Whole Health in Your Practice Day 3/3

Welcome to
Day 3!
Coming together is a beginning.
Keeping together is progress.
Working together is success.
-Henry Ford
Photo: Adam Rindfleisch

Pulse Check Reviews from Day 2
Photo: John Twohig via Foter.com

Implementation Topics
The
System
Graphic: Vectorstock.com

12. Loving-Kindness
Meditation
No act of kindness, no matter how small, is ever wasted.
Photo: Flickr.comPhoto: mythirdactblog.wordpress.com

Kindness and Compassion Heal
• Progressive, favorable changes in brain function
• Increases mindfulness, positive emotions and
compassion in your daily life
• Enhances pro-social behavior
• Changes gene expression
Weng et al, Psychol Sci. 2013;24(7):1171-1180.
Galante et al, J Consult Clin Psychol. 2014;82(6):1101-14.
Bankard et al, J Relig Health. 2015;54(6):2324-43.
Photo: Brookings.edu
Passport
Ch 10

A Meditation
Photo: pinterest.com

Mindful Awareness:
Loving-Kindness
• There are many ways
mindful awareness
can tie in to
relationships
• This exercise asks you
to focus outward as
well as inwardPhoto: pickthebrain.com

Loving-Kindness Meditation:
What did you notice during this
experience?
Photo: istockphoto.com

Whole Health in Your Practice
13. Community
Photo: Pixabay.com

Community Passport, p. 311
Small acts, when multiplied by millions
of people, can transform the world.
-Howard Zinn

How is Community connected with
Whole Heath?

“Me” is possible because of “We”
• People don’t exist in a vacuum. Whole Health
can only occur in community.
– Loved ones, social circle
– Whole Health team
– Organizations and groups (VFW, DAV, support groups, etc.)
– Neighborhood
– Online Communities
– Hospital/facilities
– Health Care system
– Nation
– Ecosystem

Websites: 1. VA Patient Centered Care
External site (no firewall)
OPCC&CT resources for Veterans & family members)
http://www.va.gov/patientcenteredcare/

Whole Health Veteran Handouts
https://www.va.gov/PATIENTCENTEREDCARE/veteran-handouts/index.asp
~60 handouts related to the Circle

2. OPCC&CT SharePoint Hub
• Internal – OPCC&CT SharePoint Hub
https://vaww.infoshare.va.gov/sites/OPCC/Pa
ges/Default.aspx
–Education page on SharePoint
https://vaww.infoshare.va.gov/sites/OPCC/Ed
ucation/SitePages/Home.aspx

2. SharePoint Education Page
http://vaww.infoshare.va.gov/sites/OPCC/sitePages/IHCC-home.aspx

3. Whole Health Education Website
http://wholehealth.wisc.edu

Whole Health Education Website
Whole Health Library Website
• Has resources for clinicians and Veterans
• Will be changing this fiscal year – more web-
friendly
• Over 200 different resources
• Materials from all the OPCC&CT clinical
courses

Whole Health Education Website
http://wholehealth.wisc.edu

COP Calls/VA Pulse
• Whole Health Clinical COP call- 1st Thursday
of month, 2 pm EST
https://vaww.infoshare.va.gov/sites/OPCC/COP/WholeHea
lth-ContinueTheConversation/SitePages/Home.aspx
• VA Pulse- Integrative Health Community
https://www.vapulse.net/groups/integrative-health-
community
• Email us:
vhaopcctintegrativehealth@va.gov
• FIT Consultant/IH engagements

VA Pulse – Whole Health Community
1. OPCC&CT in
generalhttps://www.vapulse.net/community/focus-
areas/opcc
2. Integrative
Healthhttps://www.vapulse.net/groups/integrative-
health-community
3. Acupuncture and
BFAhttps://www.vapulse.net/groups/va-bfa-
community
4. Others

• Online course available to all clinicians
• CEU credits - physicians, nurses, pharmacists
• Free to a limited number of VA clinicians
• Please sign up only if you can complete entire
course – you have 11 months
• Learn more at https://nciph.org/curriculum.html
• VA Contact: cassandra.griffin@va.gov
National Center for Integrative
Primary Health Care

