Whole Health in Your Practice 2 THE BIG

Whole Health in Your Practice 2. THE BIG PICTURE

A Little More About This Course • NOT “. . . just another training” • Relies on the wisdom of the group • Involves evidence – and personal experience • Keeps your self-care in mind • Focuses on building skills that you can apply in your practice tomorrow VETERANS HEALTH ADMINISTRATION

Learning Objectives • GOOD: Understand the concept of Whole Health BETTER: . . . and network with colleagues EVEN BETTER: . . . and learn skills for your practice BEST: . . . and implement Whole Health at a team level IDEAL: . . . AND a Whole Health System level EXTRA, DELUXE, GOLD STAR: . . . AND apply it to your own self-care as well VETERANS HEALTH ADMINISTRATION

Important Elements of Whole Health in Practice The Circle of Health VETERANS HEALTH ADMINISTRATION Personal Health Planning

The Aspirations Model VETERANS HEALTH ADMINISTRATION

Whole Health Encourages You to Think about Your Mission • Why are you here in the VA? • Why are you here on the planet? • What REALLY matters? • What do you want your health for? 7

http: //www. tanzaniaparks. com/kili. html “What do you want your health for? ” People’s answers may surprise you!

The Experience: Relationship Between Clinicians and Patients/Families What Matters to the Patient is the basis of their Personalized Health Plan A strong relationship allows the provider to partner with the patient to help create their Plan My Story What matters to me? My Story Relationship Who I am VETERANS HEALTH ADMINISTRATION Who I am

Purpose in Life = Longer Life • • 7, 108 Americans Ages 25 -75 Followed for 14 years Answered three questions: 1. I don’t wander through life 2. I think about the future 3. I feel there is still more to do in life VETERANS HEALTH ADMINISTRATION Hill, Psychol Sci, 2014; 25(7): 1482– 6.

Purpose in Life = Longer Life • Regardless of – Age – Retirement Status – Relationships – Depression • There was a survival benefit (hazard ratio 0. 85) if answers indicated a sense of purpose VETERANS HEALTH ADMINISTRATION Hill, Psychol Sci, 2014; 25(7): 1482– 6.

Which statement gets the best response? Statement A Statement B “Your A 1 c is clear up to 10. That means your sugars have been really high for a while, and we need to bring them down. Studies show this will put your heart, retinas, nerves, and kidneys at risk. ” “I know your goal is to dance at your granddaughter’s wedding. Keeping your sugars in a good place will help your heart, legs, and the rest of your body be up for it! And it will keep that A 1 c number down, too. ” VETERANS HEALTH ADMINISTRATION

What if the Conversation Changed Focus? Worse then Expected Disease Better than Expected Health

VHA Strategic Goals, 2013 – 18. . . and Beyond 1. Provide Veterans personalized, proactive, and patient-driven health care “…to optimize health and well-being. ” 1. Incentivize measurable improvements in health outcomes. 1. Align resources to deliver sustained value to Veterans. HOW? Whole Health is one approach… VETERANS HEALTH ADMINISTRATION

How do you define Whole Health? 15

FRAMEWORK FOR WHOLE HEALTH: “CIRCLE OF HEALTH” Components of Proactive Health and Well-being Page 5

Defining Whole Health Patient-centered care that affirms the importance of the relationship and partnership between patients and their community of healthcare providers. The focus is on empowering the self-healing mechanisms within the whole person while co-creating a personalized, proactive, patient-driven experience. This approach is informed by evidence and makes use of all appropriate therapeutic approaches, health-care professionals and disciplines to achieve optimal health and well-being. VETERANS HEALTH ADMINISTRATION

Core Concepts for Transforming to Whole Health • Holism: People are more than a broken body part or a list of All aspects of my life are medical problems interconnected and impact my health • Self Healing: People possess the innate capacity to heal, and There approaches that can mobilizing that is an important priority strengthen – or weaken – my capacity to heal and stay well • Mindful Awareness: Self-awareness leads to better health, and there are ways to enhance it Paying more attention to my body and mind helps me make better decisions in my self care VETERANS HEALTH ADMINISTRATION Explore. va. gov

