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.
Background: Veterans Affairs is dedicated to providing a Whole Health approach to care, including offering complementary and integrative health (CIH) approaches to Veterans. Objective: The objective of this study was to examine the association of CIH participation with Veterans’ patient-reported outcomes over time. Research Design: A survey of patient-reported outcomes at 5 timepoints: baseline, 2, 4, 6, and 12 months. Subjects: Veterans participating in any type of CIH approach at 2 Veterans Affairs medical centers. Measures: Mixed hierarchical models with repeated variables were used to test the hypothesis that participating in any CIH approach would be associated with Veterans’ overall physical/mental health [Patient-Reported Outcomes Measurement Information System 28 (PROMIS 28)], pain intensity, perceived stress (Perceived Stress Scale-4), and engagement in their care (Patient Activation Measure-13), controlling for age, male sex, site, participation in other CIH approaches, and surveys completed. Results: We received 401 surveys from 119 Veterans (72% male, age range: 29–85 y) across all timepoints. Yoga participation was related to decreases in perceived stress (P<0.001), while tai chi participation was associated with improvements in overall PROMIS 28 physical and mental health functioning (P<0.02). Specific types of CIH were associated with significant improvements in PROMIS 28 subscales: meditation participation with physical functioning at 2, 6, and 12 months; tai chi participation with anxiety at 2 and 6 months, and ability to participate in social role activities at 2 months. No CIH approach was associated with Veterans’ pain or engagement in their care. Conclusion: As specific CIH approaches are associated with improvements in patient-reported outcomes, clinicians, Veterans, and family members may use this information in discussions of nonpharmacological options to address health and well-being.
Background Despite increasing commitment to patient engagement in research, evaluation of the impact of these efforts on research processes, products, and teams is limited. Objective To explore the impacts of engaging patients as consultants to research studies by examining the experiences, impacts, and lessons learned from a program facilitating patient engagement at a Veterans Health Administration research center. Design We developed a logic model to articulate the activities being implemented to support patient engagement and their anticipated outcomes. Then, we conducted qualitative, semi-structured interviews with participants in the local Veteran Consulting Network to qualitatively explore these outcomes. Participants Twelve researchers and eleven Veteran patients with experience working on at least one grant or funded study. Approach Interview transcripts were inductively coded using a consensus-based approach. Findings were synthesized using framework analysis and mapped back onto our logic model of expected patient engagement impacts. Key Results Patient engagement improved the perceived quality and relevance of research studies as patient consultants challenged researchers’ assumptions about patient populations and clinical contexts and gave feedback that helped improve the feasibility of proposed grants, readability of study materials, comprehensiveness of study assessments, and cultural sensitivity and relevance of interventions. Patient engagement also had personal benefits to researchers and patients. Researchers reported improved communication skills and higher job satisfaction. Patients reported a sense of purpose and satisfaction from their work with greater awareness of and appreciation for research. Conclusions Engaging patients in research can have multiple benefits to the people and work involved. Our evaluation process can serve as a template for other organizations to plan for and assess the impact of their own patient engagement programs. Creating logic models and updating them based on feedback from program users make engagement goals explicit, help verify expected mechanisms to achieve impact, and facilitate organizational learning.
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.
Research Objective VHA is piloting the Whole Health System of Care (WHS) at 18 sites to shift care from a disease‐focused “find‐it, fix‐it” model to one driven by patients’ personal health goals, to foster patient self‐management, and to improve well‐being. As part of the Comprehensive Addiction and Recovery Act, VHA initiated a demonstration program in 18 VA Medical Centers to implement WHS. We report on its impact on Veterans. Study Design A longitudinal survey of Veterans with chronic pain at the 18 flagship medical centers. Veterans were surveyed at baseline and 6 months using 12 patient‐reported outcome measures. Outcomes were compared between Veterans who did not use WHS services and Veterans with different levels of WHS service use, using standardized mean differences/Cohen’s D. We conducted a longitudinal cohort analysis of Veterans who started using WHS after April 2018. This analysis compared opioid dose levels using administrative pharmacy data (quarterly morphine equivalents) for the 6‐month period before using WHS to opioid levels one year later. This analysis included Veterans from the same time periods who did not use WHS services. Population Studied Survey: a random sample of Veterans with chronic musculoskeletal pain at 18 VA medical centers; we report on 3622 patients who completed baseline and 6‐month surveys (response rate: 49.3% baseline; 74.2% follow‐up). Administrative cohort analysis: 112 202 Veterans with chronic pain who received continuous VA care between October 2017 and March 2019 and used >2 WHS (without WHS services prior to April 2018) or no WHS throughout the evaluation period. Principal Findings 46% of survey respondents and 5.9% of the administrative cohort used >2 WHS services. Effect sizes for survey measures were small overall; however, those who used WHS services reported greater improvements in perceptions of care, engagement in health care and self‐care, life meaning and purpose, pain, and perceived stress. Opioid use among Veterans using WHS decreased 23% compared with 11% decrease among those with no WHS use. Conclusions WHS use, especially high levels of WHS use, was positively associated with improvements in several patient‐reported health and well‐being outcomes. While effect sizes were small for survey measures over this 6‐month period, they are promising for the future impact of VHA’s WHS initiative. Administrative data identified meaningful reductions in opioid use among WHS users. Implications for Policy or Practice The use of WHS services among Veterans with chronic pain has important implications for pain management, and Veteran health and well‐being. Implementing a system of care that is designed to provide these services to patients presents an opportunity to radically change the way health care is delivered and impact patients’ lives and not just fix their diseases. Primary Funding Source Department of Veterans Affairs.
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