Nearly 32 hours of material
1. Introduction to Interprofessional (IP) Integrative Health
in Primary Care
2. Prevention and Lifestyle Behavior Change Through IP
Collaborative Practice
3. IP Healthcare Wellbeing
4. Addressing Primary Care Patients Through an
IP/Integrative Lens
5. Collaborative IP Integrative Interventions
6. IP Practice in Community Settings and Systems at
Large
National Center for Integrative
Primary Health Care

Whole Health Education – VA Staff
VAStaff
Clinical Programs/Points of Entry (Whole Health in Your Practice, Pain,
Nutrition)
Training for Non-Clinical Roles (WH Coaching, WH Facilitated Groups,
WH Partner)
Training for Facility Education Champions (to deliver local 1-day and
modularized courses – 101, 1-day WHYP, WHYL)
Whole Health Engagements & Whole Health 101 (FIT)
Community of Practice Calls (Clinical, Coaching, Facilitator)
Virtual Programs (TMS/TRAIN) and Whole Health Education Website

Transition Assistance Program (prior to separation)
Whole Health Orientations with WH Partners
Peer-Led Group-Based Program for Veterans (Taking Charge of My Life and Health) with WH
Facilitators
Whole Health Coaching Sessions
Working with Whole Health Providers in Clinical Care
Services Provided by Wellbeing Clinics
Online Veteran Education (Handouts and Videos) and App (Coming Fall 2018)
Veterans
Whole Health Education – Veterans

Whole Health Education SharePoint
Whole Health Education Homepage Link

Print Products
Click Here
Print Products

Other National Resources:
The VA Integrative Health
Coordinating Center

CIH and Standard Medical Benefits
3 Steps to provide guidance and regulatory
change
1. CIH Memo
– Supports CIH implementation and will initiate vetting
process for CIH services through the VEC and Integrative
Health Coordinating Center (IHCC)
– Signed by VEC Co-Chairs May 3rd, 2016
– Signed by Dr. Shulkin (USH) on May 24th, 2016

2. CIH Directive
• LIST II: Generally Considered Safe
– Requires common knowledge, throughout the
expert scientific community
• Both internal and external to VHA
• Reasonable certainty that it is not harmful under the
conditions of intended use
– Optional for inclusion in VA facility, depending on
capability (staff/space) at sites

3. Regulatory Change
• Regulation incorporated into Benefits Handbook
• More lengthy process, but permanent outcomes
• Now all sites are mandated to provide the CIH
approaches featured in List One

VERA and Whole Health
• Whole Health will be a new price
category in VERA (category 4)
• In order to qualify for that category, a
Veteran needs 10 CIH visits (occurring on
different days)
–Visit: Stop code or CHAR 4 code

VERA and Whole Health
• Whole Health will be a new price category in VERA
(category 4)
• In order to qualify for that category, a Veteran needs
10 CIH visits (occurring on different days)
• Allocation Resource Center (ARC) currently tracking
a list of 30+ CPT codes to determine VERA
reimbursement.
• For a list of the CPT codes, see the VERA Fact Sheet
located on the IHCC SharePoint at
https://vaww.infoshare.va.gov/sites/OPCC/Shared%20Documents/Forms/AllItems.aspx?Root
Folder=%2fsites%2fOPCC%2fShared%20Documents%2fCIH%20Coding%20Guidance&FolderC
TID=0x01200092D5EAC253479641B8D0A20FE4165E94

Business Infrastructure
• Two CIH/Wellbeing Stop Codes
– 159 – Either position
• CIH treatment
– 139 – Either position
• Wellbeing approaches
• Co-pay exemption regulatory change underway;
Timeline 1-2 years
• CHAR 4 codes
• National Note Title – Integrative Health Note
• https://vaww.infoshare.va.gov/sites/OPCC/Shared%2
0Documents/CIH%20Coding%20Guidance

Ongoing Efforts
• Office of Community Care
• Telehealth
• Volunteer Services
• Position Descriptions
– Acupuncturist, GS-9/13
– Whole Health Program Manager, GS-11
– Health Coach, GS-7/9
– Whole Health Partner Supervisor, GS-8
– Whole Health Program Assistant, GS-7
– Whole Health Partner, GS-6
– Yoga Instructor GS-6
– Tai Chi/Qi Gong Instructor, GS-6

