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Age-Friendly Health Systems Transformation: A Whole Person Approach to Support the Well-Being of Older AdultsAge-Friendly Health Systems Transformation: A Whole Person Approach to Support the Well-Being of Older Adults
The COVID-19 pandemic established a new normal for health care delivery, with leaders rethinking core practices to survive and thrive in a changing environment and improve the health and well-being of patients. The Veterans Health Administration (VHA) is embracing a shift in focus from “what is the matter” to “what really matters” to address pre- and postpandemic challenges through a whole health approach.1 Initially conceptualized by the VHA in 2011, whole health “is an approach to health care that empowers and equips people to take charge of their health and well-being so that they can live their life to the fullest.”1 Whole health integrates evidence-based complementary and integrative health (CIH) therapies to manage pain; this includes acupuncture, meditation, tai chi, yoga, massage therapy, guided imagery, biofeedback, and clinical hypnosis.1 The VHA now recognizes well-being as a core value, helping clinicians respond to emerging challenges related to the social determinants of health (eg, access to health care, physical activity, and healthy foods) and guiding health care decision making.1,2
Well-being through empowerment—elements of whole health and Age-Friendly Health Systems (AFHS)—encourages health care institutions to work with employees, patients, and other stakeholders to address global challenges, clinician burnout, and social issues faced by their communities. This approach focuses on life’s purpose and meaning for individuals and inspires leaders to engage with patients, staff, and communities in new, impactful ways by focusing on wellbeing and wholeness rather than illness and disease. Having a higher sense of purpose is associated with lower all-cause mortality, reduced risk of specific diseases, better health behaviors, greater use of preventive services, and fewer hospital days of care.3
This article describes how AFHS supports the well-being of older adults and aligns with the whole health model of care. It also outlines the VHA investment to transform health care to be more person-centered by documenting what matters in the electronic health record (EHR).
AGE-FRIENDLY CARE
Given that nearly half of veterans enrolled in the VHA are aged ≥ 65 years, there is an increased need to identify models of care to support this aging population.4 This is especially critical because older veterans often have multiple chronic conditions and complex care needs that benefit from a whole person approach. The AFHS movement aims to provide evidence-based care aligned with what matters to older adults and provides a mechanism for transforming care to meet the needs of older veterans. This includes addressing age-related health concerns while promoting optimal health outcomes and quality of life. AFHS follows the 4Ms framework: what matters, medication, mentation, and mobility.5 The 4Ms serve as a guide for the health care of older adults in any setting, where each “M” is assessed and acted on to support what matters.5 Since 2020, > 390 teams have developed a plan to implement the 4Ms at 156 VHA facilities, demonstrating the VHA commitment to transforming health care for veterans.6
When VHA teams join the AFHS movement, they may also engage older veterans in a whole health system (WHS) (Figure). While AFHS is designed to improve care for patients aged ≥ 65 years, it also complements whole health, a person-centered approach available to all veterans enrolled in the VHA. Through the WHS and AFHS, veterans are empowered and equipped to take charge of their health and well-being through conversations about their unique goals, preferences, and health priorities.4 Clinicians are challenged to assess what matters by asking questions like, “What brings you joy?” and, “How can we help you meet your health goals?”1,5 These questions shift the conversation from disease-based treatment and enable clinicians to better understand the veteran as a person.1,5
For whole health and AFHS, conversations about what matters are anchored in the veteran’s goals and preferences, especially those facing a significant health change (ie, a new diagnosis or treatment decision).5,7 Together, the veteran’s goals and priorities serve as the foundation for developing person-centered care plans that often go beyond conventional medical treatments to address the physical, mental, emotional, and social aspects of health.
SYSTEM-WIDE DIRECTIVE
The WHS enhances AFHS discussions about what matters to veterans by adding a system-level lens for conceptualizing health care delivery by leveraging the 3 components of WHS: the “pathway,” well-being programs, and whole health clinical care.
The Pathway
Discovering what matters, or the veteran’s “mission, aspiration, and purpose,” begins with the WHS pathway. When stepping into the pathway, veterans begin completing a personal health inventory, or “walking the circle of health,” which encourages self-reflection that focuses on components of their life that can influence health and well-being.1,8 The circle of health offers a visual representation of the 4 most important aspects of health and well-being: First, “Me” at the center as an individual who is the expert on their life, values, goals, and priorities. Only the individual can know what really matters through mindful awareness and what works for their life. Second, self-care consists of 8 areas that impact health and wellbeing: working your body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind. Third, professional care consists of prevention, conventional care, and complementary care. Finally, the community that supports the individual.
