How Healing Works with Dr. Wayne Jonas

Dr. Kavitha Reddy: Whole Health from the VA Perspective

• Dr. Wayne Jonas and Dr. Kavitha Reddy • Season 1 • Episode 1

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Welcome to our inaugural episode of How Healing Works! I'm happy you're here.

In this episode, I sit down with Dr. Kavitha Reddy, the Associate Director of Employee Whole Health in the VHA Office of Patient-Centered Care and Cultural Transformation (OPCC & CT). Dr. Reddy has a wealth of knowledge to share in the area of whole person care. This is why I asked her to be our first guest. We discuss the Veterans Affairs’ perspective on whole person care through a program called Whole Health (https://www.va.gov/WHOLEHEALTH/), including the use of a tool they created and I’ve adapted for non-VA environments called the Personal Health Inventory. 
We explore questions that clinicians can ask their patients and themselves to understand them as a whole person. One question I like to start with is: “What matters to you?” This simple question can jumpstart a journey to healing. In our conversation we also discuss, "How do you motivate and engage your patients to care about their health? As Dr. Reddy says, “It's all interconnected. If you want to work on your sleep, and that's where your motivation is, it will absolutely impact how you eat, how you move, how you're able to work with your colleagues and interact with your family. There's no wrong starting point and I think that's the part of the transformation piece. We're used to sharing our information and wanting to fix. We have to step back and let them express where they're motivated to start and then we start to see meaningful change.” 

Watch the full interview here: https://vimeo.com/805971904?share=copy  

Below are links to topics discussed in this episode.

VA Whole Health: https://www.va.gov/WHOLEHEALTH/

Personal Health Inventory: https://drwaynejonas.com/wp-content/uploads/2019/09/PHI-Flyer-V11-Color.pdf 

CME Course–Introducing Whole Person Care into Your Practice: IntegrativeHealthCME.org 

Check out the book: "Healing and Cancer: A Guide to Whole Person Care"
Visit https://www.healingandcancerbook.com/ for more information.

Connect:
Twitter: @DrWayneJonas
Facebook: Dr. Wayne Jonas
Instagram: @drwaynejonas
LinkedIn: Dr. Wayne Jonas
LinkedIn: Alyssa McManamon

Visit Healing Works Foundation www.healingworksfoundation.org for more information.

Dr. Wayne Jonas is a board-certified physician and Dr. Alyssa McManamon is a triple-board certified hematologist/oncologist. The opinions expressed on this show are those of the hosts and guests and do not necessarily represent the views and opinions of their places of employment, the Department of Veterans Affairs, or the United States government. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Wayne Jonas and Dr. Alyssa McManamon have no relevant financial disclosures.

Please note that this transcript is produced electronically and may not be an accurate representation of what was said. It may not be reproduced, edited, altered or modified in any way without prior written permission. Any use of quotes or excerpts from this interview requires explicit permission from Healing Works Foundation. Please contact us at healing@healingworksfoundation.org if you would like to use any part of this transcript for quotes or other purposes.

“How Healing Works with Dr. Wayne Jonas”

Interview with Dr. Kavitha Reddy—Whole Health, VA Perspective

Dr. Wayne Jonas:

Hello, everyone, and welcome to our next installment of How Healing Works. It is a great pleasure to introduce my guest today, Dr. Kavitha Reddy, to the program. Currently, Dr. Reddy is the Associate Director of Employee Whole Health at the VA Office of Patient-Centered Care and Cultural Transformation. We're going to talk about that on the interview. For the past 10 years, Dr. Reddy has worked for the VA, championing whole person healthcare for veterans and clinicians, something I think we all agree is an important part of healthcare in general. She's also the principal investigator in a large research study focused on non-drug, non-pharmacological treatments for chronic pain in veterans, something that has been part of guidelines all over the country for years, and the veterans are doing it and she's evaluating. She's also a member at large on the board of directors for the Academic Consortium of Integrative Medicine and Health, and we'll send you the URL for that so you can look up and see what that is.

Today, we're going to talk a little bit about the Whole Health program within the VA, and why it's there and what it's doing, and some of the impact that it has had, especially focused on clinical wellbeing and whole person health outcome through the lens of the Veteran Affairs. So welcome, Dr. Reddy. Thank you so much for being part of this interview and broadcast.

Dr. Kavitha Reddy:

Aw, thanks for having me. Really, really happy to be here with you.

Dr. Wayne Jonas:

I'd like to start off by letting listeners know a little bit about you, and who you are and how you got into doing what you do. It's a little unusual for an emergency room physician that's taken care of acute things that need to be done at this point. This is looking through a little bit longer term lens. Can you just tell us a little bit about, number one, how you even got to be a physician, why that happened, how you went into emergency and internal medicine, and then how did you pivot, or have you pivoted, to what you're doing now in the area of Whole Health? Tell us a little bit about yourself.