Research
• VA’s Office of Health Services Research & Development
(HSR&D)
– More than 80 ongoing CIH research
– http://www.hsrd.research.va.gov/research/portfolio_description.c
fm?Sulu=24
• PRIMIER (Patients Receiving Integrative Medicine
Interventions Effectiveness Registry)
– Includes 3 VA systems
– Collects patient-reported outcomes and extracted HER data for a
large national registry
– http://www.bravewell.org/current_projects/bravenet/bravenet/

Connect!
• IHCC Email
vhaopcctintegrativehealth@va.gov
• FIT CIH Specialty Team Email
VHAOPCCCTCIHSpecialtyTeam@va.gov
• IHCC SharePoint
http://vaww.infoshare.va.gov/sites/OPCC/sitePages/IHCC-home.aspx
• VA Pulse IH Community https://www.vapulse.net/groups/integrative-
health-community
• FIT SharePoint Page
http://vaww.infoshare.va.gov/sites/OPCC/SitePages/FIT-programs.aspx

Each course’s host site will
have different materials to
put in this section.

Video – The Pathway to Whole Health
• https://www.youtube.com/watch?v=0nkO-3PA29c

https://www.youtube.com/watch?v=0nkO-3PA29c
The Pathway to Whole Health

Video – Skill Building to Promote Wellbeing
https://www.youtube.com/watch?v=zjYvs9K_4n8

Skill-Building to Promote Well-Being
https://www.youtube.com/watch?v=zjYvs9K_4n8

Biloxi Whole Health Strategic Plan:
Focusing on the Pathway
• Added Whole Health New Employee presentation
• Whole Health Pathway Course: Set up clinics to
capture data/workload/outcomes
• Coaching: Vital component
• Outreach –Vet Centers/community partners
• Networking to establish partnerships
• Meet the veteran where they are at
• Processes
• Confidentiality
• Health for Life event

Biloxi Promising Practice
• Complementary Integrative Medicine
• Tai Chi/Yoga expansion
• Healing Touch expansion
• Healthy Kitchen, Yoga, and more WHP classes
• Initiate:
• Battlefield acupuncture
• Relaxation therapy via MP3 for procedures

Central Arkansas VA Health Care
• Integrative Medicine Patient Aligned Care Team
(IMPACT)
• Combines both PACT and pain rehab concepts
• Uses Health Coaching and both PHI and Personal
Health Planning
• Focuses on quality of life for each individual Veteran
• Functional Medicine informs treatment plans
• IMPACT assumes primary care responsibilities and
may cover any or all aspects of care

Central Arkansas VA
IMPACT
Veterans in IMPACT assess that:
1. “When all is said and done, I am the person who is
responsible for managing my healthcare”: 95%
2. “Taking an active role in my healthcare is the most
important factor in determining my health and ability to
function”: 97%
3. “I am confident that I can take actions that will help
prevent or decrease some problems associated with
my health condition”: 91%
4. “I am confident I can maintain lifestyle changes like diet
and exercise even during times of stress”: 83%

Central Arkansas VA
“Living” Notes within CPRS
Personalized Health Plan
• Each new PHP demotes the
previous PHP
• Records in the reminder box
of the cover sheet
• Is editable
• Is printable
• Is limited to a particular
user class
– Those individuals with
Whole Health training

“Living” Notes within CPRS
Central Arkansas VA IMPACT:
Personal Health Inventory on
CPRS

