THE IMPERATIVE FOR CHANGE
The Veterans Health Administration (VHA) is undertaking one of the most significant changes in the philosophy and practice of health care ever embarked on by an organized health care system. The mission of VHA is “to honor America’s Veterans by providing exceptional health care that improves their health and well-being.” VHA is the largest integrated health care system in the country and, while facing challenges with issues of access, it is broadly recognized for the high quality of its health care services. The health care crisis in the United States includes high costs that rise exponentially, and disappointing outcomes—particularly in chronic diseases as stated in an Institute of Medicine report on Integrative Medicine and the Health of the Public, “The disease-driven approach to care has resulted in spiraling costs as well as a fragmented health system that is reactive and episodic as well as inefficient and impersonal.”1 As with most Americans, Veterans have an increasing number of chronic conditions and they may be returning to civilian life with serious and complex service-related injuries. This combination of disease-driven care, increasing chronic conditions, and greater number of service-related injuries represent significant challenges to VHA. The shortcomings of health care in our country and the resulting financial imperative call for a complete redesign of health care. There is no greater commitment to advancing health care than in VHA—for Veterans, and for the country.
THE FUTURE STATE
To meet these challenges, VHA declared its number 1 strategic priority “to provide personalized, proactive, patient-driven health care to Veterans.” These core characteristics of the future of health care are described as: Personalized: tailoring a person’s health care to their individual characteristics, such as medical conditions, genes, circumstances, and values; Proactive: using strategies that strengthen the person’s innate capacity for health and healing, such as mind-body approaches and nutritional strategies before surgery or chemotherapy, and Patient-driven: health care that is based in and driven by what really matters to the person in their life, and aligns their health care and goals accordingly. The philosophical approach of Complementary and Alternative Medicine and Integrative Health (IH), clearly provides a framework that aligns with this approach to health care that focuses on what matters most to each person and empowers the individual to make informed choices to support greater well-being. Recognizing the enormity of the organizational transformation ahead, in 2011 VHA established the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) and charged the Office with catalyzing and sustaining cultural transformation for and with Veterans from a primarily reactive, disease focused, physician-centered care model to a personalized, proactive, patient-driven approach that prioritizes the Veteran and their values, and partners with them to create a personalized strategy to optimize their health, healing, and well-being.
To deliver this care, VA is working to radically change and enhance both the experience and practice of health care. The foundation of an optimal “experience” of care is the healing relationship, within which providers can use the power of their words and the strength of their caring to support healing, even when physical curing is not possible. Care can be provided in healing environments with attention to making the spaces feel safe, comfortable, and peaceful. VHA leaders across the country have made this cultural transformation a priority and national training programs are underway to help every employee understand their role in creating healing relationships and healing environments. In addition, VHA construction and design guidelines have been updated to support the creation of healing spaces for Veterans as renovation occurs and new spaces are created.
The new personalized model and “practice” of care starts with the Veteran at the center and begins with an exploration of their values and goals and their vision of health. The goal is to change the conversation from “What is the matter with you?” to “What matters to you?”, as it was so aptly stated by Maureen Bisognano, the President and CEO of the Institute for Healthcare Improvement. By starting with an exploration of what matters most to that person, and making their health care in service of this, their health care is now relevant in a very different way; this is patient-driven health care. This whole health approach does not stop there, but must also support Veterans in acquiring the skills and ongoing support needed to succeed in making sustainable changes in their health and life. Whole Health refers to patient-centered care that affirms the importance of the relationship between the patient and their community, including their providers, as well as the power of self-care strategies to strengthen innate healing capacities. This approach is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health, healing, and well-being, at all points along the spectrum of health and disease. Veterans may use conventional and complementary approaches in the prevention and treatment of disease, as well as to support healing. When combined with Veteran self-care, this whole health approach will result in better health outcomes, improved quality of care, greater patient and provider satisfaction, and greater cost-effectiveness. When fully engaged, the Whole Health approach helps Veterans to live their fullest life.
One of the ways that the VA is changing the conversation with Veterans is to look at their life and health through the Circle of Health pictured on the right. All of the areas in the circle are important and they are all interconnected. Improving one area can benefit other areas in one’s life and influence overall physical, emotional, mental, and spiritual and well-being. The human body and mind have tremendous healing capacities, and one can make choices that either weaken or strengthen these healing abilities, such as the immune system. At the center is the individual, who they are and what really matters most to them. The skill of mindful awareness helps one to be conscious of their current state—in any area of the circle. Learning to be mindful allows one to be proactive in every area of health—whether being aware that you are eating because you are tired and not because you are hungry, or being aware that your level of stress is very high, or that you are at the start of a pain cycle. Practicing this skill is the difference between reacting after a problem exists, and responding proactively. The green circle is self-care. These are the circumstances and choices one makes in everyday life, choices that can have a huge impact on one’s health. The next ring (dark blue) represents professional care which may include diagnostic tests, pharmaceuticals, supplements, surgeries, examinations, screening, treatments, and counseling. This also includes complementary approaches such as acupuncture and mind-body therapies which the VHA is working to expand. The outer ring represents the people and communities to whom one is connected, or wishes to be. It should be noted, that very often the underlying principles in complementary practices (whether self-care strategies employed by the person themselves or therapies provided by a practitioner) are those that aim to strengthen the innate capacity to heal. This is a philosophy that expands beyond the typical conventional medical approach.
