Innovations in Care: Complementary and Integrative Health in the Veterans Health Administration Whole Health System.

Abstract

INNOVATIONS IN CARE: COMPLEMENTARY AND INTEGRATIVE HEALTH IN THE VETERANS HEALTH ADMINISTRATION WHOLE HEALTH SYSTEM Consistent with its long history of innovation, the Veterans Health Administration (VA) has recently committed to a massive expansion of the provision of complementary and integrative health (CIH) approaches as part of standard care, and to an even more massive transformation to a Whole Health System of care. These shifts are being driven by several factors: mounting evidence on the effectiveness of CIH approaches for many conditions; increasing demand from Veterans; increasing need to offer nonpharmacologic pain management strategies to counter the opioid epidemic; and significant support from Congress and the VA’s leadership. To-date, Veteran response and health outcomes of this shift are extremely positive. COMPLEMENTARY AND INTEGRATIVE HEALTH AS A PART OF WHOLE HEALTH Implementation of CIH approaches within the VA’s medical centers began in the late 1990s but proceeded generally in an inconsistent and limited fashion, driven largely by Veteran demand and provider interest. In response to increasing demand for CIH approaches from Veterans, clinicians, and Congress, the Integrative Health Coordinating Center was established within the Office of Patient Centered Care and Cultural Transformation in 2014 to identify and reduce barriers to implementing CIH approaches across the VA, including developing national policy on the provision of CIH approaches. Over the past 5 years, the VA has made significant progress in expanding the availability of CIH approaches to Veterans, especially to address pain and mental health conditions. CIH approaches are delivered in the VA not only as an add-on or a set of new tools, but as a critical component in the context of a larger transformation to a Whole Health System model of care. This model shifts from focusing on episodic, disease-centered care to engaging and empowering Veterans early on and throughout their lives to take charge of their life and health. The model emphasizes self-care along with conventional care and CIH approaches such as yoga, meditation, and acupuncture. POLICY AND LEGISLATIVE SUPPORT In May 2017, after years of internal discussion and debate, VA Directive 1137: Provision of Complementary and Integrative Health was approved by the Under Secretary for Health, representing a significant change in how care is delivered across the VA, and advancing personalized and patient-centered care.1 The directive mandates that evidence-based CIH approaches be offered as part of the standard VA medical benefits package—a radical step forward in providing truly integrative care, and one which no other health care system to-date has taken on this scale. The Integrative Health Coordinating Center, in collaboration with its Advisory Workgroup leadership and key VA stakeholders, is charged with reviewing available published evidence on each CIH approach and deciding whether this evidence is sufficient to recommend inclusion of the CIH approach in the medical benefits package. To-date, with support from VA leadership, we have approved 8 approaches: acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, tai chi, and yoga. Every VA medical facility is now required to provide access to these where appropriate for Veterans’ plan of care, either at the VA medical center, in the community, or via telehealth. Because the VA is the nation’s largest integrated health care system, this innovation has potential for great impact for federal and state health policy related to the provision of CIH approaches within any health care setting. CIH visits have grown exponentially recently with a notable increase in the year following the release of the VA Directive 1137. Although not every CIH approach is available at every VA medical facility, all facilities currently offer some approaches, and we are seeing rapid progress across the country in our goal to ultimately achieve that type of access. The Comprehensive Addiction and Recovery Act (CARA) legislation, signed into law in 2016 (Public Law No:114-198),2 contributed significant momentum to the expansion of CIH approaches in the VA. This legislation required both a comprehensive plan for how the VA would expand availability of CIH approaches, and most importantly, a 3-year pilot to expand the provision of CIH approaches in no fewer than 15 VA medical centers. To meet this requirement, the VA launched 18 “Whole Health Flagship” facilities in 2018, the first wave of facilities in the national deployment of the Whole Health System model, which includes CIH approaches. Early data has shown impressive uptake of Whole Health services at these Flagship facilities: among Veterans with chronic pain, 31% participated in at