Benefits of being a part of the Impact Clinic
1. It allowed me to stop using prescription
opiates for chronic pain. Pain is currently
managed thru Acupuncture, pain patches,
Diclofenac, more physical activity, a Tins
Machine, Damp Heating Pad, and a series of
special exercises prescribed by Physical
Therapy.
2. I am currently walking at least (1)
one mile daily along with stretching
exercises. I also do (50) fifty reps daily with
a Bull Worker and 6.6 pound hand weights
that help strengthen my upper body.
3. I learned about and now practice
Mindfulness to include breathing,
meditation, sleep, and eating. These
techniques add great value in managing
overall health and day-to-day activities.
4. My last labs were greatly improved.
Cholesterol was well below normal, along
with other medical findings. This is
extremely important because I am a cardiac
patient and have a mixed auto-immune
disorder.
5. Having access to a dedicated and
professional staff that genuinely tries to find
the root cause of my medical conditions has
been absolutely Super!
6. Last but certainly not least, I learned about
healthy food and a proper diet. Probably
most important, the value of fresh or frozen
vegetables and the harmful effects of sugar
alcohols.
My Women’s Center Doctor (Dr.
Traore) referred me to the Impact
Clinic in May 2016.
At the time, I was a mess.
Overweight (254lbs), Diabetes
(A1C 7.2), high cholesterol, high
blood pressure, arthritis out of
control and so my pain was great
all over
my body.
Dr. Roca and the Impact Clinic
have totally changed my life.
They focused on my strengths
and helped me deal with my
weaknesses so that today, I have
a health plan that I
follow daily. It’s all one day at a
time.
Today, I am now at 195lbs, A1C
is 5.8, cholesterol is 160, blood
pressure is usually 120/65 and I
feel good. My pain in my left
ankle is still there. I’m planning
surgery to help alleviate some of
the problem with it in October.
Now, I have a much better quality
of life and I see myself remaining
independent and strong for many
years to come.
Central Arkansas VA
IMPACT Wall of Success

Birmingham VA
Shared Medical Appointments (SMAs) for Pain
1. Participants completed “Wish Cards” - 3x5 index cards
– Wrote needs and wishes (consultations, med refills, etc.),
– Turned in at the end of every meeting
2. Patients completed PHI at least once
3. Health facilitators helped them with SMART Goals
4. Encouraged engagement in some aspect of self-care, or
and integrative program(e.g., Mindfulness, Yoga, or Tai
Chi)
5. Participants encouraged to reduce opioid use/reliance

Birmingham SMA Findings
• 12 question “Report Card” (see next slide) to assess
progress
– Administered ~4 sessions
• 28 out of 42 completed the 9 month program
• ~25 consultations were made to Physical Therapy, Tai
Chi or Yoga or MOVE weight management
• ~40 % of patients made substantial reductions in opioid
reliance (25% or more reduction)
• 3 patients were able to discontinue one or more opioids
altogether
• Staff became more engaged

Birmingham VA
Barriers/Challenges
• Organization and set up of the SMA (sending
letters, phone calls, room reservation,
teaching materials, Staff engagement)
• Early patient engagement and “buy in”
• Be patient, change is slow, do not get too
discouraged if there is little movement
(patient engagement) in the first few sessions

Birmingham VA
Recommendations
• SMAs are one approach for engaging patients in
self-care and Integrative Medicine
• SMAs and patient-centered care help people
reduce opioids in a safe and trusting
environment
• We have modified the program to be a 9 week
program consisting of 9 weekly sessions with a
group of ~25 patients

Birmingham VA
Recommendations and POC
• Guests members (PACTs) from the Huntsville
CBOC and the Tuscaloosa VA attended first
meeting to observe
• Goal: Spread practice to all CBOCs in Alabama in
the next 12 months with at least one PACT
participating at each CBOC
• POC’s: Joseph Michael (Mike) Moates, M.D.
(joseph.moates@va.gov) and Sherri Cox, RN,
HPDP coordinator (sherri.cox2@va.gov )

Washington DC VAMC
Integrative Health & Wellness (IHW) Program

Washington DC VAMC
IHW Program Offerings
• Group Acupuncture
• Gentle and Restorative
Yoga
• Meditation
• Tai Chi/Qigong
• Nutritional Workshops
• Wellness Massage.
• Whole Health Groups
• Healthy Food Demo’s
• Individual Health Coaching
• Whole Health Retreat

Washington DC VAMC
3-Day Whole Health Retreat
• Exploring What Really Matters through completion
of the PHI
• Helpful self-care techniques to enhance well-being
• Experiential activities to delve further into each
Component of Proactive Health and Well-being
• Better access for those who work or are in school
• Bonding and building trust with other Veterans

Washington DC VAMC
Findings
Veterans active in Whole Health and IHW services
reported:
–Improved pain management
–More skill handling difficult emotions
–Elimination or reduction of opioid use
–Increased flexibility
–Improved mobility

