Whole Health in the Veterans Health Administration.

The Whole Health System being developed and implemented at the Veterans Health Administration is an approach to care which aims to shift the discussion from "What's the Matter With You?" to "What Matters to You?" This article describes some of the progress and future challenges in the implementation of this approach across the VHA.

“The ancients knew something, which we seem to have forgotten.”

“We still do not know one thousandth of one percent of what nature has revealed to us. It is entirely possible that behind the perception of our senses, worlds are hidden of which we are unaware.”

—Albert Einstein

Our use of the term “Whole Health” to describe the work we are doing in the Veterans Health Administration (VHA) to put the Veteran at the center did not emerge into wide usage until 2014. However, the transformation that underlies this work has been going on in the VHA for 2 decades or more. The most concrete example of that perhaps is the stand-up of the Office of Patient Centered Care & Cultural Transformation (Whole Health Home (va.gov)) in 2011 under the leadership of Dr Tracy Gaudet. But clearly that would not have happened if VHA had not already been moving for some time in the direction of “personalized, proactive, patient-driven care” as a guiding concept, as well as toward a commitment to make complementary and integrative health approaches more widely available to Veterans. And the fact that “Cultural Transformation” was included in our office’s name to me suggests that even in 2011 VHA leadership had a sense of the importance and magnitude of the shift we would be making as an organization on this journey toward whole person care.

We define Whole Health as “an approach to care that empowers and equips a person to take charge of their health and well-being and live their life to the fullest.” The core idea is that a health system like the VHA can move beyond a singular focus on disease-oriented care—which is still the main focus of our entire American healthcare system—to work toward health creation and promoting well-being. Or, as we often say, “Moving from what’s the matter with you to what matters to you.” In no way does this mean we sacrifice the commitment to providing the highest quality disease treatment and disease prevention—as VHA currently does —but we broaden the system’s mission to put what is most important to the Veteran and their family at the center of every interaction and every decision. There is clear evidence now that decreased meaning and purpose in life can increase the risk of early mortality by a factor of 2.4. The Whole Health approach aims to help the veteran reconnect with meaning and purpose in her or his life as a fundamental component of our mission to preserve and promote health.

The Whole Health System as we are currently implementing it in the VHA has 3 primary components. The first is the Pathway, a non-clinical experience in which a Veteran has the chance to connect with a fellow Veteran trained in Whole Health and facilitation skills to begin a conversation about what matters to them most in their life, what strengths and resources they might already have to leverage in getting closer to what matters, and where they might benefit from new skills or support in the process. This conversation can happen in person—either in a group or individual setting—or virtually. It can also happen through the recently released Live Whole Health app. Often part of this process is starting a Personal Health Inventory (Personal Health Inventory - PHI IB 10-773 29950 (va.gov)), a living document which the Veteran can then use to help organize their plan and communicate with other members of their Whole Health team. The Pathway is often the start of a process of “Walking the Circle of Health,” part of building skills and resources to help achieve the mission, aspiration, and purpose identified by the Veteran (Figure 1).

Figure 1.

Circle of health.

The second component of the WHS is the Well-Being Program, where a Veteran can go to access new skills and education in nutrition, movement, and healthy lifestyle. This is also where they can access the evidence-based complementary/integrative health which since 2017 has been covered by the VA medical benefits package. The covered CIH approaches include acupuncture, biofeedback, guided imagery, clinical hypnosis, massage therapy, meditation, yoga, and taichi. Chiropractic is also available across the VHA, considered part of mainstream rehabilitation medicine since 2005. Whole Health coaching is another key component of the WHS, which can be accessed through the well-being program but also directly as part of clinical care in many medical centers.

The final component is Whole Health Clinical Care (Figure 2). Here, the Veteran continues to access the high quality disease management and preventive healthcare currently provided by VHA—but with a broadened perspective in which their clinical team is aware of what is most important to them and actively incorporates this into the conversation about their health and well-being. As part of building this part of the system, we are engaged in a large education campaign, with roughly 33,000 VHA staff reached to date.

Figure 2.

The Whole Health system.

We frequently remind both ourselves and the rest of the VHA that “no one owns Whole Health.” Or perhaps more accurately, “Only the Veteran owns Whole Health.” The concept is much bigger than any specific office or program, or even an entire health system. The concept is rooted in a return to the traditional values which have informed healthcare for thousands of years—that engaging the whole person, not just the physical body but the emotional, mental and spiritual aspects as well is critical to healing. What is different now, and the reason this represents a new paradigm, is that we are doing that while still maintaining a commitment to evidence-based, disease-oriented biomedicine, with all the amazing benefits that have been brought on both individual and population health levels. That fusion of modern scientific biomedical thinking with traditional values of whole person health is where the “transformation” defines itself.

We see this fusion of old and new, of purely scientific and humanistic/intuitive ways of knowing integrating seamlessly, as the future of healthcare in the U.S. In support of that vision, the VHA, along with the Whole Health Institute and the Samueli Foundation, are co-sponsoring a National Academies of Sciences, Engineering and Medicine consensus panel entitled: “Transforming health care to create whole health: strategies to assess, scale, and spread the whole person approach to health.” This panel, which launched in October 2021, will work over the coming year and a half to examine and explore whole person models of care both inside and outside the VHA, with the ultimate goal of informing future strategies for building whole health systems across the entire U.S. healthcare system (Transforming Health Care to Create Whole Health Strategies to Assess Scale and Spread the Whole Person Approach to Health | National Academies).

One of the most important challenges still ahead is in the area of outcome evaluation and measurement. Now that VHA has fully committed itself to advancing not only disease care but well-being for our Veterans, how will we measure our efforts in that arena? Healthcare systems generally measure disease-oriented outcomes or at best, health-related quality of life scales. But the concept of well-being is much larger than just HRQoL and has many different dimensions ranging from emotional to financial to social to role-based and beyond. We are excited to now be piloting a brief validated measure of psychosocial or role-related well-being as part of routine clinical care, in hopes of building momentum for the integration of this measure across VHA care. The measure was developed by Dr Dawne Vogt, one of our colleagues from VHA Health Services Research, and has great potential not only to inform our work in helping Veterans be more engaged in the parts of life they feel are most important to them, but also to help “change the conversation” between Veterans and their clinical teams to make focusing on what matters most a routine part of a Veteran’s interactions and relationship with the VA.

We are just at the beginning of the Whole Health journey in the VHA, and many questions remain to be answered. In addition to the question of how best to measure well-being, we need to know whether or not Whole Health leads to cost avoidance, and whether tele-Whole Health is as effective as in person. And we need to know which components of the Whole Health System are most critical and whether there are some parts which are more important for certain populations. Perhaps most importantly, we need to understand how best to inform the spread of Whole Health with a commitment to health equity and to acknowledging the impacts of the structural determinants of health, and how to best address the infinite diversity across our Veteran population in our approach to creating well-being.