Physical Meaning and Purpose Life Story Mind Culture Relationships Emotions Values Photo credit: Jabi - El de verdad via Foter. com / CC BY-NC

Our Current “Disease Care System” 68, 000 Diagnosis Codes Photo credit: Via. Moi via Foter. com / CC BY-NC-ND W 6162 XA = V 9107 XA = VETERANS HEALTH ADMINISTRATION (ICD-9 has 14, 025) Struck by a duck Burn due to water skis catching on fire

And a Few Others. . . • Collision with roller skater • Struck by an orca • Bitten by sea lion • Sucked into a jet engine • Prolonged stay in weightless environment VETERANS HEALTH ADMINISTRATION Photo credit: symtnr via foter. com • Unspecificed spacecraft accident • Hurt at the library • Hurt at the opera • Accident while knitting • Problems in relationship with in-laws

$ $ Appetite Suppressant Opioids Triptan Obesity HA Statin Dyslipidemia HTN $ LBP Disease Focused Care GERD Depression SSRI DM Insulin ACE PPI $

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Personalized, Proactive, Patient-Driven PERSONALIZED A dynamic adaptation or customization of recommended education, prevention and Tailor my care treatment that is specifically relevant to the individual user, based on the user’s to me as a person history, clinical presentation, lifestyle, behavior and preferences. PROACTIVE Acting in advance of a likely future situation, rather than just reacting; taking initiative Help me prevent future to make things happen rather than just adjusting to a situation or waiting for problems and prepare for any something to happen. Using strategies that strengthen the person’s capacity for health problem that comes up health and healing, such as mind-body approaches prior to surgery. PATIENT-DRIVEN An engagement between a patient and a health care system where the Support me with what patient is the source of control such that their health care is based in their needs, values, and how the patient wants to live. This matters most to me requires that we change the conversation and start from a different place. VETERANS HEALTH ADMINISTRATION Mentalhealth. va. gov

1. Whole food diet 2. Aerobic Exercise 3. Stress management (60 mins/day) 4. Social Support Mean change in relative telomere length over 5 years http: //www. scientificamerican. com/article/my-what-long-telomeres-you-have/ with lifestyle intervention compared with control Ornish, Lancet Oncol. 2013; 14(11): 1112 -20.

It’s Vital to Know the Patient: “On Being Sane in Insane Places” 8 “sane” people admitted to different psych hospitals in 1973 All given the diagnosis of Schizophrenia in remission Steve took it via Foter. com • • • 4 Psychologists 1 Psychiatrist 1 Pediatrician 1 Painter 1 Homemaker VETERANS HEALTH ADMINISTRATION Average length of stay: (7 -52 s y a 19 d ) days Rosenhan DL, Science, 1973; 179 (4070): 250 -8.

Conclusions: “Being Sane” Study • “It could be a mistake, and a very unfortunate one, to consider that what happened to us [as patients] derived from malice or stupidity on the part of the staff. ” • “Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. ” • “Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves. . . ” VETERANS HEALTH ADMINISTRATION

Precursors to Suicide • “We did the clinical reminders, we met the measures, but we missed their suffering” VETERANS HEALTH ADMINISTRATION U. S. Air Force photo illustration/Airman 1 st Class Corey Hook

Whole Health and Suicide Prevention • Mission, Aspiration, and Purpose –Asking about them helps identify at-risk Veterans. • Mindful awareness –Enhances stress management skills • Self-care fosters resilience and buffers against challenging events that might contribute to suicide risk VETERANS HEALTH ADMINISTRATION