Washington DC VAMC
Key Take-Aways and POC
• For those interested in the 3-day Whole Health
Retreat there is a Facilitator Guide available from
IHW staff
• For more information please contact Dr. Michael
Knep, Chief of Patient Centered Care and Director,
Integrative Health & Wellness or Jennifer Rapien,
IHW Clinic Coordinator, at (202) 745-8000, x53882

In General: Strong Practices, Challenges,
and Recommendations for PHP’s
• Strong Practices
– Tailor the PHP to the local context
– Adapt the process to integrate PHP with other VA
tools
• Challenges
– Responsibility for PHP and implementation of full
process cannot reside with just one person
– Must find the balance between reach and depth of
implementation

• Recommendations
– Thoughtful consideration of which patients, providers,
clinics
– Build follow-up into process from onset (Including
time to follow-up & persons responsible)
In General: Strong Practices, Challenges,
and Recommendations for PHP’s

VA North Texas Health Care System
• Two Whole Health / PHI Group formats:
• MHICM SW
–Trial of 6 weekly PHI-themed groups
• MHICM Peer Specialist
–Trial of more than one year, weekly Circle of
Health & Meditation Practice groups on
inpatient psychiatric unit

Introducing Veterans to the PHI
• Positives
– Appreciated questions, felt cared about
– Realized connection between physical and mental
health
– Helps break through denial about some behaviors
– Circle of Health visual VERY helpful
– Practicing explaining components of health and
well-being over time got easier

Introducing Veterans to the PHI
• Challenges
– Shifting Veteran identity from “I’m sick” to “I can
actively improve my overall health”
– Veterans who tire easily or have attention
limitations
– Getting Veterans to come up with own goal, in
their own words

VA North Texas Feedback
• “When people have a mental illness, people don’t think you have
anything to say that’s worthwhile. Something is wrong with you,
so whatever you have to say isn’t important. But now you’re
sitting down with me, and you WANT to hear what I have to say.
It gives me a sense of finally being HEARD. For someone to ask
me what matters to me, that’s HUGE.”
- Veteran
• “I’m better able to identify and notice willingness and what
matters to the Veteran… I know better how to reach some
Veterans.”
- Clinician

VA North Texas
Admissions, Days of Care, ED Visits
• Sample of 21 patients who had a PHI during June
2014. Mostly males with no combat experience
and over 50% service connection
• Several measures evaluated 6 months pre and post
implementation of the PHI
• Total admissions reduced from 13 to 3
• Average number of bed days of care (BDOC) decreased
from 18 to 1.7 days
• Total number of ER visits was down from 13 to 2

To Summarize
Range of ways to adopt and adapt PHP process for local context
and needs
• Location of Use:
– VAMC PACT team
– CBOC
– Wellness groups
– Shared Medical Appointments
– Pain clinic
– Mental health
• Target Patient Populations:
– All Primary Care; Specific Chronic Diseases; Non-Acute visits; Pain;
Serious Mental Illness

Strong Practices, Challenges, and
Recommendations - PHP Implementation
• Strong Practices
– Tailoring the PHP to the local context
– Adapting the process to integrate PHP with other VA tools
• Challenges
– Responsibility for PHP and implementation of full process cannot
reside with a single provider
– Finding the balance between reach and depth of implementation
• Recommendations
– Thoughtful consideration of which patients, providers, clinics
– Build follow-up into process from onset (Including time to follow-up &
persons responsible)

14. Implementation
Your Life, Your Practice

Discussing Self-Care: Demo p. 19

Reflection on the Demo
• What struck you about the demonstration?
• What did you appreciate?
• What was would you add?
• How would you make modifications to make it
work in your practice?

Putting it all Together
• Find a partner
• Using the guides on page 19 and 21, do the
ENTIRE process of Personal Health Planning:
–Elevator Speech
–MAP/PHI
–Choose a Circle and Set Goals
–Create a REAL follow up plan
• There are prompts to help you on the guide

15. Implementation
Your Team

Whole Health Takes a Village
• No one clinician can be responsible for it all
• Whole Health adds support for clinical care –
peer partners, coaches, CIH providers, and
many others.
• The PHP will grow and shift over time.
• It should not take more time. This should
not be another item on the ‘to do’ list.
• It won’t always be possible to do this the
way you would ideally like to
And... You keep doing the best you can, and
that is a lot.
Photo: Foter.com

What Makes a Team Successful?
What was the best team you have ever
been on? Why?

