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What Health Services Researchers Can Do to Inform the Implementation of VA's Whole Health System of Care

In this month’s lead commentary, Dr. Benjamin Kligler has outlined VA’s effort to implement the Whole Health (WH) System of Care throughout VA. Such large-scale transformation is highly complex, and the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) has engaged in a wide range of implementation strategies to spread the use of WH throughout VA. Gaining the buy-in of policy makers, VISN leadership, and medical centers requires evidence that investing in this transformation will, in fact, improve the health of Veterans. As VA embraces the core tenets of a learning healthcare system, program offices have sought the expertise of VA’s large cadre of expert health services researchers to evaluate these types of initiatives. QUERI Partnered Evaluation Initiatives serve as a critical pathway for developing these partnerships between operations and researchers. Since 2013, our team at the Center for Evaluating Patient Centered Care in VA (EPCC) has partnered with OPCC&CT to evaluate the development and implementation of a healthcare system focused on providing care aligned with what matters most to each individual Veteran.

As Dr. Kligler notes, the aim of this revised system is to provide care aligned with patients’ goals, preferences, and priorities, and to partner with patients to achieve well-being. These changes take time. Our team has found that over a three-year period the 18 WH flagship sites made great strides towards implementation, yet only one site reached advanced implementation.1 Moreover, implementation does not equal cultural transformation, which, as others have argued, takes 7 to 10 years to achieve in an organization. QUERI researchers who have studied the implementation of individual evidence-based practices understand the complexity and need to develop successful strategies to truly change provider and patient behavior. The changes proposed in the WH system of care are multi-faceted, and thus require more strategies and greater effort to generate change.

It is important to understand the conceptual grounding for how the WH system can in fact improve the well-being of Veterans. In partnership with OPCC&CT, we developed a logic model, in which we posit that a WH approach begins its impact by improving Veterans’ experiences of care and in turn, improving their engagement with healthcare services and self-care. The model further posits that the WH approach helps patients reach their own personal health goals and improves patients’ sense of well-being in the world. And, yes, such engagement may impact longer term disease-based outcomes. Preliminary analyses of our longitudinal survey of patients receiving WH care during a six-month period demonstrate that exposure to at least two WH services results in more positive perceptions of care and greater engagement in healthcare and self-care.

Yet many questions remain, and health services researchers are well-positioned to address them. While Dr. Kligler notes some preliminary evidence of the impact of exposure to WH services on Veterans with chronic pain, further research is needed to understand how different components of the system of care contribute to improved outcomes, and whether these vary for different populations of Veterans. Moreover, a question remains about whether individual services have greater overall value when delivered within the context of a system of care that fully embraces a WH approach.

The Whole Health Pathway relies, in part, on engaging peers in the delivery of WH. VA has a long history of engaging Peer Support Specialists in mental health and substance abuse services. The use of peers to help Veterans engage in the Whole Health Pathway may be critical to helping Veterans identify what matters most. We have learned that peer delivery of the “Taking Charge of My Life and Health” program, a curriculum facilitated by peers to help Veterans explore their “mission, aspiration, and purpose” and develop a personal health plan had a positive impact on the Veterans who chose to engage.2 Yet establishing these groups and securing patient participation remains challenging. The field pivoted during COVID-19 to offer this program via telehealth, and we have learned from Veterans that there may be great benefits and some drawbacks to participating remotely.

Well-being programs encompass many different types of group and individual programs. Questions remain regarding the use of complementary and integrative health (CIH) services. Utilization data show great engagement in many types of CIH, and our partner QUERI center, the Complementary and Integrative Health Evaluation Center, led by Drs. Stephanie Taylor and Steven Zeliadt, continues to assess the spread and impact of CIH services on Veterans. Questions also remain regarding the impact of these services on different populations of Veterans. Further, WH coaching continues to expand throughout VA. Early studies have demonstrated that WH coaching can lead to improvements in well-being.3 Understanding more about the value and impact of this model of coaching, who should provide coaching, and how coaching impacts different populations of Veterans requires further examination. How does this model compare to other models of health coaching? How does it compare to usual care?

A truly transformed system of care requires that a WH approach become part and parcel of every Veteran interaction at VA. How clinicians embrace a WH approach in their interactions with patients may in fact be at the core of truly transforming the culture of care. As Kligler notes, the integration of the WH approach into primary care and mental healthcare is a primary goal for the next several years. How this occurs, and what implementation strategies are effective in integrating WH concepts into current practice patterns still need to be considered. HSR&D researchers who study how to change provider behavior have lots to contribute to this effort. Moreover, to truly transform a system, this approach to care must be delivered throughout the care system, including specialty care services. It remains unclear how WH can and should be integrated into specialty care services.

VA has begun to embrace WH for employees as an important pathway to improving the well-being of our workforce. We recognize employee well-being as an important area for research to understand how facilities engage with employee WH efforts, and how this impacts employees and the Veterans they serve. Questions regarding WH are now included in the All Employee Survey; additional approaches to assessing implementation of, and engagement in, WH for employees are needed.

Finally, if HSR&D researchers are to embrace the goal of WH to improve the health and well-being of Veterans, we must embrace metrics that reflect that goal. Designing studies with outcomes that are purely disease-based results in a more fragmented system of care for Veterans. Thus, researchers should consider well-being as a primary outcome for the interventions they study. Measuring patient-reported outcomes in the course of clinical care is also a fruitful area for research, as is the feasibility of doing so with VA’s new EHR.

In sum, VA’s Whole Health System of Care implementation could be truly transformative for the health and well-being of Veterans. It is incumbent on health services researchers to critically examine WH’s implementation and its associated outcomes to inform VA’s investment in this expansive effort.

  1. Bokhour BG, Hyde J, Zeliadt S and Mohr D. “Whole Health System of Care Evaluation: A Progress Report on Outcomes of the WHS Pilot at 18 Flagship Sites.”
  2. Abadi MH, et al. “Evaluation of a Peer-led Program Pro-moting Self-care and Empowerment,” Journal of Alternative and Complementary Medicine 2021; 27(S1):S37-S44. doi: 10.1089/acm.2020.0124.
  3. Purcell N, et al. “How VA Whole Health Coaching Can Im-pact Veterans’ Health and Quality of Life: A Mixed-Meth-ods Pilot Program Evaluation,” Global Advances in Health and Medicine 2021; Vol 10.

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