Well-Being Programs
VHA provides WHS programs that support veterans in building self-care skills and improving their quality of life, often through integrative care clinics that offer coaching and CIH therapies. For example, a veteran who prioritizes mobility when seeking care at an integrative care clinic will not only receive conventional medical treatment for their physical symptoms but may also be offered CIH therapies depending on their goals. The veteran may set a daily mobility goal with their care team that supports what matters, incorporating CIH approaches, such as yoga and tai chi into the care plan.5 These holistic approaches for moving the body can help alleviate physical symptoms, reduce stress, improve mindful awareness, and provide opportunities for self-discovery and growth, thus promote overall well-being
Whole Health Clinical Care
AFHS and the 4Ms embody the clinical care component of the WHS. Because what matters is the driver of the 4Ms, every action taken by the care team supports wellbeing and quality of life by promoting independence, connection, and support, and addressing external factors, such as social determinants of health. At a minimum, well-being includes “functioning well: the experience of positive emotions such as happiness and contentment as well as the development of one’s potential, having some control over one’s life, having a sense of purpose, and experiencing positive relationships.”9 From a system perspective, the VHA has begun to normalize focusing on what matters to veterans, using an interprofessional approach, one of the first steps to implementing AFHS.
As the programs expand, AFHS teams can learn from whole health well-being programs and increase the capacity for self-care in older veterans. Learning about the key elements included in the circle of health helps clinicians understand each veteran’s perceived strengths and weaknesses to support their self-care. From there, teams can act on the 4Ms and connect older veterans with the most appropriate programs and services at their facility, ensuring continuum of care.
DOCUMENTATION
The VHA leverages several tools and evidence-based practices to assess and act on what matters for veterans of all ages (Table).5,10-16 The VHA EHR and associated dashboards contain a wealth of information about whole health and AFHS implementation, scale up, and spread. A national AFHS 4Ms note template contains standardized data elements called health factors, which provide a mechanism for monitoring 4Ms care via its related dashboard. This template was developed by an interprofessional workgroup of VHA staff and underwent a thorough human factors engineering review and testing process prior to its release. Although teams continue to personalize care based on what matters to the veteran, data from the standardized 4Ms note template and dashboard provide a way to establish consistent, equitable care across multiple care settings.17
Between January 2022 and December 2023, > 612,000 participants aged ≥ 65 years identified what matters to them through 1.35 million assessments. During that period, > 36,000 veterans aged ≥ 65 years participated in AFHS and had what matters conversations documented. A personalized health plan was completed by 585,270 veterans for a total of 1.1 million assessments.11 Whole health coaching has been documented for > 57,000 veterans with > 200,000 assessments completed.13 In fiscal year 2023, a total of 1,802,131 veterans participated in whole health.
When teams share information about what matters to the veteran in a clinicianfacing format in the EHR, this helps ensure that the VHA honors veteran preferences throughout transitions of care and across all phases of health care. Although the EHR captures data on what matters, measurement of the overall impact on veteran and health system outcomes is essential. Further evaluation and ongoing education are needed to ensure clinicians are accurately and efficiently capturing the care provided by completing the appropriate EHR. Additional challenges include identifying ways to balance the documentation burden, while ensuring notes include valuable patient-centered information to guide care. EHR tools and templates have helped to unlock important insights on health care delivery in the VHA; however, health systems must consider how these clinical practices support the overall well-being of patients. How leaders empower frontline clinicians in any care setting to use these data to drive meaningful change is also important.
TRANSFORMING VHA CARE DELIVERY
In Achieving Whole Health: A New Approach for Veterans and the Nation, the National Academy of Science proposes a framework for the transformation of health care institutions to provide better whole health to veterans.3 Transformation requires change in entire systems and leaders who mobilize people “for participation in the process of change, encouraging a sense of collective identity and collective efficacy, which in turn brings stronger feelings of self-worth and self-efficacy,” and an enhanced sense of meaningfulness in their work and lives.18
Shifting health care approaches to equipping and empowering veterans and employees with whole health and AFHS resources is transformational and requires radically different assumptions and approaches that cannot be realized through traditional approaches. This change requires robust and multifaceted cultural transformation spanning all levels of the organization. Whole health and AFHS are facilitating this transformation by supporting documentation and data needs, tracking outcomes across settings, and accelerating spread to new facilities and care settings nationwide to support older veterans in improving their health and well-being.
Whole health and AFHS are complementary approaches to care that can work to empower veterans (as well as caregivers and clinicians) to align services with what matters most to veterans. Lessons such as standardizing person-centered assessments of what matters, creating supportive structures to better align care with veterans’ priorities, and identifying meaningful veteran and system-level outcomes to help sustain transformational change can be applied from whole health to AFHS. Together these programs have the potential to enhance overall health outcomes and quality of life for veterans.