Dr. Kavitha Reddy:

Great. I do get asked that question a lot. How's an ER doc involved in integrative medicine and health? Well, interestingly, I've had healthcare and that influence around me really my whole life, in my family and my community. It's not surprising that I found myself looking at the field of medicine when I was thinking about my future. What is interesting, I think, is that always something that I had felt a deep connection to was how can I be of service? How can I be of service to humanity, to culture, to community? That's really been something I've gravitated to since I was young. Interesting, as you say, when I went into the medical field, extremely intrigued by the science really, the science of the human body, the science of healing, so I was intrigued by that and it brought me to the field of emergency medicine because, of course, you're really acutely looking at how to solve and fix and help people in real time.

I would say really enjoyed doing that work for a long time, but the issue, honestly, that arose for me as I was doing this work is you are constantly surrounded by a deep understanding of what people are missing. They're missing a sense of community, they're missing a social support, they don't always have equitable access to resources, and you start to see these same people coming in over and over and it led to, honestly, a feeling of helplessness on my part. I suppose you could classify that perhaps as burnout. I look at it more as disillusionment with the system the way it was. So personally and professionally, I would say about 10 years into the career, I started looking at what are the other ways we could be of service to people more effectively? It led me to an understanding of what integrative medicine and health was, and I went back to do my fellowship in that.

That was about 10 years ago and since then, I'm still on this journey of trying to understand how we transform healthcare systems to actually be healing to people, to be of service to people, and to be equitable in how we offer it.

Dr. Wayne Jonas:

You're saying there are needs that people have in order to become healthy and heal that we don't address completely all the time in healthcare. Is that right?

Dr. Kavitha Reddy:

As much as we want to, right?

Dr. Wayne Jonas:

We sure do. We see that. Like you said, you saw it and you saw, "Well, how do I fill some of those gaps?" So taking care of the whole person is what I call and paying attention to the core aspects that are needed. It's fascinating. So the science of service, you've immersed yourself in the science of service, so putting those two things together that you'd wanted to do. That's great. Let's see. You work in an office called the Office of Patient-Centered Care and Cultural Transformation. That is an unusual name, especially the cultural transformation part at the end. Can you tell us a little bit about why is it named that and what does that mean in terms of what it's doing?

Dr. Kavitha Reddy:

Absolutely. the first part of it probably is more obvious to folks when we talk about patient-centered care. There was really a deep awareness, I think in all healthcare systems, that we needed to move from a sort of fragmented disease-based system to one that really put the person at the center of driving that care. To get to that state, you really do require a transformation of systems, a transformation of the culture. We can set out specific interventions and tactics, but until you get to the culture actually embracing wellbeing, wanting to do this as a system and as an organization, it'll often pull right back to the previous model. That's the deeper work really, right? That's the deeper work in getting all of the incentives and the metrics to align with the work that you're doing, and I would say a journey that we're still on. We often look back at our name and although we say it's long, we say that really is the meaningful part of the term.

Dr. Wayne Jonas:

That's great. Is it patient-centered care or person-centered care?

Dr. Kavitha Reddy:

Good question. It is technically Office of Patient-Centered Care, and I would say we have really evolved using person-centered care in a lot of our definitions of what we do.

Dr. Wayne Jonas:

Well, if you do want to change the name, you might propose to the VA that they make that [inaudible 00:07:01].

Dr. Kavitha Reddy:

Easy change, right?

Dr. Wayne Jonas:

I think it's an important change because as soon as you're a patient, you're different than a whole person. Right?

Dr. Kavitha Reddy:

Very good point.

Dr. Wayne Jonas:

You go down a certain path once you're classified as a patient and put in a gown.

Dr. Kavitha Reddy:

Yeah.

Dr. Wayne Jonas:

Great. So it is delivering something that the VA uses widely, a term called whole health. Can you also describe a little bit about what you mean by that?

Dr. Kavitha Reddy:

I love this term, and you said it already, this is really about whole person care. Whole Health for the VA is really defined as empowering and equipping people to live their life to the fullest by meeting their health and wellbeing goals. That's really the definition, but what does it mean as a model? The whole health system in VA really seeks to expand our thinking around what healthcare is defined as. I think traditionally we define healthcare as the clinical visit. You said it, you're a patient in a system, you come in to get your medical issues addressed. But what we're really trying to say is healthcare is so much bigger than just that clinical visit. It involves so many determinants of our health, in our community, in our families, in our neighborhoods. How do we actually think about delivering that healthcare so people are looking at their quality of life?

In order to do that, we had to create a model, the whole health model, that allowed space for people to explore their own goals for wellbeing, and we call that the pathway. It's really the entry point into the model. How can they actually access wellbeing services, and that's another core piece of the model, so that they're really having a very comprehensive plan? It's not just based on treatments or interventions, but approaches such as acupuncture, meditation, Tai chi. These approaches that we know are complimentary and are evidence based and it involves education, skill building, understanding how to meet your goals and overcome challenges, even leaning on and using health coaches to help you really set those plans. All of that doesn't need to be done in a clinical visit. It can be done in your community, from your home virtually. It can be done in other parts of the healthcare setting, but it really broadens our thinking about where care is delivered.

