In a recent presentation at a National Academy of Medicine workshop, Tracy Gaudet, MD, the founding director of the Veterans Administration’s Office of Patient Centered Care and Cultural Transformation, described how radically her team is approaching their work to create health in the veterans they serve.
“We start with peer conversations between the veterans and their peers about what is important to them,” began Gaudet – who from 1995-2011 led integrative medicine programs at the flagship University of Arizona program founded by Andrew Weil, MD and then Duke Integrative Medicine, before being chosen to found the VA’s new office.
She continued: “Then, circling out from that, we have well-being centers. And then—only then—there is the clinic when one needs it. I say it again—it’s a total rewiring of what health care is and how it works.”
Gaudet recently returned to her integrative roots to keynote the May 2018 International Conference on Integrative Medicine and Health, sponsored by the Academic Consortium for Integrative Medicine and Health. In a presentation entitled Radical Redesign of Health Care: The Why, What and How and available here, Gaudet shared what she called “Aha!” moments that have guided the VA’s “whole health strategy.”
The values and practices of integrative health that were infused in Gaudet through her 15 years in the integrative community routinely informed these “Aha!” moments.
Gaudet’s first “Aha!” was that the Office’s service to veterans would not be contained by, or centered in, the clinical and inter-professional work. It wouldn’t come merely through integrating new practices and practitioners such as mindfulness and acupuncturists, with regular treatment – although this is work the VA’s Integrative Health Coordinating Center is directly furthering.
Instead they took from a “whole health” approach Gaudet had been involved in developing at Duke. They fostered a “whole systems approach” to influencing the health and wellbeing of veterans and their families.
This direction reminded me of a conversation with Gaudet in 1998 when she and her small team were developing what would become the first Fellowship in Integrative Medicine at the University of Arizona. In those early days of “CAM” integration, her team had just returned from a retreat, where, as Gaudet shared, they realized that “it’s not about the modalities – it’s about the approach.”
Here was an early “Aha!” – shifting the center of focus from the practitioners and practices to the human being for whom care was being offered.
At the VA, Gaudet’s next big “Aha!” was that the VA’s clinical operations were not the best locations for managing the new program. Clinicians were already over-burdened. Gaudet mimicked the response of time-pressured clinicians: “What, now I’m supposed to deal with the person’s whole life?”
She shared her clarity: “My assessment was that trying to do a wholistic approach within the medical system wouldn’t work,” she recalled. “The big ‘Aha!’ was that our whole health strategy could not be based in the clinic.”
Their next decision involved a significant “Aha!” – though she did not characterize it directly as such – that broke with the pattern of most medical delivery organization routine behavior.
A typical response of hospitals and other medical delivery organizations that look outside the disease model and hitch themselves to the health bandwagon is to build something. Typically, this will be a gym or a wellness center. Sometimes it’s an integrative medicine facility.
To Gaudet and her team, the strategy seemed limited: “We didn’t want to just send veterans down the street to a wellness center. We needed to somehow build the skills and reduce the stress and bring a new way of being to the veterans.” Gaudet drew again on her prior experience: “We took a concept from Duke of personal health planning. We developed a whole health model with the veteran at the center.”
The next “Aha!” required a deep dive into what makes a human being tick. Gaudet and her team accepted that no amount of cajoling, counseling or education about healthy choices could cause veterans to break harmful patterns until the veteran’s call to action was wedded to his or her personal sense of meaning. “It comes down to meaning and purpose – to discovering and rediscovering their personal sense of mission and what they want to live for,” Gaudet reflected. To be able to play with a grand-child. To see a relative graduate. To take a long-desired journey.
Gaudet said that this concept of engaging Veterans to get clear on what is most meaningful to them is being rolled out inside the VA. Via fits and some false starts, this line of engagement is beginning to flower in the center of the whole health encounter.
A first tactic in enforcing this direction was to vastly increase the use of health coaches, taking advantage of their motivational interviewing skills. Yet simple mathematics drove Gaudet and her team to another “Aha!” The size of the VA’s population of beneficiaries was the critical factor: “We have 9-million Veterans, and their families – how do we scale this?” Neither the present health coach work force nor the budget to rapidly train up and employ an army of healthy coaches was readily available. What, then, was possible?
Gaudet and her team chose to step even further outside of the clinical delivery site and clinician practice boxes. Grounded as they were in a patient-centered, empowerment model, they realized that the process of clarifying meaning and purpose would “ideally come through trained peers.” The Office developed an 8-9 week Circle of Health program to train and empowered the peer-based operation. The programs are now operational in 18 facilities where the VA is funded to engage the whole health program.
If you haven’t noticed, the VA’s cultural transformation under Gaudet is, indeed, radical. And it for all parties – for the veterans and their clinicians – not merely those in the dominant school.
Interestingly, Gaudet took the “Radical Redesign” in her title from Don Berwick, MD, a leader of transformation in the dominant school of medicine who co-authored an influential 2015 paper entitled New Rules for Radical Redesign in Health Care. Notably, two years prior, the former CMS Administrator and co-founder of the Institute for Healthcare Improvement credited integrative medicine leaders for mentoring him in the “health creation” concepts that significantly inform these radical redesigns.
One additional “Aha!” is here for the conventional medical community – and likely for many in integrative health and medicine. The most progressive efforts toward health creation – like Gaudet’s work with her team through the Office for Patient Centered Care and Cultural Transformation – are informed by the ideas and practices in the long evolution of the integrative health movement. Aha!