A few tips from the literature
• Shared mission and passion
• Coordination, cooperation, communication
• Experienced, adaptable, and diverse
members
• Break down siloes, handle conflict
• Clear roles, inclusive, democratic
• Strong, collaborative leadership
• Safety to make mistakes
• ...and more research is needed!
Craigie et al, Fam Med, 2004;36(10):733-8. Janss et al, Med Ed, 2012;46:838-49.
Klug et al, R Soc Open Sci 2016;3:160007. Weller, et al, Postgrad Med J 2014;90:149-54.
Photo: 123RF.com

More tips from the literature
• A high-performing team needs 5 things:
1. Shared goals that everyone can articulate
2. Clear roles
• Function, responsibility, accountability
3. Mutual trust
• No punishments
• Safe to admit errors or ask questions or try new
things
Smith et al, Implementing Optimal Team-Based Care, National Academy of Medicine, Sept 2018.

More tips from the literature
• A high-performing team needs 5 things:
4. Effective communication
• Constantly refining skills
• Bidirectional
5. Measurable processes and outcomes
• How do you know the team is effective?
• Feedback give frequently
Smith et al, Implementing Optimal Team-Based Care, National Academy of Medicine, Sept 2018.

Thinking About Roles:
A Small Group Exercise: Round 1
• Pick a number between 1 and 20 and tell
your team – no duplicates!
• The next slide will assign you a role on the
team based on your number
• Your team will be given a task
– Discuss how you would each help out
– Who else would you want on your team?

Role Assignments
1. PACT Provider (MD, NP,
PA, etc.)
2. PACT Nurse
3. Psychologist
4. Movement Expert
(yoga, tai chi, PT, OT,
etc.)
5. Chaplain
6. Mindfulness Instructor
7. Dietitian
8. MSA
9. Chiropractor
10. WILD CARD – pick a role
11. Pharmacist
12. Hospitalist
13. Health Promotion
Disease Prevention
14. Acupuncturist
15. Whole Health Coach
16. LPN
17. Veteran Peer (trained in
WH)
18. Leadership Pentad
Member
19. Social work

A Small Group Exercise
Your Task:
Adopt the PHI for use throughout
your site
– How you would each help out in your role?
– How would you communicate, delegate?

How did that go?

Round 2
Think of a new number from 1-20
and share with your team.
No duplicates!

Role Assignments, Round 2
11. Chaplain
12. PACT Nurse
13. Psychologist
14. Movement Expert
(yoga, tai chi, PT, OT,
etc.)
16. Mindfulness Instructor
17. Dietitian
18. MSA
19. Chiropractor
20. PACT Provider (MD, NP,
PA, etc.)
2. Hospitalist
3. Health Promotion
Disease Prevention
4. Acupuncturist
5. Whole Health Coach
6. LPN
7. Veteran Peer (trained in
WH)
8. Leadership Pentad
Member
9. Social work
10. Pharmacist

Your Task:
Increase likelihood all a Veteran’s team
members are discussing/adding to the
PHP
– How you would each help out in your role?
– How would you communicate, delegate?

Now, it’s panel time...
• Seven volunteers with different roles will sit
up at the front of the room
• Each will take 2-3 minutes to share their
perspectives on the person in the demo
– What would you discuss for their PHP?
– What can you do to support Veteran Whole
Health in your clinical role?
• Observers are welcome to ask questions at the
end.
Image: Thehipp.org

16. Implementation:
Your Site

Your Team & Planning (Page 24)
Objectives
• Meet up with your team, follow the guide
• Create a plan you can share with your leadership
Manual Resources
• Examples of Implementation Strategy Topics (page 24)
• Outline for Team Discussion (page 25)
• Strategies for Implementation – Worksheet
– Recorder – Use outline for report on page 26
– Present to the Leadership

17. Implementation:
Reports
Image: unleashed.org/au

Whole Health in Your Practice Day 3/3

Whole Health in Your Practice Day 3/3

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