- Kligler B, Hyde J, Gantt C, Bokhour B. The Whole Health transformation at the Veterans Health Administration: moving from “what’s the matter with you?” to “what matters to you?” Med Care. 2022;60(5):387-391. doi:10.1097/MLR.0000000000001706
- Centers for Disease Control and Prevention. Social determinants of health (SDOH) at CDC. January 17, 2024. Accessed September 12, 2024. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
- National Academies of Sciences, Engineering, and Medicine. Achieving Whole Health: A New Approach for Veterans and the Nation. The National Academies Press; 2023. Accessed September 9, 2024. doi:10.17226/26854
- Church K, Munro S, Shaughnessy M, Clancy C. Age-friendly health systems: improving care for older adults in the Veterans Health Administration. Health Serv Res. 2023;58 Suppl 1(Suppl 1):5-8. doi:10.1111/1475-6773.14110
- Laderman M, Jackson C, Little K, Duong T, Pelton L. “What Matters” to older adults? A toolkit for health systems to design better care with older adults. Institute for Healthcare Improvement; 2019. Accessed September 9, 2024. https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf
- U.S. Department of Veterans Affairs. Age-Friendly Health Systems. Updated September 4, 2024. Accessed September 9, 2024. https://marketplace.va.gov/innovations/age-friendly-health-systems
- Brown TT, Hurley VB, Rodriguez HP, et al. Shared dec i s i o n - m a k i n g l o w e r s m e d i c a l e x p e n d i t u re s a n d the effect is amplified in racially-ethnically concordant relationships. Med Care. 2023;61(8):528-535. doi:10.1097/MLR.0000000000001881
- Kligler B. Whole Health in the Veterans Health Administration. Glob Adv Health Med. 2022;11:2164957X221077214.
- Ruggeri K, Garcia-Garzon E, Maguire Á, Matz S, Huppert FA. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes. 2020;18(1):192. doi:10.1186/s12955-020-01423-y
- U.S. Department of Veterans Affairs. Personal Health Inventory. Updated May 2022. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTH/docs/PHI-long-May22-fillable-508.pdf doi:10.1177/2164957X221077214
- Veterans Health Administration. Personal Health Plan. Updated March 2019. Accessed September 9, 2024. https:// www.va.gov/WHOLEHEALTH/docs/PersonalHealthPlan_508_03-2019.pdf
- Veterans Health Administration. Whole Health: My Life, My Story. Updated March 20, 2024. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTH/mylifemystory/index.asp
- U.S. Department of Veterans Affairs. Whole Health Library: Whole Health for Skill Building. Updated April 17, 2024. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTHLIBRARY/courses/whole-health-skill-building.asp
- U.S. Department of Veterans Affairs. Making Decisions: Current Care Planning. Updated May 21, 2024. Accessed September 9, 2024. https://www.va.gov/geriatrics/pages/making_decisions.asp
- U.S. Department of Veterans Affairs. Life-Sustaining Treatment Decisions Initiative (LSTDI). Updated March 2024. Accessed September 12, 2024. https://marketplace.va.gov/innovations/life-sustaining-treatment-decisions-initiative
- U.S. Department of Veterans Affairs. Center for Health Equity Research and Promotion: Surgical Pause Saving Veterans Lives. Updated September 22, 2021. Accessed September 9, 2024. https://www.cherp.research.va.gov/features/Surgical_Pause_Saving_Veterans_Lives.asp
- Munro S, Church K, Berner C, et al. Implementation of an agefriendly template in the Veterans Health Administration electronic health record. J Inform Nurs. 2023;8(3):6-11.
- Burns JM. Transforming Leadership: A New Pursuit of Happiness. Grove Press; 2003.
- US Department of Veterans Affairs, Veterans Health Administration. Whole Health: Circle of Health Overview. Updated May 20, 2024. Accessed September 12, 2024. https://www.va.gov/WHOLEHEALTH/circle-of-health/index.asp
The COVID-19 pandemic established a new normal for health care delivery, with leaders rethinking core practices to survive and thrive in a changing environment and improve the health and well-being of patients. The Veterans Health Administration (VHA) is embracing a shift in focus from “what is the matter” to “what really matters” to address pre- and postpandemic challenges through a whole health approach.1 Initially conceptualized by the VHA in 2011, whole health “is an approach to health care that empowers and equips people to take charge of their health and well-being so that they can live their life to the fullest.”1 Whole health integrates evidence-based complementary and integrative health (CIH) therapies to manage pain; this includes acupuncture, meditation, tai chi, yoga, massage therapy, guided imagery, biofeedback, and clinical hypnosis.1 The VHA now recognizes well-being as a core value, helping clinicians respond to emerging challenges related to the social determinants of health (eg, access to health care, physical activity, and healthy foods) and guiding health care decision making.1,2
Well-being through empowerment—elements of whole health and Age-Friendly Health Systems (AFHS)—encourages health care institutions to work with employees, patients, and other stakeholders to address global challenges, clinician burnout, and social issues faced by their communities. This approach focuses on life’s purpose and meaning for individuals and inspires leaders to engage with patients, staff, and communities in new, impactful ways by focusing on wellbeing and wholeness rather than illness and disease. Having a higher sense of purpose is associated with lower all-cause mortality, reduced risk of specific diseases, better health behaviors, greater use of preventive services, and fewer hospital days of care.3
This article describes how AFHS supports the well-being of older adults and aligns with the whole health model of care. It also outlines the VHA investment to transform health care to be more person-centered by documenting what matters in the electronic health record (EHR).
