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Bolton RE, Mohr DC, Charns M, Herbst AN, Bokhour BG. Creating Whole Person Health Care Systems: Understanding Employee Perceptions of VAs Whole Health Cultural Transformation. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:813-821. [PMID: 37935016 DOI: 10.1089/jicm.2023.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Objective: Whole person health care, like that being implemented in the U.S. Veterans Health Administration (VHA), involves person-centered approaches that address what matters most to patients to achieve well-being beyond the biomedical absence of disease. As whole health (WH) approaches expand, their integration into clinical practice is predicated on health care employees reconceptualizing practice beyond find-it-fix-it medicine and embracing WH as a new philosophy of care. This study examined employee perspectives of WH and their integration of this approach into care. Design: We conducted a survey with responses from 1073 clinical and 800 nonclinical employees at 5 VHA WH Flagship sites about their perceptions and use of a WH approach. We used descriptive statistics to examine employees' support for WH and conducted thematic analysis to qualitatively explore their perceptions about this approach from free-text comments supplied by 475 respondents. Results: On structured survey items, employees largely agreed that WH was a valuable approach but were relatively less likely to have incorporated it into practice or report support within their organization for WH. Qualitative comments revealed varying conceptualizations of WH. While some respondents understood that WH represented a philosophical shift in care, many characterized WH narrowly as services. These conceptualizations contributed to lower perceived relevance, skepticism, and misgivings that WH diverted needed resources away from existing clinical services. Organizational context including leadership messaging, siloed structures, and limited educational opportunities reinforced these perceptions. Conclusions: Successfully transforming the culture of care requires a shift in mindset among employees and leadership alike. Employees' depictions didn't always reflect WH as a person-centered approach designed to engage patients to enhance their health and well-being. Without consistent leadership messaging and accessible training, opportunities to expand understandings of WH are likely to be missed. To promote WH transformation, additional attention is needed for employees to embrace this approach to care.
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Affiliation(s)
- Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Health Law, Policy, and Management Department, Boston University School of Public Health, Boston, MA, USA
| | - Martin Charns
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Health Law, Policy, and Management Department, Boston University School of Public Health, Boston, MA, USA
| | - Abigail N Herbst
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Chung VC, Ho FF, Lao L, Liu J, Lee MS, Chan KW, Nilsen P. Implementation science in traditional, complementary and integrative medicine: An overview of experiences from China and the United States. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 109:154591. [PMID: 36610171 DOI: 10.1016/j.phymed.2022.154591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 11/28/2022] [Accepted: 12/04/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The introduction of traditional, complementary and integrative medicine (TCIM) services into health systems has been advocated by the World Health Organization, but there is a paucity of reviews synthesising the experiences of (i) implementing TCIM services in conventional healthcare settings and (ii) introducing evidence-based practice in TCIM. Knowledge of the first issue will assist policymakers to innovate implementation interventions in their own health system contexts. Addressing the second issue will facilitate the closure of the evidence-practice gap in TCIM and improve the translation of research evidence into health outcome benefits. PURPOSE The aim of this study was to identify, describe and analyse publications on these two key TCIM policy issues via an overview from an implementation science perspective. METHODS Publications describing international experiences of implementing TCIM services or evidence for TCIM practices were identified by searching MEDLINE, EMBASE and Global Health databases in November 2021. The findings were summarised using a narrative synthesis approach. RESULTS Sixty-three relevant publications were included in the analysis. Current experiences in China and the United Sates (US) reflect varying policy priorities at different stages of implementing TCIM services. In the US, where TCIM have yet to be introduced into mainstream healthcare settings, implementation interventions were designed to facilitate the provision of specific, evidence-based TCIM modalities via referrals from conventional clinicians. The application of these strategies at the health system, regulatory, financial, community, provider and patient levels provided a comprehensive picture of how TCIM implementation may be facilitated via multi-level interventions. In China, the major form of TCIM is traditional Chinese medicine (TCM), for which service provision has already been adopted at all levels of healthcare. With the high volume of clinical research that has been generated in the past several decades, a key policy question at this stage is how to translate TCM-related clinical evidence into practice. The development of clinical practice guidelines (CPGs) is the main implementation intervention, but adherence by TCM clinicians has been poor, due to the conflict between classical individualised practice and CPG standardisation. While tailoring interventions to facilitate CPG uptake is indicated, concurrent innovations in TCM clinical research methods would improve the compatibility between classical and CPG-based practice. CONCLUSION Policymakers managing different stages of TCIM implementation will benefit from the experiences of practitioners in the US and China. Multi-level implementation interventions launched in the US provide ideas for the initial introduction of TCIM into a conventional medicine-dominated health system. As TCIM service provision and related clinical research become more common, China's experience will inform how clinical evidence related to TCIM may be disseminated and implemented to improve service quality.
