In this issue: Whole Health
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From the HSR Director's Desk
Whole Health: The Time Has Come
Modern medical practice has made great discoveries that have saved countless lives but at the same time can lead us on a course of over-medicalizing individuals without considering their preferences, life goals, and ultimately, their humanity. As one of the largest single providers of medical care in the U.S., VA has been a national leader in the rapid scale-up of person-centered care—initially for mental health care and now more broadly through VA’s Whole Health program—especially under the leadership of the Office of Patient-Centered Care and Cultural Transformation. This growth has complemented similar trends in VA recovery-oriented mental health services, such as focusing on Veterans’ life goals beyond their immediate treatment needs and modeling an “athlete-coach” perspective in the patient-provider relationship.
Overall, research, in close partnership with VA operations leaders, has played a prominent role in the scale-up and spread of whole health best practices nationally, namely through the development of practice-based infrastructures, strong data curation of person-centered outcomes, and validation and deployment of change strategies to support provider uptake of whole health best practices. This strong researcher-clinical partnership has led to significant impacts in the way VA has provided comprehensive Veteran-centered care for pain management, PTSD, and complex chronic conditions and settings, most recently for homeless-experienced Veterans. Hand in hand with VA operational leaders, VA investigators are poised to further impact the care experience for Veterans, through national partnerships with DOD and NIH to conduct comprehensive pragmatic trials involving the Whole Health system of care on pain management, mental health, and conditions related to military exposures (e.g., COPD), and ultimately, through innovative programs and policies that address social determinants to optimize Veterans’ life goals and journey beyond the clinic walls, especially for at-risk and marginalized populations.
–Amy Kilbourne, PhD, MPH, Acting Director, Health Systems Research
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Introduction
The benefits of addressing “whole health” (WH) in healthcare have gained increased attention and support within VA. This holistic approach looks beyond symptoms and disease to also encompass patients’ goals, well-being, and social determinants of health (SDoH)—factors such as economic and housing stability, loneliness, discrimination, and healthcare access, which can influence health or even be the root cause of health problems.
VA’s Health Systems Research (HSR, formerly HSR&D) and Quality Enhancement Research Initiative (QUERI) work to build scientific evidence that supports VA’s transformation to a Whole Health system of care and informs VA’s WH treatments, programs, and policies. Investigators with HSR and QUERI assess ways to promote Veterans’ WH, develop effective interventions to optimize WH, and speed implementation of WH practices. Their work includes partnerships with diverse offices and programs across VA, such as the Office of Rural Health, the Office of Mental Health and Suicide Prevention, the Office of Patient Centered Care & Cultural Transformation, Women’s Health, Primary Care, and specialty care services such as cardiology and pulmonary medicine.
Measuring What Matters Most: Considering the Whole Person in Healthcare Research
“The question ‘What’s the matter with you?’ has generally been the guiding principle in our find-it and fix-it problem-based approach to healthcare. Whole health shifts the focus to the question ‘What matters to you?’”
—Benjamin Kligler, MD, MPH, Executive Director, VA Office of Patient Centered Care & Cultural Transformation
At a 2023 HSR State of the Art (SOTA) conference on “Measuring What Matters Most (M3): Whole Person Outcomes in Clinical Care, Research, and Population Health,” about 60 internal and external operations and research experts gathered to discuss current knowledge of whole person measures, and to identify a research agenda that closes research gaps and supports Veterans’ WH in clinical care and as a population. This includes examining well-being not only as an outcome, but as a moderator or mediator that might influence the effectiveness of disease interventions.
An upcoming HSR-sponsored supplement of the journal Medical Care will include findings from the SOTA conference and related research, plus perspectives from the broader field on how measurement of well-being and whole person outcomes can improve health and healthcare delivery.
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What We’ve Done Lately
Recent impactful Whole Health research by HSR investigators includes:
- Examining the relationship between Veterans’ use of VA WH services and mental health treatment. Engagement in evidence-based psychotherapy (EBP) among Veterans with behavioral health conditions is often low. This study found that Veterans with depression, anxiety, and/or PTSD who used VA’s WH system of care were more likely to engage in EBP.
- Examining VA’s WH model of care within the context of PTSD.
This study compared patient-reported outcomes between Veterans who used WH services versus those who did not, among Veterans with and without PTSD. Researchers found that Veterans with PTSD were more likely to have used WH than those without PTSD, and Veterans with PTSD who used WH services experienced small improvements over 6 months in physical and mental health functioning, while Veterans without PTSD who used WH services experienced small improvements in physical health but not mental health.
- Determining whether complementary and integrative health approaches are associated with pain care quality in VHA primary care. Complementary and integrative health (CIH) approaches have been recommended in national and international clinical guidelines for chronic pain management. This study found that incorporating CIH approaches may reflect higher overall quality of care for Veterans with musculoskeletal pain seen in primary care settings.
- How VA WH coaching can impact Veterans’ health and quality of life. This study found that surveyed Veterans who participated in a pilot VA WH coaching program showed significant improvements in mental health, stress, and perceived health competence. Participants were highly satisfied with their coaching experience, describing effective program components and improvement opportunities.
- Understanding Veteran and provider perspectives on the impact of tele-WH services. Although the value of synchronous telehealth for monitoring disease and increasing access to healthcare has been well established, its role in promoting well-being as part of a WH system of care had not previously been explored. This study found that Veterans and providers perceived WH services provided via telehealth to be a strong complement to in-person services and a promising mechanism for improving engagement with WH-aligned services and promoting Veterans’ well-being.
