What Matters Most: A Whole Health Approach

Renn Sweeny, PhD

Overview

• Challenges of the Traditional Healthcare Model

• Importance of Patient Engagement• Whole Health Model

– Pathway– Wellbeing – Clinical Care

1

The Economics and the Outcomes

UC Project for Global InequalityCrow, B and Lodha, S. (2011) Atlas of Global Inequalities. Oakland, CA. University of CA Press.

“Fixing” the problem is no longer so easy.

Leading cause of death-Not infection anymore.

Chronic conditions drive this now.

This Photo by Unknown Author is licensed under CC BY-NC-ND

Employee Age and Chronic DiseaseCompared to the U.S. health care workforce as a whole, VHA employees are older with a mean age of 48 years; the burden of chronic disease is significant with increasing age of our workforce.

51%

42%

30%

21%

16%21%

19% 19% 17% 16%19%

23%27%

30%34%

7%11%

15%19% 21%

2%5%

9%12% 13%

0%

10%

20%

30%

40%

50%

60%

<30 30-39 40-49 50-59 60+

No chronic conditions 1 chronic condition 2-3 chronic conditions

4-5 chronic conditions 6+ chronic conditions

Growing Chronic Disease Burden as we Age

The root cause of the crisis is that we have put the disease at the center, not the person.

5

Engagement

• We only see a given patient for a few hours a year, depending on our clinical role

• They don’t follow our recommendations very well– 50% for most meds, even

lower for chronic condition meds

– 30% for lifestyle changes, but better in a group

Brown MT, et al. Am J Med Sci, 2016;351(4):387-99. Martin LR, Ther Clin Risk Manage, 2005;1(3):189-199.

Photo: americandatabank.com

Engagement is Key!

• Patient Engagement: the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes maximizing outcomes or improving experiences of care.

7(Higgins, Larson, Schnall, 2017)

Patient Engagement Research• 2014 Review of 10 trials

>3,000 participants– Multiple chronic diseases (DM,

CAD, HTN, COPD, asthma, arthritis, etc.)

• Variety of interventions to enhance engagement (groups, in-person one-on-one, web-based, telephone visits)

• Improved clinical outcomes (A1c, lipids, BP, depression) and quality of life

Simmons et al. Genome Med, 2014;6:16.

Photo: Continuouscare.io

Engagement Research

• Concept analysis of 722 articles on engagement• Identified 4 key elements (PACT):

1. Personalization (it’s individualized)

2. Access (to things they need which help)

3. Commitment (it matters and is meaningful to them – MAP)

4. Therapeutic Alliance (good clinician connection)

(Environment came up as well)

Higgins T et al. Patient Education and Counseling, 2017;100:30–36.

Connecting to What Matters• “Constructive behavior change arises when the

person connects with something of intrinsic value, importance, or something that is cherished. Intrinsic motivation for change arises in an accepting, empowering atmosphere that makes it safe for a person to explore the possibly painful present in relation to what is wanted or valued.”– Miller & Rollnick (2012)

10

Meaning and Overall Health• 2017 review and meta-

analysis• 66 studies, n=73,546• Positive effect of “Meaning

in Life” found in all 66 of them– Multiple aspects of health– Overall effect size 0.26

(small-to-moderate)– 0.1 for mortality, 0.34

cancer

Czekierda et al, Health Psychol Rev, 2017;11(4):387-418.

MS HIV Spinal cord injury CHF DM2 CHD Cancer Post-polio Arthritis Post-transplant

And...Meaning and Purpose Save $

• There was a dose response relationship in older adults (n=15,680) with:– Fewer admissions– Fewer ED visits– Lower medical expenditures

overall– Lower drug expenditures

• The highest tertile also had a 19% increase in adherence to chronic care rec’s

Musich et al, Pop Health Manage, 2018;21(2):139-47.

Image: psychologytoday.com

The Whole Health System

VHASLC Whole Health Director: William Marchand, MDVHASLC Program Manger: Kellie Davis, BSN RN

Whole Health: A Partnership

Whole Healthis an approach to health care that

empowers and equips people to take charge of their health and well-being,

and live their life to the fullest.

Dream Rangers

16

https://www.youtube.com/watch?v=bp7S56aoIhU

Emotions

Mind

Relationships

Meaning and PurposeCulture

Photo credit: Jabi - El de verdad via Foter.com / CC BY-NC

Values

Life Story

Physical

Fundamentals: The Whole Person

18

What’s the matter with you?

19

What matters to you?

Explore the “MAP”: Examples of ?’s• To partner with you in your care, it would help if I

really understand what is important to you in your life.

• What really matters to you in your life? What do you want your health for?

• What brings you a sense of joy and happiness? • How does your current health impact what is

most important to you?• What is your vision of your best possible health

Nafradi et al. PLoS One. 2017 Oct 17;12(10):e0186458.

21

Pathway

• Peer Partners

Don't walk behind me; I may not lead. Don't walk in front of me; I may not follow. Just walk beside

me and be my friend.

-Albert Camus

An Invitation

Circle of Health

Components of Proactive Health and Well-being

Well-Being Programs

• Skill-Building Classes• Health Coaching• Complementary/ Integrative

Health therapies– Acupuncture– Biofeedback– Yoga– Tai Chi– Meditation– Guided Imagery– Massage

Whole Health Clinical Care

• Linking to What Matters Most, Empowering & Equipping• Integration with other parts of system

This Photo by Unknown Author is licensed under CC BY-SA

Connecting to What Matters

Statement A“You have been in and out of detox 6 times in the last year. You aren’t following through with your appointments. You better stop drinking or you will die...”

Statement B“How is your dog Buster? I know he gives you a reason to keep going. Where does he go when you are in the hospital? What do you say we talk about ways to stay out of the hospital so you can take care of Buster? What ideas do you have about that?

28

Fundamentals: Personal Health Planning

Ask what really matters

Gather info. (e.g., Personal

Health Inventory)

Co-create a realistic, practical

plan

Equip them with tools they need

to succeed

And it isn’t just about the

plan...

• “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.” ― Atul Gawande

Being Mortal: Illness, Medicine and What Matters in the End