AGE-FRIENDLY CARE
Given that nearly half of veterans enrolled in the VHA are aged ≥ 65 years, there is an increased need to identify models of care to support this aging population.4 This is especially critical because older veterans often have multiple chronic conditions and complex care needs that benefit from a whole person approach. The AFHS movement aims to provide evidence-based care aligned with what matters to older adults and provides a mechanism for transforming care to meet the needs of older veterans. This includes addressing age-related health concerns while promoting optimal health outcomes and quality of life. AFHS follows the 4Ms framework: what matters, medication, mentation, and mobility.5 The 4Ms serve as a guide for the health care of older adults in any setting, where each “M” is assessed and acted on to support what matters.5 Since 2020, > 390 teams have developed a plan to implement the 4Ms at 156 VHA facilities, demonstrating the VHA commitment to transforming health care for veterans.6
When VHA teams join the AFHS movement, they may also engage older veterans in a whole health system (WHS) (Figure). While AFHS is designed to improve care for patients aged ≥ 65 years, it also complements whole health, a person-centered approach available to all veterans enrolled in the VHA. Through the WHS and AFHS, veterans are empowered and equipped to take charge of their health and well-being through conversations about their unique goals, preferences, and health priorities.4 Clinicians are challenged to assess what matters by asking questions like, “What brings you joy?” and, “How can we help you meet your health goals?”1,5 These questions shift the conversation from disease-based treatment and enable clinicians to better understand the veteran as a person.1,5
For whole health and AFHS, conversations about what matters are anchored in the veteran’s goals and preferences, especially those facing a significant health change (ie, a new diagnosis or treatment decision).5,7 Together, the veteran’s goals and priorities serve as the foundation for developing person-centered care plans that often go beyond conventional medical treatments to address the physical, mental, emotional, and social aspects of health.
SYSTEM-WIDE DIRECTIVE
The WHS enhances AFHS discussions about what matters to veterans by adding a system-level lens for conceptualizing health care delivery by leveraging the 3 components of WHS: the “pathway,” well-being programs, and whole health clinical care.
The Pathway
Discovering what matters, or the veteran’s “mission, aspiration, and purpose,” begins with the WHS pathway. When stepping into the pathway, veterans begin completing a personal health inventory, or “walking the circle of health,” which encourages self-reflection that focuses on components of their life that can influence health and well-being.1,8 The circle of health offers a visual representation of the 4 most important aspects of health and well-being: First, “Me” at the center as an individual who is the expert on their life, values, goals, and priorities. Only the individual can know what really matters through mindful awareness and what works for their life. Second, self-care consists of 8 areas that impact health and wellbeing: working your body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind. Third, professional care consists of prevention, conventional care, and complementary care. Finally, the community that supports the individual.
Well-Being Programs
VHA provides WHS programs that support veterans in building self-care skills and improving their quality of life, often through integrative care clinics that offer coaching and CIH therapies. For example, a veteran who prioritizes mobility when seeking care at an integrative care clinic will not only receive conventional medical treatment for their physical symptoms but may also be offered CIH therapies depending on their goals. The veteran may set a daily mobility goal with their care team that supports what matters, incorporating CIH approaches, such as yoga and tai chi into the care plan.5 These holistic approaches for moving the body can help alleviate physical symptoms, reduce stress, improve mindful awareness, and provide opportunities for self-discovery and growth, thus promote overall well-being
Whole Health Clinical Care
AFHS and the 4Ms embody the clinical care component of the WHS. Because what matters is the driver of the 4Ms, every action taken by the care team supports wellbeing and quality of life by promoting independence, connection, and support, and addressing external factors, such as social determinants of health. At a minimum, well-being includes “functioning well: the experience of positive emotions such as happiness and contentment as well as the development of one’s potential, having some control over one’s life, having a sense of purpose, and experiencing positive relationships.”9 From a system perspective, the VHA has begun to normalize focusing on what matters to veterans, using an interprofessional approach, one of the first steps to implementing AFHS.
As the programs expand, AFHS teams can learn from whole health well-being programs and increase the capacity for self-care in older veterans. Learning about the key elements included in the circle of health helps clinicians understand each veteran’s perceived strengths and weaknesses to support their self-care. From there, teams can act on the 4Ms and connect older veterans with the most appropriate programs and services at their facility, ensuring continuum of care.