THE ROLE OF IH AT THE VA
In the words of the VHA National Leadership Council, “A proactive approach to optimize health and healing addresses all aspects of life that can influence outcomes. Many of the strategies that may be of benefit extend beyond what is conventionally addressed or provided by the health system.” Consequently, the infrastructure and operations to support this broader approach to health and healing does not exist, and there has been no mechanism for a formal national strategy to coordinate and support these activities. In April 2014, the OPCC&CT was asked to create the VHA Integrative Health Coordinating Center (IHCC) to fill this need.
The IHCC will have 2 core functions: (1) to identify and remove barriers to providing IH across the system; and (2) be a resource for clinical practices and education for both Veterans and for clinicians. The priority functions of the IHCC will include, but are not limited to, developing innovative policy and programs regarding integrative approaches to personalized, proactive, patient-driven care across existing VHA clinical staff (nurses, physicians, pharmacists, psychologists), and new VHA complementary staff such as licensed acupuncturists, IH coaches, and massage therapists; facilitating and serving as subject matter experts to develop new occupation codes, credentialing and privileging, qualifications, and supervision as these staff may be hired across service lines in multiple settings and working with appropriate program offices to develop workload capture models for new complementary staff. In addition, the IHCC is partnering with the VA Health Science Research & Development to expand related research, beginning with facilitators and barriers to the provision of IH in VA.
A unique element of health care in the VA is that chiropractic care is part of the traditional medical benefits. The number of Veterans receiving chiropractic services in VA has expanded from about 4000 in FY2005, to over 26,000 in FY2013. Although this is a great accomplishment, the vision of a truly integrated health team that incorporates chiropractors and other IH practitioners is work that lies ahead. In addition to clinical services, Rehabilitation and Prosthetic Services is working to develop innovative approaches to foster chiropractic interprofessional education strategies and research projects that will continue to move this vision forward.
STRATEGIES TO DRIVE CHANGE
To drive innovation in a large system, there must be “Innovation Engines” which include VA health care facilities with strong leadership and a commitment to a cultural transformation to the new model of care. Five of these Centers of Innovation are established facilities and 4 additional Centers are “emerging,” as they are in the process of building and opening new VA Medical Centers. These facilities serve as regional innovation hubs across the country. The 5 established sites include Los Angeles, CA; Dallas, TX; Birmingham, AL; Washington, DC; and East Orange, NJ. An example of the innovative strategies taking place can be seen at the East Orange New Jersey Health Care System. The facility has created a health and wellness center which integrates both primary care and mental health services and includes space for various IH services such as yoga and meditation. There is a demonstration kitchen, and an outdoor greenhouse program where Veterans teach other Veterans about gardening and horticulture and learn to take food from the garden to the kitchen. The facility trains their staff as well as students in innovative patient-centered approaches through their onsite simulation center. They also developed an educational program designed to introduce Veterans to IH practices such as breathing, meditation, Qigong, and yoga exercises that can be learned and practiced independently through hearing from fellow Veterans.
The VA Greater Los Angeles Healthcare System, a similar center for health and well-being has been created where Tai Chi and Mindfulness Based Stress Reduction are transforming lives and helping Veterans overcome years of pain, substance abuse, and isolation. For a glimpse in how these services have impacted Veterans view this short video titled “Patient Centered Care Through the Eyes of a Veteran” at: http://www.youtube.com/watch?v=cVpCxguQmN8&feature=youtu.be. In Washington, DC, the IH team has expanded access to IH services through the creation of virtual online IH services and information. The mission of this effort is to promote comprehensive health and well-being in Veterans and in Staff through the integration of safe, effective integrative and complementary modalities using a self-directed model. Through this Virtual Wellness Clinic, Veterans can access a compilation of free online resources to improve and maintain health and well-being. The DC VA Medical Center DC VAMC Health and Wellness Links Webpage is accessible to all at: http://www.washingtondc.va.gov/Wellness/.