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Affiliation(s)
- Vincent Ch Chung
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Fai Fai Ho
- School of Chinese Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Lixing Lao
- Virginia University of Integrative Medicine, Fairfax, VA, United States
| | - Jianping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Myeong Soo Lee
- Division of Clinical Medicine, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Kam Wa Chan
- Department of Medicine, University of Hong Kong, Hong Kong
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Bokhour BG, Hyde J, Kligler B, Gelman H, Gaj L, Barker AM, Douglas J, DeFaccio R, Taylor SL, Zeliadt SB. From patient outcomes to system change: Evaluating the impact of VHA's implementation of the Whole Health System of Care. Health Serv Res 2022; 57 Suppl 1:53-65. [PMID: 35243621 DOI: 10.1111/1475-6773.13938] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/22/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To describe how a partnered evaluation of the Whole Health (WH) system of care-comprised of the WH pathway, clinical care, and well-being programs-produced patient outcomes findings, which informed Veterans Health Administration (VA) policy and system change. DATA SOURCES Electronic health records (EHR)-based cohort of 1,368,413 patients and a longitudinal survey of Veterans receiving care at 18 WH pilot medical centers. STUDY DESIGN In partnership with VA operations, we focused the evaluation on the impact of WH services utilization on Veterans' (1) use of opioids and (2) care experiences, care engagement, and well-being. Outcomes were compared between Veterans who did and did not use WH services identified from the EHR. DATA COLLECTION Pharmacy records and WH service data were obtained from the VA EHR, including WH coaching, peer-led groups, personal health planning, and complementary, integrative health therapies. We surveyed veterans at baseline and 6 months to measure patient-reported outcomes. PRINCIPAL FINDINGS Opioid use decreased 23% (31.5-6.5) to 38% (60.3-14.4) among WH users depending on level of WH use compared to a secular 11% (12.0-9.9) decrease among Veterans using Conventional Care. Compared to Conventional Care users, WH users reported greater improvements in perceptions of care (SMD = 0.138), engagement in health care (SMD = 0.118) and self-care (SMD = 0.1), life meaning and purpose (SMD = 0.152), pain (SMD = 0.025), and perceived stress (SMD = 0.191). CONCLUSIONS Evidence developed through this partnership yielded key VA policy changes to increase Veteran access to WH services. Findings formed the foundation of a congressionally mandated report in response to the Comprehensive Addiction and Recovery Act, highlighting the value of WH and complementary, integrative health and well-being programs for Veterans with pain. Findings subsequently informed issuance of an Executive Decision Memo mandating the integration of WH into mental health and primary care across VA, now one lane of modernization for VA.
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Affiliation(s)
- Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Justeen Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Benjamin Kligler
- Office of Patient Centered Care & Cultural Transformation, US Department of Veterans Affairs, Washington, District of Columbia, USA.,Department of Family and Community Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, New York, USA
| | - Hannah Gelman
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Anna M Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Jamie Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Rian DeFaccio
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.,Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, California, USA
| | - Steven B Zeliadt
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
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Reed DE, Bokhour BG, Gaj L, Barker AM, Douglas JH, DeFaccio R, Williams RM, Engel CC, Zeliadt SB. Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites. Glob Adv Health Med 2022; 11:21649561211065374. [PMID: 35174004 PMCID: PMC8841911 DOI: 10.1177/21649561211065374] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/19/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD. Methods We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD. Results A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 ( 95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 ( 95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services. Conclusion Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.
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Affiliation(s)
- David E. Reed
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Boston, MA, United States
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
| | - Anna M. Barker
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
| | - Jamie H. Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
| | - Rian DeFaccio
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
| | - Rhonda M. Williams
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Charles C. Engel
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Steven B. Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
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