least one Whole Health service and 26% used CIH approaches either at the VA or in the community.3 These data also showed that participating in Whole Health services led to reductions in opioid use, higher engagement in health care and self-care, and greater overall well-being compared with Veterans at Flagship facilities who did not engage in Whole Health services. One Veteran said that using CIH approaches has had life-changing consequences:Joe—Army, age 63- “My doctor mentioned yoga before surgery I had and I tried some yoga classes before my surgery. Once I was cleared, I started yoga again, Tai Chi, and nutrition classes. I have been able to quit smoking! I have been going to the Partners class to explain to others about how you meet with a coach. I don’t know where I would be without this. Whole Health is essential in moving the VA forward.” Responses from employees involved in Whole Health services also reported lower voluntary turnover, lower burnout, and greater motivation. In fiscal year 2019, 37 Whole Health System sites were added, with additional sites providing CIH and Whole Health services. TELEHEALTH As with the general population, the Veteran patient population is geographically dispersed with some Veterans residing in rural locations far from a VA medical center. Telehealth has the capacity to expand access to services by decreasing geographic, physical, and transportation barriers. Over the past few years, the VA has dedicated significant time and resources to expanding access to Whole Health and CIH approaches such as yoga, tai chi, meditation, acupressure, and health coaching through telehealth technology. With ∼17% of the Veteran population having experience using telehealth technology to receive health care services as of fiscal year 2020 optimizing access to Whole Health and CIH approaches via telehealth can expand the reach of these evidence-based approaches. In fiscal year 2019, almost 4000 unique Veterans received over 10,000 CIH approach visits through telehealth, representing a 4-fold increase in unique Veterans compared with fiscal year 2018. Since the start of the COVID-19 pandemic, with in-person visits temporarily shutting down for nonurgent services, additional VA medical centers began offering CIH and Whole Health approaches via telehealth. We expect significant growth in this approach into the future as health care delivery continues to be shaped by this pandemic. STRATEGIES FOR EXPANDING ACCESS TO COMPLEMENTARY AND INTEGRATIVE HEALTH APPROACHES To help increase the provision of Whole Health and CIH approaches, the VA has developed provider trainings for Whole Health coaches and mindfulness facilitators, and skills trainings in Battlefield Acupuncture (protocolized auricular acupuncture for pain), clinical hypnosis, and guided imagery. To-date, the VA has trained over 4600 providers in Battlefield Acupuncture, 88 in Battlefield Acupressure, 2370 in health coaching, and 124 in mindfulness facilitation, with more being trained all the time. We are also currently piloting an online training in clinical hypnosis. Although some trainings had been designed to be provided virtually or as a hybrid of online and in-person training, almost all are being adapted to an online format due to COVID-19 except for Battlefield Acupuncture and Battlefield Acupressure. A second strategy to expand capacity is the development of new standards and guidance to support hiring of additional CIH providers, involve CIH volunteers, and provide direction for the delivery of CIH care in the community. To this end, the VA has developed provider minimum proficiencies for: acupuncture, massage therapy, meditation, clinical hypnosis, biofeedback, yoga, and tai chi. To facilitate hiring, we have also developed position descriptions for tai chi and yoga instructors and Whole Health coaches, and qualification standards for acupuncturist and massage therapists. The VA is currently exploring the development of qualification standards for yoga therapists, yoga instructors, tai chi instructors, and health coaches. CONCLUSIONS The VA has taken a bold step to dramatically expand access to CIH approaches as part of the Whole Health System of care. Although other health systems are gradually and incrementally adding specific services such as acupuncture to their covered benefits, the VA is the first in the country to take this step on a significant scale. Preliminary data show improvements in Veteran outcomes and staff well-being are linked with this innovation. As the VA continues to develop new and better ways of making CIH approaches available to all Veterans, and to collect data on the outcomes of this expanded access for Veterans and employees, we hope to demonstrate to the rest of the United States health care system how an emphasis on whole person care and self-management skills should become the new standard across the industry.