OUTCOMES AND RESEARCH
The Office is working in close alignment with the VA Office of Research and Development. The VA Evidence-Based Synthesis Program located in West Los Angeles analyzed the systematic reviews that were published from January 2005 to March 2013 to provide an overview of the existing literature on acupuncture. This was then used to produce an evidence map that provides a visual overview of the distribution of evidence (both what is known and where there is little or no evidence base) for acupuncture, as well as a set of executive summaries that help stakeholders interpret the state of the evidence and inform policy. The evidence map on acupuncture showed a positive effect of acupuncture on headaches, migraines, and chronic pain as well as a potential positive effect in multiple domains including depression and insomnia. Evidence synthesis is currently underway for yoga, tai chi, and mindfulness meditation.
In addition, VA is partnering with the Bravewell Collaborative to pilot PRIMIER2 (Patients Receiving Integrative Medicine Interventions Effectiveness Registry) in the Centers of Innovation. The Bravewell Collaborative’ s integrative medicine practice-based research network, BraveNet, is planning a data registry project (PRIMIER) to uniformly collect patient-reported outcomes, provider input, and extracted electronic health record data into a large dataset that can be used for quality improvement, research, and determination of best practices. This type of observational, practice-based data collection is now being widely used across medical settings for monitoring diseases, conditions, health services, and device safety. PRIMIER will continue to expand to include other integrative medicine centers from both the public and private sectors to create a national registry that will help improve the health and well-being of patients. The data registry will provide foundational new knowledge on how integrative medicine is being used in real-world settings that will ultimately inform future clinical trials as well as decision making in clinical settings.
One of the biggest challenges facing this work is that there is a fundamental gap in much of professional health care education and this whole person approach. If we are to achieve a true transformation of health care, then our workforce, and in particular our clinicians, must be educated in this patient-driven approach and in integrative therapies. The VHA Whole Health Clinical Education Program which includes an IH focus is the first step in addressing this need. Launched last year, a 2 and a half day face to face education entitled “Whole health: change the conversation—advancing skills in the delivery of personalized, proactive and patient-driven care” is designed as a core course for a wide array of VHA clinicians, and prioritizes transformative and experiential learning in this new approach to health care. It has received outstanding evaluations from over 1000 clinicians and leadership who have taken the course. In addition, an online curriculum with over 40 modules will soon be launched to provide more content-specific education. These courses, cocreated with VA and the University of Wisconsin Integrative Medicine leaders provide evidence-based information and case studies to discuss nonmedical/surgical and nonpharmacological ways of treating common conditions that Veterans face. In addition, it offers a personal experience for clinicians for their own health and well-being. University of Wisconsin Department of Family Medicine and the Pacific Institute for Research and Evaluation provide evidence-based information and case studies to discuss nonmedical/surgical and nonpharmacological ways of treating common conditions that Veterans face. In addition, it offers a personal experience for clinicians for their own health and well-being. The courses will prepare clinicians to work with their patients to develop personalized health planning strategies that reflect the goals and of each Veteran, and integrate proactive approaches such as nutrition, stress management, movement, and mindful awareness. By the end of September 2014, over 1000 providers will have completed this training. View these brief videos for an overview of the “Whole health: change the conversation” course: http://www.youtube.com/watch?v=AP6z5kfN6MU and http://www.youtube.com/watch?v=SAL5ZL_GqUc.
Another key initiative is a Joint Incentive Fund Department of Defense (DoD)-VA project to improve Veterans’ and Service members’ access to IH services: the “Tiered Acupuncture Training Across Clinical Settings” (ATACS) project. A VHA and DoD network of medical acupuncturists are being identified and trained in Battlefield (auricular) Acupuncture by regional training conferences organized jointly by VHA and DoD. The goal of the project is for providers to return to their facilities with the skills to train local providers in Battlefield Acupuncture, which has been used successfully in DoD front-line clinics around the world.
One strategy the OPCC&CT has used to support IH providers in the field is hosting a monthly IH community of practice conference call which includes national updates, highlights strong practices across the field, and publicizes new developments and research findings related to IH. This forum supports an ongoing conversation between practitioners across the system and facilitates the expansion of strong IH practices across VA.
IH: THE WAY FORWARD
The OPCC&CT is now serving as the lead office in supporting the implementation of IH in VHA. This will only be accomplished by expanding on existing efforts and strengthening partnerships both internal and external to the VA. By modeling the clinical and educational approach to Whole Person Health care, and learning together, the future of health care can be defined. And through patient-driven care that embraces integrative approaches, Veterans will live their fullest lives. As a result, their health will be better, their outcomes will improve, and the costs will be reduced.
1. Schultz AM, Chao SM, McGinnis JM. Institute of Medicine. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. 2009.Washington, DC: The National Academies Press.
2. Abrams DI, Dolor R, Roberts R, et al.. “The BraveNet prospective observational study on integrative medicine treatment approaches for pain”. BMC Complement Altern Med. 2013;13:146.