017–2019) services whole health 23% (95% CI: –31.9 to –6.5)
From page 194...
... misuse and savoring positive 2.06 (95% CI, 1.17–3.61; p=.01) whether ob chronic pain in experiences served reduction (Garland et Salt Lake City At 3 months, compared with the support in opioid use al., 2022; Utah 8 weekly, 2-hour, group, the MORE group had translates to Roberts et al., group mindfulness Greater reductions in emotional distress health outcomes 2022)
From page 195...
... 92% in 2009 unclear Improved childhood immunization rates from 80% in 1998 to 93% in 2006 Citations to pri Increased colorectal screening rates from mary sources are 49% in 2008 to 59% in 2009 non-functional 42% reduction in emergency room use links 36% reduction in hospital days 58% reduction in specialist use continued 195
From page 196...
... al., 2013) Patients matched to comprehensive care team Open access
From page 197...
... TABLE 5-3  Kitsap Mental Health Services Race to Health! Program Study Population Study Design Intervention Comparator Outcomes Risk of Bias Implement- Medicare Pre–post 846 people Matched co- Difference of difference for first 2.5 years Selection bias ing a whole clients at Kitsap comparison enrolled in the hort of 2,643 favored intervention group: from willinghealth model Mental Health of matched Race to Health!
From page 198...
... practitioner, social care p=.03) , but hospitalization rates were not a randomized worker, primary different controlled care clinician, and trial interdisciplinary In a predefined high-risk group, ED visits team using 12 (848 [n=106]
From page 199...
... progress Lower health care spending ($1,768– group 2,673 vs.
From page 200...
... TABLE 5-4  Continued 200 Study Population Study Design Intervention Comparator Outcomes Risk of Bias Scoping 6 studies with a Scoping PACE provides Participants in Studies comparing PACE to other pro- The 6 included review of total of 12,746 review comprehensive other caregiv- grams have mixed results studies were Program of adults partici- included stud- health ing programs 2/3 studies showed PACE participants more descriptive All-Inclusive pating in a care ies used cross and social services including had worse or declining activities of daily limiting assessCare for program sectional as to community- Wisconsin living, 1/3 showed improvement ment for risk of the Elderly well as retro- dwelling older Partnership 2/3 studies showed PACE participants had bias (PACE) versus spective and adults Program, less hospital use, 1/3 showed no difference other care prospective Medicaid 2/2 studies showed increased use of Selection bias programs cohort designs long-term community-based services utilization and from who en (2002–2013)
From page 201...
... conventional care of other social services (4%) , dental (13%)
From page 202...
... TABLE 5-6  Vermont Blueprint for Health 202 Study Population Study Design Intervention Comparator Outcomes Risk of Bias Vermont's Residents in Sequential Residents seen in Residents Quality Supported Community- Vermont who cross-sectional 123 participating seen in non- In post-year 2, participants had signifi- practices actively Oriented All- were seen for analysis, patient-centered participating cantly higher rates of adolescent well-care engaged in Payer Medical care difference medical homes practices visits, breast cancer screening, cervical measuring and Home Model of difference supported by cancer screening, appropriate testing for improving out comparing community health pharyngitis, and for people with diabetes come measures (Jones et al., post year 2 teams and pay- eye exams, A1c testing, lipid testing and 2016)
From page 203...
... Bethesda, MD., NICoE, usual planning for co- valuable while clinicians at larger facilities responding to for service were surveyed care clinicians, morbid traumatic perceived it as duplicative the survey members with with a 20–30% and service brain injury and Usual-care clinicians expressed a desire traumatic response rate members psychological to have more information from NICoE brain injury receiving care health conditions about eligibility criteria and services avail(TBI)
From page 204...
... Study Population Study Design Intervention Comparator Outcomes Risk of Bias Integrated Acute medical Prospective Implemented in Other regions 15,000 to 35,000 referrals per year Limited methods community hospitaliza- observational 2000 of New Annually from 2008 to 2014, a 30% presented in system to tion rate per cohort analy- Acute demand Zealand lower hospitalization rate in Canterbury reports reduce acute 100,000 people sis of national management sys- compared with New Zealand as a whole hospital in New Zealand health trends tem of supported 14% reduction in long hospital stays Reports focused demand (2008–2017) primary care teams (over 24 days)
From page 205...
... Community reha- Evaluation bilitation enable- focused on acute ment and support services and teams hospitalization 24-hour general usage practice Localized clinical guidance web site and shared electronic medical record TABLE 5-9  Health In all Policy Initiative (Australia) Study Population Study Design Intervention Comparator Outcomes Risk of Bias South Austra- 918 public ser- Mixed- Collaboration None Increased public servants' awareness Quantitative lian Health vant interviews, methods across sectors to of the health impacts of their agencies' data on number in All Policies 5 document case study develop policies on policies of policies initiative reviews, 144 (2012–2016)
From page 206...
... (2010–2013) and common ment in community health response rate, and compari- goals)
From page 207...
... 3.6, had similar morbidity conditions therapeutic plan CareWell p=.002) characteristics registered in 6 definition, patient program Non-statistically significant trends to(Mateo-Abad health systems stabilization at wards reductions in weight, glucose, blood et al., 2020; in Basque home by multi- pressure Rosete and Region disciplinary team, Nuno-Solinis, integrated care 2016)
From page 208...
... TABLE 5-11  Gesundes Kinzigtal Model (Germany) Study Population Study Design Intervention Comparator Outcomes Risk of Bias From rural Residents Observational None In 2010, of the 60,000 residents of No comparison Germany, in- of Kinzigtal analysis Kinzigtal, 31,000 were insured by AOK group tegrated care River Valley, (2006–2015)
From page 209...
... significance not nurses, dieticians, available in physiotherapists, English nutrition counselEvaluation of Residents Longitudinal ing, social workers Patients in- Greater improvements in 2 of 5 indica- Primary research the popula- of Kinzigtal cohort study sured by same tors of overuse (long-term NSAID use and studies in tion-based River Valley, (2004–2011) insurer in inappropriate medications for vascular German Integrated Germany, who other regions dementia)
From page 210...
... in Gesundes survey Overall, no positive or negative trend Kinzigtal: Full article only in health care indicators seen over time Interim results in German compared to control of a trend study Unclear how In setting of notable shared savings and members (Siegel and reduced cost, no decrease in quality com- selected to comNiebling, pared with more expensive usual care may plete survey be significant 2018) Survey response rate 23.4% in 2013 and Risk of response 24.9% in 2015 bias 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)
From page 211...
... Study Population Study Design Intervention Comparator Outcomes Risk of Bias What does 4.8 million Prospective Change over EBAIS teams provide 80% of care for Many primary community- Costa Ricans observational time health needs data sources in oriented pri- covered under cohort analy- Spanish mary health model sis of national Other By 2019 care look health trends countries More than 94% population empaneled Temporal like?
From page 212...
... with no external 2008) 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.
From page 213...
... 2019. To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation?
From page 214...
... 2021. Complementary and integrative health approaches offered in the Veterans Health Administration: Results of a national organizational survey.
From page 215...
... 2010. Gesundes Kinzigtal integrated care: Improving population health by a shared health gain approach and a shared savings contract.
From page 216...
... 2020. Impact of the Carewell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
From page 217...
... 2020. Implementing sustainable primary health care reforms: Strategies from Costa Rica.
From page 218...
... 2020. Innovations in care: Complementary and integra tive health in the Veterans Health Administration Whole Health System.


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