DOCUMENTATION
The VHA leverages several tools and evidence-based practices to assess and act on what matters for veterans of all ages (Table).5,10-16 The VHA EHR and associated dashboards contain a wealth of information about whole health and AFHS implementation, scale up, and spread. A national AFHS 4Ms note template contains standardized data elements called health factors, which provide a mechanism for monitoring 4Ms care via its related dashboard. This template was developed by an interprofessional workgroup of VHA staff and underwent a thorough human factors engineering review and testing process prior to its release. Although teams continue to personalize care based on what matters to the veteran, data from the standardized 4Ms note template and dashboard provide a way to establish consistent, equitable care across multiple care settings.17
Between January 2022 and December 2023, > 612,000 participants aged ≥ 65 years identified what matters to them through 1.35 million assessments. During that period, > 36,000 veterans aged ≥ 65 years participated in AFHS and had what matters conversations documented. A personalized health plan was completed by 585,270 veterans for a total of 1.1 million assessments.11 Whole health coaching has been documented for > 57,000 veterans with > 200,000 assessments completed.13 In fiscal year 2023, a total of 1,802,131 veterans participated in whole health.
When teams share information about what matters to the veteran in a clinicianfacing format in the EHR, this helps ensure that the VHA honors veteran preferences throughout transitions of care and across all phases of health care. Although the EHR captures data on what matters, measurement of the overall impact on veteran and health system outcomes is essential. Further evaluation and ongoing education are needed to ensure clinicians are accurately and efficiently capturing the care provided by completing the appropriate EHR. Additional challenges include identifying ways to balance the documentation burden, while ensuring notes include valuable patient-centered information to guide care. EHR tools and templates have helped to unlock important insights on health care delivery in the VHA; however, health systems must consider how these clinical practices support the overall well-being of patients. How leaders empower frontline clinicians in any care setting to use these data to drive meaningful change is also important.
TRANSFORMING VHA CARE DELIVERY
In Achieving Whole Health: A New Approach for Veterans and the Nation, the National Academy of Science proposes a framework for the transformation of health care institutions to provide better whole health to veterans.3 Transformation requires change in entire systems and leaders who mobilize people “for participation in the process of change, encouraging a sense of collective identity and collective efficacy, which in turn brings stronger feelings of self-worth and self-efficacy,” and an enhanced sense of meaningfulness in their work and lives.18
Shifting health care approaches to equipping and empowering veterans and employees with whole health and AFHS resources is transformational and requires radically different assumptions and approaches that cannot be realized through traditional approaches. This change requires robust and multifaceted cultural transformation spanning all levels of the organization. Whole health and AFHS are facilitating this transformation by supporting documentation and data needs, tracking outcomes across settings, and accelerating spread to new facilities and care settings nationwide to support older veterans in improving their health and well-being.
Whole health and AFHS are complementary approaches to care that can work to empower veterans (as well as caregivers and clinicians) to align services with what matters most to veterans. Lessons such as standardizing person-centered assessments of what matters, creating supportive structures to better align care with veterans’ priorities, and identifying meaningful veteran and system-level outcomes to help sustain transformational change can be applied from whole health to AFHS. Together these programs have the potential to enhance overall health outcomes and quality of life for veterans.
The COVID-19 pandemic established a new normal for health care delivery, with leaders rethinking core practices to survive and thrive in a changing environment and improve the health and well-being of patients. The Veterans Health Administration (VHA) is embracing a shift in focus from “what is the matter” to “what really matters” to address pre- and postpandemic challenges through a whole health approach.1 Initially conceptualized by the VHA in 2011, whole health “is an approach to health care that empowers and equips people to take charge of their health and well-being so that they can live their life to the fullest.”1 Whole health integrates evidence-based complementary and integrative health (CIH) therapies to manage pain; this includes acupuncture, meditation, tai chi, yoga, massage therapy, guided imagery, biofeedback, and clinical hypnosis.1 The VHA now recognizes well-being as a core value, helping clinicians respond to emerging challenges related to the social determinants of health (eg, access to health care, physical activity, and healthy foods) and guiding health care decision making.1,2
Well-being through empowerment—elements of whole health and Age-Friendly Health Systems (AFHS)—encourages health care institutions to work with employees, patients, and other stakeholders to address global challenges, clinician burnout, and social issues faced by their communities. This approach focuses on life’s purpose and meaning for individuals and inspires leaders to engage with patients, staff, and communities in new, impactful ways by focusing on wellbeing and wholeness rather than illness and disease. Having a higher sense of purpose is associated with lower all-cause mortality, reduced risk of specific diseases, better health behaviors, greater use of preventive services, and fewer hospital days of care.3
This article describes how AFHS supports the well-being of older adults and aligns with the whole health model of care. It also outlines the VHA investment to transform health care to be more person-centered by documenting what matters in the electronic health record (EHR).
