Achieving Whole Health A New Approach for Veterans and the Nation (2023) / Chapter Skim
Currently Skimming:
6 Scaling and Spreading Whole Health
6 Scaling and Spreading Whole Health
Pages 219-296
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 219... ...
instructed the committee to consider ways to transform health care by scaling and disseminating whole person care to the entire population. This chapter and the one following will consider how the Department of Veterans Affairs (VA)
|
From page 220... ...
This chapter addresses three key contextual conditions that will FIGURE 6-1 The committee's framework for scaling and spreading a whole health model of care.
|
From page 221... ...
A shift from the current state to whole health care will require a transformation that incorporates individuals' core values, goals, and priorities and focuses on upstream factors while maintaining high-quality disease management. It will also require breaking down conceptual, administrative, financial, and policy barriers that isolate clinical care from the coordinated assessment and management of upstream factors, such as adequate housing, financial security, food security, and social support, which account for most of the variance in health outcomes (Magnan, 2017)
|
From page 222... ...
The whole health models this report describes in Chapter 4 provide good examples of how local and regional health systems can shift their philosophical approach and service delivery design within their local policy environments. Extending whole health across the entire United States will, however, require strong bottom-up demand from patients, families, health care professionals, and the public at large at the national level as well as top-down macro and meso public policy and infrastructure change to support and operationalize it.
|
From page 223... ...
Examples from History Three historical examples, the mental hygiene movement (Novick, 1949) , the Flexner report (Flexner, 2002)
|
From page 224... ...
. Beers, James, and Meyer formed the National Committee for Mental Hygiene
|
From page 225... ...
Flexner's indictment of the status quo mobilized medical societies and legislators at state and federal levels and led to strong regulatory support through professional sanctions and new licensing laws. Although his efforts boosted the development of modern academic medical centers across North America and beyond, Flexner's primarily topdown, macro-level strategy also produced significant negative consequences, including a devastating effect on historically Black medical schools across the United States (Savitt, 2006)
|
From page 226... ...
. The success of the mental hygiene movement, the consequences, for good and ill, of the Flexner report, and the transformative change wrought by the Medicare and Medicaid Act in the 20th century offer lessons for the 2 42 U.S.C.
|
From page 227... ...
STRUCTURES AND PROCESSES FOR SCALE AND SPREAD Beyond, and in support of, the systems change described in the previous section, scaling and spreading whole health systems will require new structures and processes along with practical ways to integrate them. The statement of task asked the committee to describe strategies, including implementation science strategies, that can overcome barriers to scaling and implementing components of whole health, such as integration of mental health, complementary and integrative health, health coaching, peer-to-peer approaches, and well-being.
|
From page 228... ...
health care in the face of the barriers described above include health ecosystems at the macro level, integrated delivery systems at the meso level, and interprofessional care teams at the micro level (Mitchell et al., 2010)
|
From page 229... ...
Federally qualified health centers (FQHCs) also provide care through interprofessional care teams which are effective in coordinating a broad variety of health services to meet the diverse needs of their patients (Wright, 2012; Wright et al., 2017)
|
From page 230... ...
Such assessments also help determine the ratio of primary care teams to the population served and 3 https://www2.census.gov/geo/maps/DC2020/AIANWall2020/2020_AIAN_US.pdf (accessed December 15, 2022)
|
From page 231... ...
While PACTs are focused primarily on core clinical services and do not generally have embedded social services such as homeless coordinators, nutritionists, or the many other disciplines required to comprehensively address whole health, they are associated with several positive clinical outcomes. These include fewer hospitalizations, specialty care visits, emergency department visits, and specialty mental health visits; an increase in mental health visits in primary care settings and in use of preventive services; lower levels of staff burnout; higher patient satisfaction with access to care; and clinical improvements for patients with diabetes, heart disease, and hypertension (Bidassie, 2017; Hebert et al., 2014; Leung et al., 2019; Nelson et al., 2014; Randall et al., 2017; Rodriguez et al., 2014)
|
From page 232... ...
Community care team members could include social support professionals to help with housing, food insecurity, childcare, elder care, educational, training, and employment needs; peer-support specialists; home health aides; disability support professionals; and religious or spiritual supports, among others. In addition, community care teams have the capacity to address many upstream factors -- one of the committee's five foundational elements of whole health (see Chapter 2)
|
From page 233... ...
Extended whole health care teams include members and services more peripheral to an individual's care plan but still involved on an as-needed basis to augment the core team. For example, someone with recurrent major depression that is usually managed by their primary care clinician may have a mental health specialist as part of the extended care team for consultation and occasional check-ins.
|
From page 234... ...
