That there should be a huge transformational drama underway in the US medical industry is a desire and dream that powers the integrative health movement and the work of many others. Those who might enjoy a sort of reality TV examination of not the fantasy but the multi-dimensional actuality of what such change looks like have a treat coming. The scene of action is 18 huge medical centers distributed across the entire United States. The script writers are 25 scientists on an evaluation team. The drama cuts across 4 deeply inter-related story lines: the impact of the transformational change on patients, on employees, on utilization, and on the extent of implementation and cost. We the people literally own this story. The investment and outcomes – from which any delivery organization can learn – are revealed in plain English in the public domain. If the launch of the transformational journey was Episode 1 of the series, then this 39-page report after two years is Episode 2. It’s deep insight into a dream coming true in the Whole Health System of Care at the US Veterans Administration (VA). It’s long awaited. And it is exciting.
Not everything or anything in this story is easy. Balls get dropped. The comment from the program manager for one site (see box) opens up the multiple tiers of consideration when the charge is to fulfill on whole system transformation – not just clinical but system transformation to support the approach. The VA defines whole health this way:
… an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their life to the fullest. The goal is to transform the organization and culture of care to a system which starts with understanding the Veteran’s life mission, aspiration and purpose (i.e.,what matters most to the Veteran) and then provides care to improve Veterans’ overall health and well-being.
The researchers learned that one cultural barrier is that often medical center leaders viewed Whole Health out of an old paradigm. They considered it “as a program or service rather than an approach to care that [also] includes additional services” such as self-care, peer counseling, health coaching, acupuncture, chiropractic, mindfulness and massage. Not surprisingly, a key characteristic found in leaders of the 18 institutions that have advanced most rapidly is that they themselves have taken integrative practices into their own self care. Whole health is not a thing, but a new way of being.
The finding echoed a moment nearly 25 years ago in the evolution of thinking at the University of Arizona Andrew Weil Center for Integrative Medicine, the most influential academic center for the spread of integrative medicine in medical delivery institutions in the United States. Tracy Gaudet, MD, then the center’s founding executive director, realized that their charge was not to teach how to adorn the tree of biomedicine with a few ornamental complementary medicine therapies. Rather, the charge was to teach a new approach to the patient, including making use of new therapeutic tools, but in a new values context.
Gaudet left the VA in August of 2019 after 8 years conceptualizing and founding the VA’s Whole Health program from her position as the founding director of the VA’S Office of Patient Centered Care and Cultural Transformation. She took her foundational learning at the University of Arizona and then Duke Integrative Medicine further at the VA. The focus is no longer on a “patient” but on the veteran and on his or her family. The whole health system is grounded in an abiding first commitment to partnering with veterans to locate “what matters to you” – their own sources of joy, interest, pleasure and motivation. On this they are building the system of self-care, peer-counseling, coaching, integrative services, and necessarily transformed institutions.
That the over-all outcomes after two years have been positive is most evident not in the thorough analyses of the 25 researchers in the evaluation team captured in this report but in an action of the VA’s leadership. In September 2019, after reviewing preliminary data that would power the report, the VA’s leadership chose to more than triple to include now a total of 55 medical centers a program that began as a three-year pilot in the 18 sites noted in box.
Pilot no longer! For more and more veterans, this Reality TV show not only got an extension – whole health is hitting prime time.
The scale of change desired was declared bluntly by Gaudet and long-time integrative leader Ben Kligler, MD, MPH last year in an open access column entitled Whole Health in the Whole System of the Veterans Administration: How Will We Know We Have Reached This Future State? Gaudet brought Kligler in to lead the VA’s Integrative Health Coordinating Committee. He is presently serving as acting director of this effort to transform the entire VA to a “future state” of a veteran-centered, health-focused system.
The report’s executive summary provides two pages of outcomes from the multiple research projects backing the report. Keep in mind that these are just 2 years into a start-up operation. Here is a sampling:
- 31% of Veterans with chronic pain (up to 55% at one center) engaged in some whole health services (expected to reach 44% of Veterans with chronic pain by the end of 2020).
- Opioid use among comprehensive whole health users decreased 38% compared with an 11% decrease among those with no whole healt use.
- Greater improvements, compared to non-users of whole health services, in: perceptions of the care being more patient-centered; engagement in healthcare and self-care; engagement in life indicating improvements in mission, aspiration and purpose; and improvements in perceived stress indicating improvements in overall well-being
- Employees involved with whole health reported: lower voluntary turnover; lower burnout; greater motivation; and more likelty to rate their facility as a ‘best place to work.’
- Facilities with higher employee involvement in whole health had higher ratings on hospital performance and higher ratings on receiving patient-centered care.
- Cost data are preliminary; early indications are positive. Whole health-using veterans with mental health conditions had substantially smaller increases in outpatient pharmacy costs (3.5% versus 12.5%) and those with chronic conditions similarly (4.3% increase versus 15.8%) compared to veterans not using whole health services.
I contacted Kligler, the present acting director of the VA’s Office of Patient Centered Care and Cultural Transformation, for a perspective from where he sits, on the outcomes. He sent this note:
We are so excited that veterans and VA staff are experiencing the level of benefit from whole health that we see in our flagship outcome report. This data is giving us the momentum we need to continue the effort to spread Whole Health across the entire system.
Leadership matters. Engaged leaders of the separate VA medical centers led in multiple ways besides personal engagement with and participation in self-care processes. They “provide tangible support during the early transformation phases, which includes addressing barriers to hiring staff, allowing key staff to have protected time to work on implementation activities, assistance with addressing challenges, and requiring all staff to take part in Whole Health trainings.”
The report and all the appendices are the work of over two dozen scientists, led by Boston University associate professor Barbara Bokhour, PhD, director of the Evaluating Patient Centered Care (EPCC) program. These are in turn examining the on-the-ground efforts of literally thousands of care-givers and administrators. The drama that unfolds is not dry. One needn’t have an over-active imagination to picture the multitude of human vignettes captured in the studies. Those desiring whole system change will experience a satisfying and fascinating affirmation of what is possible with change when principles are applied toward the “future state”. These early data are strong enough that such positive changes may be expected to continue to reveal themselves through future episodes of this drama that is all of our drama: treating the huge population of veterans that the U.S.’ continually replenishes with its penchant for wars and global policing.
One cannot close without thinking of the much-needed yet still fantasy spin-off sequel: implanting the VA’s Whole Health System of Care in the production-oriented, cog-in-a-machine medical industry that is civilian medicine. A.K.A. the treatment that most of us receive. This translation is now part of Gaudet’s charge in her new position directing the Whole Health Institute that she is birthing out of a yet unreported commitment level from the $44-billion fortune of Walmart heiress Alice Walton.
But is translation possible with the current payment and delivery model in US medicine? This report from the VA evaluation team notes that one key barrier to whole health is a “misalignment of incentives.” Unlike the medical industry that produces treatment for the civilian population, the VA single payer. In fact, the VA’s clinical incentive structure also different in that it is a full-on UK National Health System model in operating not only as single payer but also with employed clinicians. Can we see translation of this whole health model to civilian care without dramatic Congressionally-mandated changes in the US medical industry? Without such changes, the Gaudet-Walton experiment may be a Sisyphean undertaking.
Post-script: In the time of COVID-19 it may be useful and helpful to note that the roll-out into the first 18 centers of this ambitious and transformative initiative – not a “program but an approach” – was born out of the 2016 Obama-era Comprehensive Addiction and Recovery Act (CARA) in response to the nation’s crisis in chronic pain management. What good may come of the present, overwhelming public health challenge?