AGE-FRIENDLY CARE
Given that nearly half of veterans enrolled in the VHA are aged ≥ 65 years, there is an increased need to identify models of care to support this aging population.4 This is especially critical because older veterans often have multiple chronic conditions and complex care needs that benefit from a whole person approach. The AFHS movement aims to provide evidence-based care aligned with what matters to older adults and provides a mechanism for transforming care to meet the needs of older veterans. This includes addressing age-related health concerns while promoting optimal health outcomes and quality of life. AFHS follows the 4Ms framework: what matters, medication, mentation, and mobility.5 The 4Ms serve as a guide for the health care of older adults in any setting, where each “M” is assessed and acted on to support what matters.5 Since 2020, > 390 teams have developed a plan to implement the 4Ms at 156 VHA facilities, demonstrating the VHA commitment to transforming health care for veterans.6
When VHA teams join the AFHS movement, they may also engage older veterans in a whole health system (WHS) (Figure). While AFHS is designed to improve care for patients aged ≥ 65 years, it also complements whole health, a person-centered approach available to all veterans enrolled in the VHA. Through the WHS and AFHS, veterans are empowered and equipped to take charge of their health and well-being through conversations about their unique goals, preferences, and health priorities.4 Clinicians are challenged to assess what matters by asking questions like, “What brings you joy?” and, “How can we help you meet your health goals?”1,5 These questions shift the conversation from disease-based treatment and enable clinicians to better understand the veteran as a person.1,5
For whole health and AFHS, conversations about what matters are anchored in the veteran’s goals and preferences, especially those facing a significant health change (ie, a new diagnosis or treatment decision).5,7 Together, the veteran’s goals and priorities serve as the foundation for developing person-centered care plans that often go beyond conventional medical treatments to address the physical, mental, emotional, and social aspects of health.
SYSTEM-WIDE DIRECTIVE
The WHS enhances AFHS discussions about what matters to veterans by adding a system-level lens for conceptualizing health care delivery by leveraging the 3 components of WHS: the “pathway,” well-being programs, and whole health clinical care.
The Pathway
Discovering what matters, or the veteran’s “mission, aspiration, and purpose,” begins with the WHS pathway. When stepping into the pathway, veterans begin completing a personal health inventory, or “walking the circle of health,” which encourages self-reflection that focuses on components of their life that can influence health and well-being.1,8 The circle of health offers a visual representation of the 4 most important aspects of health and well-being: First, “Me” at the center as an individual who is the expert on their life, values, goals, and priorities. Only the individual can know what really matters through mindful awareness and what works for their life. Second, self-care consists of 8 areas that impact health and wellbeing: working your body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind. Third, professional care consists of prevention, conventional care, and complementary care. Finally, the community that supports the individual.
Well-Being Programs
VHA provides WHS programs that support veterans in building self-care skills and improving their quality of life, often through integrative care clinics that offer coaching and CIH therapies. For example, a veteran who prioritizes mobility when seeking care at an integrative care clinic will not only receive conventional medical treatment for their physical symptoms but may also be offered CIH therapies depending on their goals. The veteran may set a daily mobility goal with their care team that supports what matters, incorporating CIH approaches, such as yoga and tai chi into the care plan.5 These holistic approaches for moving the body can help alleviate physical symptoms, reduce stress, improve mindful awareness, and provide opportunities for self-discovery and growth, thus promote overall well-being
Whole Health Clinical Care
AFHS and the 4Ms embody the clinical care component of the WHS. Because what matters is the driver of the 4Ms, every action taken by the care team supports wellbeing and quality of life by promoting independence, connection, and support, and addressing external factors, such as social determinants of health. At a minimum, well-being includes “functioning well: the experience of positive emotions such as happiness and contentment as well as the development of one’s potential, having some control over one’s life, having a sense of purpose, and experiencing positive relationships.”9 From a system perspective, the VHA has begun to normalize focusing on what matters to veterans, using an interprofessional approach, one of the first steps to implementing AFHS.
As the programs expand, AFHS teams can learn from whole health well-being programs and increase the capacity for self-care in older veterans. Learning about the key elements included in the circle of health helps clinicians understand each veteran’s perceived strengths and weaknesses to support their self-care. From there, teams can act on the 4Ms and connect older veterans with the most appropriate programs and services at their facility, ensuring continuum of care.
DOCUMENTATION
The VHA leverages several tools and evidence-based practices to assess and act on what matters for veterans of all ages (Table).5,10-16 The VHA EHR and associated dashboards contain a wealth of information about whole health and AFHS implementation, scale up, and spread. A national AFHS 4Ms note template contains standardized data elements called health factors, which provide a mechanism for monitoring 4Ms care via its related dashboard. This template was developed by an interprofessional workgroup of VHA staff and underwent a thorough human factors engineering review and testing process prior to its release. Although teams continue to personalize care based on what matters to the veteran, data from the standardized 4Ms note template and dashboard provide a way to establish consistent, equitable care across multiple care settings.17
Between January 2022 and December 2023, > 612,000 participants aged ≥ 65 years identified what matters to them through 1.35 million assessments. During that period, > 36,000 veterans aged ≥ 65 years participated in AFHS and had what matters conversations documented. A personalized health plan was completed by 585,270 veterans for a total of 1.1 million assessments.11 Whole health coaching has been documented for > 57,000 veterans with > 200,000 assessments completed.13 In fiscal year 2023, a total of 1,802,131 veterans participated in whole health.