Whole Health and Suicide Prevention • Professional care: Strong therapeutic relationships matter –People are comfortable with disclosure –More adherent to the plan • Community resources can offer support –Might reach those who would not seek help otherwise –Facility, local, and national resources all good to know • The Whole Health approach is well-suited to working with complex comorbidities that predispose to suicide –E. g. , chronic pain, insomnia, PTSD, depression, substance misuse VETERANS HEALTH ADMINISTRATION

Suicide Prevention Resources National Suicide Prevention Lifeline & Veterans Crisis Line: 1 -800 -273 -8255, Press 1 • Veterans Crisis Line – www. veteranscrisisline. net • Suicide Prevention Lifeline – www. suicidepreventionlifeline. org • Spread the Word: – http: //spreadtheword. veteranscrisisline. net/ • VA Office of Suicide Prevention – https: //www. mentalhealth. va. gov/suicide_prevention/ VETERANS HEALTH ADMINISTRATION

If People Feel Their Care is Centered on Them. . . • They are less likely to die following a major event such as acute myocardial infarction • Meterko et al. , Health Services Research 45(5): 1188 -1204, 2010. • Patient empowerment facilitates better adherence • Nafradi et al. PLo. S One. 2017 Oct 17; 12(10): e 0186458. • They trust their care team more • Keating et al. , J Gen Intern Med, 17(1): 29 -39, 2002. VETERANS HEALTH ADMINISTRATION Photos: va. gov

". . . Our job in medicine. . . " "We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when disability comes, but all along the way. ” Atul Gawande, MD Being Mortal VETERANS HEALTH ADMINISTRATION 34

The Disruptive Innovation The Whole Health System Offers: • Human Care • Self Care • Clinical Care Complementary and Integrative approaches are integral to Self Care and Clinical Care VETERANS HEALTH ADMINISTRATION 35

The Whole Health System VETERANS HEALTH ADMINISTRATION

VA Integrative Health Coordinating Center (IHCC) • • Created in 2013 Led by Ben Kligler, MD Multiple clinical champions Charged with implementing strategies across the system – Education – Research – Clinical Care VETERANS HEALTH ADMINISTRATION

VA Integrative Health Coordinating Center (IHCC) Two major functions: 1. Identify and address barriers to offering CIH in the VA 2. Provide resources, clinical expertise, and education for Veterans, clinicians, and leadership VETERANS HEALTH ADMINISTRATION 38

Whole Health Design Sites, 2016 -17 Portland Hudson Valley Minneapolis San Francisco Boston Tomah Iowa City Jesse Brown Columbia Greater Los Angeles St. Louis Washington DC Salisbury Central Arkansas North Texas Plano Baltimore Durham Biloxi VETERANS HEALTH ADMINISTRATION = FY 16 Facilities = FY 17 Facilities

Whole Health Design Sites, 2018 Fargo Manchester Madison Fresno Detroit Bedford Syracuse Sioux Falls Cincinnati Kansas City Mountain Home, TN Birmingham West Palm Beach VETERANS HEALTH ADMINISTRATION FY 18 Design Sites

Each VISN has one site implementing a Whole Health system model in FY 2018

18 in ’ 18. . . VETERANS HEALTH ADMINISTRATION 42

Our Mission… • Imagine and implement what you can do to move closer to a “Whole Health Care System” • Practice mindful awareness • Share wisdom and network with each other • Clearly define what tools & support you need • Explore this for ourselves: self care • Have fun! VETERANS HEALTH ADMINISTRATION

Time to Pause and Create • You have the answers • This is time to put them into action Pause Be Present VETERANS HEALTH ADMINISTRATION Proceed Towards Whole Health

Veterans committed their lives, health, and well-being to Mission Success in defense of our country. VETERANS HEALTH ADMINISTRATION

Now, we can help them be mission ready for their lives, optimizing their health in service of what matters to them. How Will We Identify Success? VETERANS HEALTH ADMINISTRATION When Veterans achieve outcomes they never even imagined.