Achieving Whole Health for Veterans and the Nation (2024)

The US health system fails to ensure that everyone has a just opportunity to be healthy. The focus on disease treatment with dominant fee-for-service payments is not equipped to promote well-being. New goals and a systematic reorientation of national health resources and activities are needed.

Building on the World Health Organization’s efforts to redefine what it means to be healthy and national calls for more people-centered care,^1,2 the US Department of Veterans Affairs (VA) has been a leader to rethink health and how people achieve it, launching its Whole Health System (WHS) of care.^3,4 The WHS empowers and equips people to take charge of their well-being and live to the fullest. It fundamentally changes care from “what’s the matter with you?” to “what matters to you?” The VA began with 200 innovation projects to test ideas about how to operationalize approaches, was followed by 25 design sites to develop the program, then began initial full-scale deployment at 18 WHS flagship sites, and now is scaling and spreading the WHS of care across its entire system.⁵ The WHS includes peer-led support; personalized health planning; coaching; well-being courses; and integrated evidence-based conventional, complementary, behavioral, and integrative practices to address all aspects of health, including social and structural determinants. If this transformational approach produces the hypothesized improvements, it could become a model for higher-value care nationally.⁶

A new consensus report from the National Academies of Sciences, Engineering, and Medicine (National Academies) examines the potential for improving health outcomes through a whole health model; identifies best practices and lessons learned from the VA WHS and other health systems; and considers ways to scale and spread whole health to the entire US population.⁷

The study committee developed generalizable evidence-based definitions of whole health and whole health care:

Whole health is physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities. To achieve this, whole health care is an interprofessional, team-based approach anchored in trusted longitudinal relationships to promote resilience, prevent disease, and restore health. It aligns with a person’s life mission, aspiration, and purpose.^7(p4)

Achieving whole health starts with understanding what matters to people and then builds the environment, resources, and support to help achieve life goals and cope with change. The committee believes that all people and communities have a right to whole health. It is a common good that should be the desired goal of any effective health care system.

The committee identified 5 foundational elements for effective whole health systems, which include the following characteristics: (1) be people-centered—understand peoples’ needs, goals, and priorities in the context of their family, community, and cultural environment, (2) be comprehensive and holistic—collaboratively and comprehensively address the entirety of a person’s well-being, spanning conventional medical care, complementary and integrative health, spiritual care, and social needs, (3) be upstream-focused—address health behaviors and the social and structural determinants of health, the root causes of poor health, (4) be equitable and accountable—ensure accountability for people, families, and communities and proactively engage with them to equitably address their prioritized needs, and (5) ensure team well-being—ensure the well-being of the entire care team by supporting them to do their jobs within a positive work environment and helping them achieve whole health themselves.

The committee highlighted 7 US and 5 international exemplars of whole health systems, including the VA WHS.⁸ Each system operationalized the foundational elements differently. Collectively, they demonstrated that whole health approaches improved patient care experience and quality measures; increased access to care and reduced emergency department use and hospitalizations; improved management of chronic pain, mental health, traumatic brain injury, and healthy aging; reduced maternal and infant mortality; improved health equity; and reduced health care expenditures.⁷ Key lessons for scaling and spreading whole health included the need for ongoing learning and adaptation, outcomes evaluation, using a range of implementation strategies tailored for multiple audiences, team-based approaches, leadership support, and synergy with high-level drivers of system change.^5,7,9,10

To advance the understanding of whole health care and scale and spread the approach nationally, the committee made 6 overarching recommendations for VA and health, social, and community care systems.

Engagement, support, buy-in, and prioritization from the bottom up and top down are needed to enable the cultural and structural transformations to scale and spread whole health care.

Interprofessional teams, organizations, and systems must understand where they are on the trajectory to delivering whole health care.

• Organizations committed to whole health should ensure that they are ready to offer whole health care to the people, families, and communities they serve.

Achieving whole health requires support in all settings throughout people's life span, and within and across communities, to ensure holistic and comprehensive care.

• The VA should integrate delivery of WHS between the Veterans Benefits Administration and the Veterans Health Administration.

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• Health care systems should create and strengthen infrastructure needed to partner with community programs, social care, and public health systems.

Each foundational element is essential and interdependent. Successful whole health systems need to attend to all 5 elements.

• The VA should incorporate all whole health foundational elements into its WHS.

• Organizations should model whole health approaches after VA and other early adopters.

• Building on its existing health center program, the Health Resources and Services Administration should lead the scale and spread of whole health care in the community.

The understanding of how to best deliver whole health care is evolving rapidly. Evaluating and adapting approaches are essential for national success.

• Systems fielding a whole health approach should systematically and continuously evaluate their implementation and disseminate lessons learned.

• The Agency for Healthcare Research and Quality should fund research to evaluate whole health care and disseminate best practices.

• Additional research support is needed from other national and international organizations, foundations, and private payers.

Scaling and spreading whole health care will not be possible without realigning infrastructure, policies, and payment. The VA and US Department of Health and Human Services should create a national Center for Whole Health Innovation that should address 5 tasks: (1) disseminate the vision of whole health for the nation, (2) define how to measure and hold systems accountable, (3) ensure structures, processes, and infrastructure development to support whole health, (4) adapt value-based payment models aligned with delivering whole health care by both public and private payers, and (5) consider equitable allocation of resources.

Whole health is a common good that benefits people, families, and communities. Scaling and spreading whole health care to ensure everyone can access needed services is a tall task and will take seismic cultural, structural, and process transformations. These include how to think about what it means to be healthy, how to deliver health care, who is accountable for delivering health care, and how to measure success. Throughout the transformation process, the people, families, and communities who seek whole health care must be engaged as equal partners in defining health goals and the preferred strategies to reach those goals. Multisector collaboration and investment on national and local levels are needed, as is substantial reallocation of resources to ensure effective, efficient, and equitable care.

Published: May 5, 2023. doi:10.1001/jamahealthforum.2023.0874

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Krist AH et al. JAMA Health Forum.

Corresponding Author: Alex H. Krist, MD, MPH, Department of Family Medicine and Population Health, Virginia Commonwealth University, 830 E Main St, One Capitol Square, Room 637, Richmond, VA 23219 (alexander.krist@vcuhealth.org).

Conflict of Interest Disclosures: Dr Meisnere reported that the National Academies of Science, Engineering, and Medicine study was funded by the Department of Veterans Affairs, the Samueli Foundation, and the Whole Health Institute. No other disclosures were reported.

Additional Contributions: This Viewpoint reflects the opinion of the full National Academies of Science, Engineering, and Medicine committee, who all participated in developing the report, Achieving Whole Health: A New Approach for Veterans and the Nation. Committee members, who were not compensated, include Alex Krist, Jeannette South-Paul, Andrew Bazemore, Tammy Chang, Margaret Chesney, Deborah Cohen, Seiji Hayashi, Felicia Hill-Briggs, Shawna Hudson, Carlos Roberto Jaén, Christopher Koller, Harold Kudler, Sandy Leake, Patricia Lillis, Ajus Ninan, Pamela Schweitzer, Sara Singer, and Zirui Song. Additionally, we would like to thank the National Academies’ staff and fellow (Marjani Cephus, Tochi Ogbu-Mbadiugha, Arzoo Tayyeb, Sharyl Nass, and Alexander Melamed), authors of commissioned papers (Asaf Bitton, Denise Hynes, and Moira Stewart), and science writer (Joseph Alper). The views expressed within this article do not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine, the National Research Council, or any of their constituent units.