- Use of WH services among Veterans with spinal cord injuries and disorders (SCI/D): Early insights from the VA SCI/D system of care. This study found that participation in WH programs across the VHA SCI/D system of care has been increasing among Veterans with SCI/D, but use of WH among Veterans with SCI/D remains low overall. Targeted efforts to increase WH program reach are needed, along with additional information about the relative effectiveness of different strategies to support WH implementation.
- Integrating peer support and WH coaching with primary care to address the healthcare needs of homeless Veterans. Although intensive outpatient programs have been developed for homeless Veterans who are high utilizers of acute care, few scalable programs have been implemented to address their needs. This study tested a novel intervention that features peer specialists and WH coaches who coordinate with primary care teams to reduce homeless Veterans’ frequent use of acute care.
- Assessing changes in Veteran-reported outcomes associated with use of WH in the VHA’s National Demonstration Project. This study found that among Veterans with chronic pain, compared to those who did not receive WH services, those who received WH services over time reported greater improvements in patient engagement in healthcare and self-care, and in their experiences of care as being more patient-centered.
- Assessing the effectiveness of VA’s WH model of care on reducing opioid use among Veterans with chronic pain. The opioid crisis has necessitated new approaches to managing chronic pain. VA’s WH model of care, with its focus on patient empowerment and emphasis on nonpharmacological approaches to pain management, is a promising strategy for reducing Veterans’ use of opioids. This study found that Veterans with chronic pain who used VA’s WH services had greater reductions in opioid use than those who did not use WH.
QUERI works with stakeholders throughout VA to deploy and evaluate implementation and quality improvement strategies that optimize care for Veterans. QUERI projects related to WH include:
- The Center for Evaluating Patient-Centered Care (EPCC-VA) examines the implementation and impact of VA’s transformation to a WH system of care.
- The Complementary and Integrative Health Evaluation Center (CIHEC), in collaboration with VA’s Office of Patient Centered Care & Cultural Transformation, evaluates the implementation of evidence-based complementary and integrative therapies and the effectiveness of novel CIH therapies for Veterans and VA employees.
- Bridge QUERI strives to help Veterans negotiate the care continuum, focusing on homelessness, the justice system, and substance abuse.
- EMPOWER QUERI works to expand access to virtual, evidence-based, preventive and mental health services for women Veterans, focusing on heart disease, depression, and reproductive health.
- Housing Transitions QUERI aims to support Veterans as they transition from VA residential programs to independent living.
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What’s Upcoming
Ongoing HSR-funded research projects that target Whole Health include:
- Evaluating the impact of WH coaching for Veterans with chronic pain and opioid dependence: The TEAMWORK trial. The intersecting problems of high-impact chronic pain and the opioid overdose crisis continue to be major public health concerns, yet few solutions to support comorbid chronic pain, opioid dependence, and opioid-related harms are available. This study, funded by the NIH-DOD-VA Pain Management Collaboratory, aims to evaluate the impact of WH coaching for Veterans with chronic pain and opioid dependence by comparing the effectiveness of treatment with usual care (pain management teams; PMT) with PMT treatment enhanced with WH coaching (PMT-WHC).
- Assessing pain, patient reported outcomes, and complementary and integrative health: The APPROACH trial. This large-scale (n=18,000) trial is assessing the effectiveness of five types of CIH approaches on chronic pain and pain-related conditions among Veterans with chronic musculoskeletal pain. The study is being conducted at 18 VA WH flagship sites, in partnership with VA’s Office of Patient Centered Care & Cultural Transformation.
- Optimizing the implementation of WH coaching for Veterans with COPD. A key component of VA’s WH system of care is WH coaching, which pairs Veterans with trained professionals who deliver one-on-one support for setting and achieving personally meaningful health and well-being goals. However, little guidance exists on WH coaching best practices for Veterans with complex clinical needs. This study is partnering with VA’s Office of Patient Centered Care & Cultural Transformation to explore how to optimize the implementation of WH coaching for Veterans with COPD, with the potential to improve the care and quality of life for this large Veteran population.
- Developing a blueprint to implement WH clinical care for Veterans with HIV. Currently, implementation of VA’s WH system of care focuses on primary and mental healthcare. This study seeks to advance WH implementation guidance for specialty care services, particularly those for Veterans with HIV. Researchers will identify and work with HIV specialty care Veterans, providers, and leaders to co-design a WH implementation blueprint that can serve as an example for WH coordination across VA primary and specialty care settings.
- Using data analytics and WH coaching to reduce frequent use of acute care among homeless Veterans. Homelessness is a robust social determinant of acute care use. This study aims to integrate use of data-driven processes with peer specialists trained in WH coaching to better tailor care for high-need, homeless Veterans in VHA and facilitate homeless Veterans’ engagement in supportive services to reduce their frequent reliance on acute care services.
- Implementing a clinical-community partnered intervention to address food insecurity among high-risk Veterans. Nearly 25% of Veterans are estimated to be food insecure (FI), experiencing limited or uncertain access to nutritionally adequate and safe foods. This study aims to address knowledge gaps related to identification of FI Veterans in clinical settings, and FI Veterans’ interactions with VA and community resources. The project also intends to develop and pilot test an intervention model to optimize screening and referral for connecting FI Veterans to relevant resources.
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