When teams share information about what matters to the veteran in a clinicianfacing format in the EHR, this helps ensure that the VHA honors veteran preferences throughout transitions of care and across all phases of health care. Although the EHR captures data on what matters, measurement of the overall impact on veteran and health system outcomes is essential. Further evaluation and ongoing education are needed to ensure clinicians are accurately and efficiently capturing the care provided by completing the appropriate EHR. Additional challenges include identifying ways to balance the documentation burden, while ensuring notes include valuable patient-centered information to guide care. EHR tools and templates have helped to unlock important insights on health care delivery in the VHA; however, health systems must consider how these clinical practices support the overall well-being of patients. How leaders empower frontline clinicians in any care setting to use these data to drive meaningful change is also important.
TRANSFORMING VHA CARE DELIVERY
In Achieving Whole Health: A New Approach for Veterans and the Nation, the National Academy of Science proposes a framework for the transformation of health care institutions to provide better whole health to veterans.3 Transformation requires change in entire systems and leaders who mobilize people “for participation in the process of change, encouraging a sense of collective identity and collective efficacy, which in turn brings stronger feelings of self-worth and self-efficacy,” and an enhanced sense of meaningfulness in their work and lives.18
Shifting health care approaches to equipping and empowering veterans and employees with whole health and AFHS resources is transformational and requires radically different assumptions and approaches that cannot be realized through traditional approaches. This change requires robust and multifaceted cultural transformation spanning all levels of the organization. Whole health and AFHS are facilitating this transformation by supporting documentation and data needs, tracking outcomes across settings, and accelerating spread to new facilities and care settings nationwide to support older veterans in improving their health and well-being.
Whole health and AFHS are complementary approaches to care that can work to empower veterans (as well as caregivers and clinicians) to align services with what matters most to veterans. Lessons such as standardizing person-centered assessments of what matters, creating supportive structures to better align care with veterans’ priorities, and identifying meaningful veteran and system-level outcomes to help sustain transformational change can be applied from whole health to AFHS. Together these programs have the potential to enhance overall health outcomes and quality of life for veterans.
- Kligler B, Hyde J, Gantt C, Bokhour B. The Whole Health transformation at the Veterans Health Administration: moving from “what’s the matter with you?” to “what matters to you?” Med Care. 2022;60(5):387-391. doi:10.1097/MLR.0000000000001706
- Centers for Disease Control and Prevention. Social determinants of health (SDOH) at CDC. January 17, 2024. Accessed September 12, 2024. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
- National Academies of Sciences, Engineering, and Medicine. Achieving Whole Health: A New Approach for Veterans and the Nation. The National Academies Press; 2023. Accessed September 9, 2024. doi:10.17226/26854
- Church K, Munro S, Shaughnessy M, Clancy C. Age-friendly health systems: improving care for older adults in the Veterans Health Administration. Health Serv Res. 2023;58 Suppl 1(Suppl 1):5-8. doi:10.1111/1475-6773.14110
- Laderman M, Jackson C, Little K, Duong T, Pelton L. “What Matters” to older adults? A toolkit for health systems to design better care with older adults. Institute for Healthcare Improvement; 2019. Accessed September 9, 2024. https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf
- U.S. Department of Veterans Affairs. Age-Friendly Health Systems. Updated September 4, 2024. Accessed September 9, 2024. https://marketplace.va.gov/innovations/age-friendly-health-systems
- Brown TT, Hurley VB, Rodriguez HP, et al. Shared dec i s i o n - m a k i n g l o w e r s m e d i c a l e x p e n d i t u re s a n d the effect is amplified in racially-ethnically concordant relationships. Med Care. 2023;61(8):528-535. doi:10.1097/MLR.0000000000001881
- Kligler B. Whole Health in the Veterans Health Administration. Glob Adv Health Med. 2022;11:2164957X221077214.
- Ruggeri K, Garcia-Garzon E, Maguire Á, Matz S, Huppert FA. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes. 2020;18(1):192. doi:10.1186/s12955-020-01423-y
- U.S. Department of Veterans Affairs. Personal Health Inventory. Updated May 2022. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTH/docs/PHI-long-May22-fillable-508.pdf doi:10.1177/2164957X221077214
- Veterans Health Administration. Personal Health Plan. Updated March 2019. Accessed September 9, 2024. https:// www.va.gov/WHOLEHEALTH/docs/PersonalHealthPlan_508_03-2019.pdf
- Veterans Health Administration. Whole Health: My Life, My Story. Updated March 20, 2024. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTH/mylifemystory/index.asp
- U.S. Department of Veterans Affairs. Whole Health Library: Whole Health for Skill Building. Updated April 17, 2024. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTHLIBRARY/courses/whole-health-skill-building.asp
- U.S. Department of Veterans Affairs. Making Decisions: Current Care Planning. Updated May 21, 2024. Accessed September 9, 2024. https://www.va.gov/geriatrics/pages/making_decisions.asp
- U.S. Department of Veterans Affairs. Life-Sustaining Treatment Decisions Initiative (LSTDI). Updated March 2024. Accessed September 12, 2024. https://marketplace.va.gov/innovations/life-sustaining-treatment-decisions-initiative
- U.S. Department of Veterans Affairs. Center for Health Equity Research and Promotion: Surgical Pause Saving Veterans Lives. Updated September 22, 2021. Accessed September 9, 2024. https://www.cherp.research.va.gov/features/Surgical_Pause_Saving_Veterans_Lives.asp
- Munro S, Church K, Berner C, et al. Implementation of an agefriendly template in the Veterans Health Administration electronic health record. J Inform Nurs. 2023;8(3):6-11.