. Teams for panels with higher social needs, for example, may include community health workers, behavioral health specialists, and other social supports but fewer physicians.
|
From page 235... ...
. Systems and payers should consider how to incorporate, coordinate, and pay for services that address upstream factors, complementary and integrative modalities, health coaching, and peer-to-peer supports, along with other services and programs that standard care delivery does not typically include.
|
From page 236... ...
. This process of spreading and scaling whole health can build on lessons from other health delivery innovation models both inside and beyond VA, several of which Chapters 4 and 5 describe (Kilbourne et al., 2012)
|
From page 237... ...
SCALING AND SPREADING WHOLE HEALTH 237 FIGURE 6-3 The ExpandNet/WHO framework for systematically scaling interventions.
|
From page 238... ...
It was designed specifically to help predict and evaluate the success of a technology-supported health or social care program (Greenhalgh et al., 2017)
|
From page 239... ...
FIGURE 6-5 Ariadne Labs arc framework for spread. SOURCE: Ariadne Labs, 2022.
|
From page 240... ...
240 ACHIEVING WHOLE HEALTH FIGURE 6-6 The Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework.
|
From page 241... ...
SCALING AND SPREADING WHOLE HEALTH 241 a five-step systematic process to identify, replicate, and eventually scale and spread practices with the greatest potential for positive impact (Figure 6-7)
|
From page 242... ...
• If successful, a handoff to local operational leaders to continuously refine local adaptation and own practice sustainment over time. SCALING AND SPREADING WHOLE HEALTH TO ALL ENROLLED VETERANS The statement of task charged the committee to comment on how VA can accelerate clinical integration with community services to expand whole person care to veterans who receive their care outside VA through the VA MISSION Act's provisions.
|
From page 243... ...
How can VA scale whole health to reach all enrolled veterans, including those who receive care outside of VA through the VA MISSION Act?
|
From page 244... ...
. One study showed that in the process of delivering whole health care to veterans and adopting a whole health approach to their own care during the pandemic, VA staff reported sig nificant improvement in their personal well-being and work experience (Reddy et al., 2021)
|
From page 245... ...
VA employees working at WHS test sites also recommended developing communication networks that build facility capacity to identify and coordinate the full range of WHS services within a community. This aligns with the committee's discussion in Chapter 4 that VA's current WHS implementation does not fully address all of the committee's five foundational elements.
|
From page 246... ...
. De-Siloing VHA and VBA Services to Address Upstream Factors As Chapter 1 described, VA is officially a single entity, yet in many ways it operates as three separate entities: the Veterans Health Administration (VHA)
|
From page 247... ...
Enhanced integration or coordination of VHA and VBA efforts could achieve veteran-centered synergies in support of VA's WHS scale and spread because a large portion of VBA's portfolio addresses issues relevant to the upstream factors that are foundational to whole health. For example, as Chapter 1 describes, VBA has a variety of programs that provide direct financial compensation for service-connected disabilities, employment benefits, educational benefits, low-interest home loans and mortgage delinquency assistance, financial management assistance, independent living assistance, and other means of support that directly address the social determinants of health (VA, 2022h)
|
From page 248... ...
also provides a unique opportunity for new veterans and their families to acquire a whole health perspective and engage VA's WHS. Unfortunately, current transition practices fail to incorporate a whole health approach.
|
From page 249... ...
These advantages could be multiplied if Solid Start were to include "fast track" enrollment in VA's WHS that engaged new veterans in comprehensive whole health care early enough in their civilian careers to have maximum impact on their well-being and social determinants of health. The simple act of orienting new veterans and their families to whole health principles and practices -- whether or not they chose to enroll in VA care -- could have the added benefit of increasing awareness of and demand for whole health practices in non-VA health systems.
|
From page 250... ...
As such, they may be eligible through VA for a unique set of important health resources, including access to specialty and subspecialty care, sophisticated diagnostics, pharmaceuticals, surgical procedures, inpatient services, and long-term residential and rehabilitation services -- but only if their non-VA health care providers identify them as veterans. In fact, both veterans and their non-VA providers stand to benefit if they realize that they may be eligible for reimbursement and coordination of care through VA's Community Care program.
|
From page 251... ...
Upon its implementation in June 2019, the MISSION Act established a new community care program designed to improve access to non-VA care for eligible veterans. The statement of task (see Chapter 1)
|
From page 252... ...
The MISSION Act also established a new urgent care benefit that eligible veterans can access through VA's network of urgent care providers in the community (VA, 2019) .10 During the Veterans Choice program era, over one-third of VA-enrolled veterans used community care (Mattocks and Yehia, 2017)
|
From page 253... ...
