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Meeting the quadruple aim through whole-person care

Covid-19 exposed how unhealthy we are as a nation making the case for whole-person care even stronger. All we need now is to focus on redesigning our health care system to deliver this type of care—and muster the courage to do it.

 

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The devastation of Covid-19—even beyond killing more than one million Americans—was its exposure of the shocking extent of underlying preconditions afflicting our population and our sad failure to treat them. Six of every 10 people in the U.S. suffer from chronic diseases. Roughly 40 million Americans have five or more chronic illnesses—accounting for 41% of all spending in the most expensive health system the world has ever seen. Nonetheless, despite all this spending, 66% of us rate our medical care as low or poor.

Our nation is among the most highly advanced when it comes to treating acute illness by delivering pills and procedures. But the truth is that our system is simply not designed to keep us healthy. Numerous studies show that medical treatment itself accounts for only about 20% of health. Nearly 80% comes from other factors rarely addressed by our system. These are emotional and mental health, behavioral and lifestyle factors, and the social and economic environment in which a person lives.

The good news is that we already have access to a better path to lifelong health and wellbeing. In our new report, The Case for Delivering Whole-Person Care, the Family Medicine Education Consortium and the Samueli Foundation funded the study of numerous real-world examples of health systems, hospitals, and clinics which are currently practicing “whole-person” care. This approach allows these institutions to achieve the elusive “quadruple aim” of reducing costs while also improving population health, the patient experience, and even the wellbeing of clinicians.

These are not pie-in-the-sky concepts. For example, the Veterans Administration has documented the remarkable success of a new care model that shifts from a traditional disease-based transactional system to a team-based, person-centered care model that addresses patients’ physical, emotional, and social wellbeing. In their four-year pilot program with 130,000 veterans at 18 sites, the VA not only reported improved outcomes and patient experience ratings, but also a significant savings of 20 percent, or more than $4,500 annually per veteran.

Whole-person care combines conventional medicine, non-drug treatments, and evidence-based complementary modalities to promote self-care. It uses approaches such as health coaching, group visits, nutritional counseling, acupuncture, yoga, meditation, therapeutic massage, stress reduction, and other non-drug approaches for healing. It explores the social and economic circumstances of the patient and assists them in helping with those. It starts with finding out what matters to the person and then exploring the determinants of health and healing that are most pertinent to them. Thus, the approach goes to the root causes of their ills and seeks to assist them with long-term solutions.

The VA’s “Whole Health” model yielded a reduction of 23% to 38% in opioid use, compared to 11% with conventional care alone. Whole health patients also reported greater improvement in perceptions of care, engagement in care and self-care, life meaning and purpose, pain, and perceived stress. Moreover, VA’s own employees reported higher engagement, job satisfaction, and intrinsic motivation, yielding reduced turnover and burnout.

There are large benefits of the whole person care approach:

  • A large Pennsylvania health system provided free healthy food along with nutrition education, yielding tangible decreases in patients’ weight, HA1C, blood pressure, and triglycerides.
  • A clinic in Arizona practicing integrative health reported increased trust and satisfaction among 90% of patients.
  • A Chicago multi-center integrative care clinic reported significant drops in hospital admissions, surgeries, and drug costs.
  • And in New York City, in a major safety net facility, patients with long Covid-19 reported greater relief when their medical care was supplemented with diet plans, physical and breathing exercises, meditation, group and individual mental health counseling.

The heart of these successes is that whole-person health care allows patients to build on and better utilize their own personal healing capacity. We are all familiar with the “social determinants of health” in which social and economic environments determine health outcomes for an entire zip code. Whole-person care taps into addressing these for the purpose of finding the “personal determinants of health” – those determinants that promote individual healing in any environment.

One practical approach to implementing this type of care is to have practitioners ask the patient to assess their physical, emotional, and spiritual wellbeing through a Personal Health Inventory (PHI). The PHI asks the provocative question: what matters to you in life and what brings you joy? It then goes on to assess how willing you are to make changes in various aspects of your life to achieve that life purpose and enjoy good health. After the PHI, an “integrative health visit” identifies the patient’s values and goals for healing. I call this the HOPE Note (Healing-Oriented Practices and Environment) Toolkit.

The HOPE Note builds off of the SOAP Note (subjective, objective, assessment, and plan) that every medical student learns to apply in everyday practice. SOAP asks “what’s the matter” and treats the immediate medical diagnosis or symptoms. HOPE reaches patients on a deeper level by not just asking “What’s the matter?” Instead, we are asking “What really matters to you?” It then focuses on addressing the root causes of the malady.

This process builds a stronger relationship with the provider, whose role is to really understand the patient’s goals for healing and then to provide the evidence and support to help them. This is all not just a feel-good process. Our research has shown that whole-person care yields tangible results supporting the quadruple aim, such as:

  • Better patient outcomes: increased ability to manage chronic pain, decreased reliance on opioids, lower HbA1c with diabetes, improved medication adherence, reduced severity of heart disease, and even reduced loneliness for seniors.
  • Improved patient experiences: improved retention and satisfaction with providers and with overall care, along with higher quality-of-care ratings.
  • Lower health care costs: reduced total cost, reduced spending on drugs, along with reductions in hospital admissions, length of hospital stays, and emergency department visits.
  • Improved clinician experience: reduced provider burnout and reduced turnover for both providers and employees.

In 2021, a study by the National Academy of Sciences, Engineering, and Medicine recognized high-quality whole-person care as the foundation of primary care for a strong U.S. health care system. It recommended system-wide implementation of “whole-person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”

We know that this approach works. All we need now is to focus on redesigning our health care system to deliver this type of care—and muster the courage to do it.

Dr. Wayne Jonas is the executive director of Integrative Health Programs at Samueli Foundation and is a board-certified, practicing family physician. He is the former director of the National Institutes of Health Office of Alternative Medicine and the World Health Organization Center for Traditional Medicine. With more than 40 years of experience, Dr. Jonas incorporates evidence-based healing into his patient care and is dedicated to helping other clinicians find ways to incorporate self-care into their own lives.

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