- Burns JM. Transforming Leadership: A New Pursuit of Happiness. Grove Press; 2003.
- US Department of Veterans Affairs, Veterans Health Administration. Whole Health: Circle of Health Overview. Updated May 20, 2024. Accessed September 12, 2024. https://www.va.gov/WHOLEHEALTH/circle-of-health/index.asp
- Kligler B, Hyde J, Gantt C, Bokhour B. The Whole Health transformation at the Veterans Health Administration: moving from “what’s the matter with you?” to “what matters to you?” Med Care. 2022;60(5):387-391. doi:10.1097/MLR.0000000000001706
- Centers for Disease Control and Prevention. Social determinants of health (SDOH) at CDC. January 17, 2024. Accessed September 12, 2024. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
- National Academies of Sciences, Engineering, and Medicine. Achieving Whole Health: A New Approach for Veterans and the Nation. The National Academies Press; 2023. Accessed September 9, 2024. doi:10.17226/26854
- Church K, Munro S, Shaughnessy M, Clancy C. Age-friendly health systems: improving care for older adults in the Veterans Health Administration. Health Serv Res. 2023;58 Suppl 1(Suppl 1):5-8. doi:10.1111/1475-6773.14110
- Laderman M, Jackson C, Little K, Duong T, Pelton L. “What Matters” to older adults? A toolkit for health systems to design better care with older adults. Institute for Healthcare Improvement; 2019. Accessed September 9, 2024. https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf
- U.S. Department of Veterans Affairs. Age-Friendly Health Systems. Updated September 4, 2024. Accessed September 9, 2024. https://marketplace.va.gov/innovations/age-friendly-health-systems
- Brown TT, Hurley VB, Rodriguez HP, et al. Shared dec i s i o n - m a k i n g l o w e r s m e d i c a l e x p e n d i t u re s a n d the effect is amplified in racially-ethnically concordant relationships. Med Care. 2023;61(8):528-535. doi:10.1097/MLR.0000000000001881
- Kligler B. Whole Health in the Veterans Health Administration. Glob Adv Health Med. 2022;11:2164957X221077214.
- Ruggeri K, Garcia-Garzon E, Maguire Á, Matz S, Huppert FA. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes. 2020;18(1):192. doi:10.1186/s12955-020-01423-y
- U.S. Department of Veterans Affairs. Personal Health Inventory. Updated May 2022. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTH/docs/PHI-long-May22-fillable-508.pdf doi:10.1177/2164957X221077214
- Veterans Health Administration. Personal Health Plan. Updated March 2019. Accessed September 9, 2024. https:// www.va.gov/WHOLEHEALTH/docs/PersonalHealthPlan_508_03-2019.pdf
- Veterans Health Administration. Whole Health: My Life, My Story. Updated March 20, 2024. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTH/mylifemystory/index.asp
- U.S. Department of Veterans Affairs. Whole Health Library: Whole Health for Skill Building. Updated April 17, 2024. Accessed September 9, 2024. https://www.va.gov/WHOLEHEALTHLIBRARY/courses/whole-health-skill-building.asp
- U.S. Department of Veterans Affairs. Making Decisions: Current Care Planning. Updated May 21, 2024. Accessed September 9, 2024. https://www.va.gov/geriatrics/pages/making_decisions.asp
- U.S. Department of Veterans Affairs. Life-Sustaining Treatment Decisions Initiative (LSTDI). Updated March 2024. Accessed September 12, 2024. https://marketplace.va.gov/innovations/life-sustaining-treatment-decisions-initiative
- U.S. Department of Veterans Affairs. Center for Health Equity Research and Promotion: Surgical Pause Saving Veterans Lives. Updated September 22, 2021. Accessed September 9, 2024. https://www.cherp.research.va.gov/features/Surgical_Pause_Saving_Veterans_Lives.asp
- Munro S, Church K, Berner C, et al. Implementation of an agefriendly template in the Veterans Health Administration electronic health record. J Inform Nurs. 2023;8(3):6-11.
- Burns JM. Transforming Leadership: A New Pursuit of Happiness. Grove Press; 2003.
- US Department of Veterans Affairs, Veterans Health Administration. Whole Health: Circle of Health Overview. Updated May 20, 2024. Accessed September 12, 2024. https://www.va.gov/WHOLEHEALTH/circle-of-health/index.asp