For example, on July 14, 2022, nine senators wrote to Department of Veterans Affairs Secretary Denis McDonough to raise concerns regarding access to community care as authorized by the MISSION Act (Daines et al., 2022)
|
From page 254... ...
One major barrier in implementing the MISSION Act has been difficulty enrolling community providers in community care networks. A survey of VA facility directors identified the following major impediments to enrolling community providers: delays in reimbursement, low Medicare reimbursement rates, and confusing VA rules for prior authorization and bundled care (Mattocks et al., 2021)
|
From page 255... ...
One study (Benzer et al., 2020) found that the lack of interoperable EHRs between VA and community care systems, combined with "bureaucratic and opaque procedures," created significant obstacles to care coordination.
|
From page 256... ...
While many of the new collaborations between VA and community systems and services developed through the MISSION Act could potentially accelerate scaling of whole health care to enrolled veterans receiving health services outside of VHA facilities, these same challenges apply. Another key question for VA's WHS is whether the MISSION Act, which specifies its focus on hospital care, medical services, and extended care services to covered veterans through health care providers, would even cover services that address upstream factors of health and well-being that are critical to scaling and spreading a whole health approach but that are typically delivered outside traditional clinical settings.
|
From page 257... ...
Until such progress is made, VA's clinical integration with community services to expand whole person care to veterans receiving care outside VA through the VA MISSION Act will remain elusive. This is unfortunate because successful implementation of the MISSION Act could serve as a powerful driver of whole health spread across the nation.
|
From page 258... ...
By organizing at the state level, the NCGWG can build upon the existing expertise, resources, and communications sys tems of state departments and programs -- including veterans affairs, mental health, housing, education, labor, commerce, and education -- along with VHA and VBA programs within the state, state chapters of veterans service organizations, military bases within the state, and the state National Guard, among many other entities and organizations. In taking a big tent approach to public–private partnership, the Governor's Working Group builds bridges that connect veterans with health care and a wide range of social services within and beyond VA for problems such as homelessness, educational needs, underemployment, and justice involvement.
|
From page 259... ...
As such, it is also positioned to serve as a national information backbone for whole health transformation. 1 Additional information is available at https://ncgwg.org/ (accessed August 2, 2022)
|
From page 260... ...
Effectively spreading whole health services requires enabling integrated services within and among interprofessional care teams, delivery systems, and health ecosystems. It also requires integrating services across clinical and nonclinical services that support the foundational elements of whole health and that may or may not exist within a given health system as well as integrating services over people's lifespans (Singhal et al., 2020)
|
From page 261... ...
The processes that support integration must also be able to adapt to the values and needs of a diverse population with different preferences as to where and how to receive care, whether individuals access care in person or virtually, or whether they access care individually or with family or caregivers. The array of services needed to support scaling and spreading whole health includes clinical services offered within health systems as well as support services that address upstream factors that contribute to health, such as housing, vocational assistance, childcare, and well-being programs that are not customarily considered part of patient care.
|
From page 262... ...
and meso (within and across teams) levels, the committee suggests that developing, scaling, and spreading new health roles, including health coaches, peer-support specialists, care coordinators, and community health workers, could significantly enhance integration.
|
From page 263... ...
. Integrated primary care and mental/behavioral health programs play a particularly important role in addressing complaints frequently encountered in primary care settings, including sleep problems (Goodie et al., 2009)
|
From page 264... ...
. The engagement of the primary care team lead and psychiatrist was a critical enabler for successful implementation (Curran et al., 2012; Eghaneyan et al., 2014)
|
From page 265... ...
According to the National Institutes of Health's National Center for Complementary and Integrative Health (NCCIH, 2021) ,11 examples of CIH interventions include • Nutritional, including special diets, dietary supplements, herbs, and probiotics; • Psychological, including mindfulness techniques; • Physical, including massage and spinal manipulation; and • Combinations of the three, such as yoga, tai chi, acupuncture, dance or art therapies, and nutritional, such as mindful eating.
|
From page 266... ...
These 12 Additional information about the Integrative Health Coordinating Center is available at https://www.va.gov/WHOLEHEALTH/professional-resources/IHCC.asp (accessed August 3, 2022)
|
From page 267... ...
. Social needs are integral upstream factors of health -- one of the committee's five foundational elements of whole health -- and include access to safe housing, food, and transportation; education, job opportunities, and employment; clean and safe built and natural environments; and financial security, among other factors.
|
From page 268... ...
Social workers are integral members of the PACE interprofessional care team and help ensure that participants' social needs are met. Mary's Center is another model that partners with and facilitates connection with social services resources in the surrounding community as needed.
|
From page 269... ...
Each of these innovations makes it easier for veterans -- and those who serve them -- to connect with needed support within their own communities and on their own terms. VA established programs such as the NRD, HUD-VASH, and the VCPs to assist local communities in identifying and, when necessary, developing their capacity to address the committee's five foundational elements.
|
From page 270... ...
Examples include supportive payment systems, robust metrics and data analysis, interoperable technology, and systematic diffusion of innovation and best practices. Integration of Health Coaches, Peer-Support Specialists, Community Health Workers, and Care Coordinators Health coaches, peer-support specialists, community health workers, and care coordinators all play an integral role in a whole health approach.
|
From page 271... ...
. A variety of studies have identified barriers and facilitators to integrating health coaching into health care teams.
|
From page 272... ...
A study examining barriers and facilitators to integrating peer support into health care teams as a means of improving patient health and well-being cited a failure to clearly define and communicate the role of the peer-support specialist within the organization overall and the care team specifically as barriers to implementation (Cabral et al., 2014)
|
From page 273... ...
Success depends on hiring the right people for the job, ensuring fidelity to the standardized model, and integrating community health workers into the care team through patient referrals, data infrastructure, team huddles, and effective communication via the EHR. One study that reviewed successful efforts to integrate community health workers into patient-centered medical homes identified four themes as facilitators: the presence of leaders with knowledge of community health workers who championed the model, a clinic culture that favored piloting innovation rather than maintaining established care models, clinic prioritization of patients' non-medical needs, and leadership perceptions of
|
From page 274... ...
. Many care coordinators are registered nurses, community health workers, or social workers.
|
From page 275... ...
. Organizational/system barriers included challenging caseloads, a lack of needed functionality in EHR systems, the need to establish alternate communication methods among care team members, and difficulty identifying community resources.
|
From page 276... ...
. Of particular relevance, HRSA is the government agency responsible for developing the Health Center Program, which now includes almost 1,400 health centers operating more than 13,500 service delivery sites across every state (HRSA, 2022b)
|
From page 277... ...
While not all FQHCs currently have the resources and infrastructure necessary to meet the whole health needs of their communities, the examples cited in this report demonstrate that the national FQHC model is highly compatible in both mission and policy with a whole health approach. Given progressive development in policy and resource allocation, HRSA's Health Center Program could fully incorporate the five foundational elements of whole health into its certification requirements.
|
From page 278... ...
Although VA has long provided clinical care through the VHA while simultaneously addressing upstream factors through the VBA, it cannot succeed in scaling its WHS in a way that fully addresses all foundational elements of whole health or provide a compelling model for national whole health without greater integration of programs and services that promote education, employment, financial security, and other social determinants of health within VA's WHS. Because so many of the services needed to support whole health currently exist in isolation from clinical programs, VA and non-VA health care systems alike should create and strengthen collaboration with community care, social service, and public health systems at local, regional, and, when appropriate, national levels.
|
From page 279... ...
Congress framed MISSION Act language specific to hospital care, medical services, and extended care services. These provisions are intended to enhance access to standard medical care, but it is unclear whether they also allow VA to extend WHS to veterans by taking advantage of community care through the MISSION Act.
|
From page 280... ...
2021. Community health workers.
|
From page 281... ...
2018. Mobilizing com munity health workers to address mental health disparities for underserved populations: A systematic review.
|
From page 282... ...
2017. A collaborative care team to integrate behavioral health care and treatment of poorly-controlled type 2 diabetes in an urban safety net primary care clinic.
|
From page 283... ...
2020. Embedding social workers in Veterans Health Administration primary care teams reduces emergency department visits.
|
From page 284... ...
2019. Integrating community health workers into health care teams without coopting them.
|
From page 285... ...
2014. Best practice guidelines for implementing and evalu ating community health worker programs in health care settings.
|
From page 286... ...
2014. The effects of health coaching on adult patients with chronic diseases: A systematic review.
|
From page 287... ...
2017. Integrating community health workers into complex care teams: Key considerations.
|
From page 288... ...
2021. Understanding VA's use of and relationships with community care providers under the Mission Act.
|
From page 289... ...
2021. VHA risks overpaying community care provid ers for evaluation and management services.
|
From page 290... ...
2018. Integrating community health workers into medical homes.
|
From page 291... ...
2013. "It's like being a well-loved child": Reflections from a col laborative care team.
|
From page 292... ...
2019. What should health care systems consider when implementing comple mentary and integrative health: Lessons from Veterans Health Administration.
|
From page 293... ...
2022a. Community Care Network -- Information for providers.
|
From page 294... ...
2014. Patient aligned care teams (PACTs)
|
From page 295... ...
2022. Outpatient care fragmentation in Veterans Affairs patients at high risk for hospitalization.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.