Dr. Wayne Jonas:

That's fantastic. I mean, you've said so much in that, like to unpack just a little bit of it here. I have yet to meet a patient who says, "I want a long life full of suffering," and so by starting and asking and having a discussion with the patient about, "What do you even want health for, what's your meaning and purpose?" I know that veterans are all about that. They have often given back to the country and they have a mission in life and I think that's universal really for everybody to have something meaningful that they're doing in life, that they feel like they're giving back, and that their life has been worthwhile, that it's high quality not just for themselves, but for their loved ones, for their friends, for their community, et cetera.

One of the unusual things that I've seen in the model of whole health is that you actually talk about that. You say what matters to you, not just for your health, but in life. What brings you joy? Why do you get up in the morning? What's your meaning and purpose? I mean, that's at the center of this model in many ways, isn't it? It's a existential or spiritual question in some way and linking that into a healthcare visit, I imagine some patients are a little startled by that when they hear you start asking those questions. "I've never had my doctor ask that," they might say in those areas, but at least in my experience in having applied these kinds of tools and similar tools is that they are very grateful and they want to have those conversations in those areas. Would you agree with that? I mean, is that part of what you're trying to do?

Dr. Kavitha Reddy:

Yeah, I absolutely love what you said. So first, mission driven. Our veteran population is very much that way and so it's very centering sometimes to come back to that term of what is your mission? What is it that you want to do to live your life to the fullest? We often use this saying where we're trying to ask what matters to you, not what's the matter with you? That reframing is very powerful. So we go into visits and we ask from an ER perspective, this is how I ask the question, "If you weren't here in the emergency room, what would you rather be doing? What would you be doing that would make you happy in this moment?" It is a complete shift in psychology. You brought that up at the very beginning in a positive thinking, and you go immediately to there's a lightness in their eyes, there's a human to human connection and immediately they feel like drivers of the conversation, not just listening to somebody telling them what they need to do.

The deeper part of that exploration, if we say it that way, is how do they become motivated around their own care and taking care of themselves? Honestly, to see them become more activated and more engaged and want to partner in their healthcare I think helps in a couple of really meaningful ways. Of course, number one, how do we get them to think about their own lifestyle and behavior change? But honestly, for me as a clinician, there's a lot of fulfillment in seeing that person become motivated and engaged. I would even argue that some of the disillusionment for clinicians is that we do all this work in trying to be of service, and we often feel like people are not changing or receiving or ready to change. That can be really frustrating over time, so it's another way to really open that motivation.

Dr. Wayne Jonas:

Great. It's an empowering process on both sides, both for the patient and for the clinician. I'm going to talk about the clinician side of that a little bit more later because it's becoming a major problem in the country as the pandemic ... even before the pandemic, but especially now the pandemic has beaten down healthcare clinicians and providers in these areas, causing burnout, destroying wellbeing, et cetera, et cetera. But I want to just revisit one thing that you said about that, or two things about that if you don't mind. You talked about motivation. Most of health, we know from extensive data, actually doesn't come from the doctor's visit. It comes from what you do between visits in your life.

In fact, 80% of what produces health is outside of anything that healthcare does. So by not getting the patient engaged, a person engaged in their own self-care, you're missing 80% of what producers health and it's no wonder that healthcare is not producing health and costing us more and more if they're not getting at these underlying determinants of healing in some way. So this sounds to me like it's a general way of using the science of behavioral change in empowerment of which there is a science, there's an extensive science on how to do that, and one of the things is to get the person engaged and motivated in. This sounds like a question that really any clinician can ask that will help open up that human to human connection and the thinking about motivating them to help. Anyway, it sounds to me like this is a mindset change that has multiple directions in terms of the pathway and the consequences of that simple question about what matters to you.

Dr. Kavitha Reddy:

If we take that even further, you think about it for yourself, if somebody were to tell you when you go to your doctor's visit, "I really need you to lose weight. I really need you to change your diet, that's what's going to get the numbers to look good," they're not wrong. They're not wrong. That's based on science as well. But the chances that I'm going to be able to do that in a meaningful way may be low if that's not where I'm motivated. We use a tool, the personal health inventory, that has a circle of health and wellbeing that has very familiar domains to you, things around movement, nutrition, relationships for surroundings, spirituality, and we allow that individual, that veteran to say, "Where do I feel motivated right now?"

What I always talk about when I'm doing any trainings or teaching is it doesn't matter where you want to start. It's all interconnected. If you want to work on your sleep, and that's where your motivation is, it will absolutely impact how you eat, how you move, how you're able to work with your colleagues and interact with your family. There's no wrong starting point and I think that's the part of the transformation piece. We're used to sharing our information and wanting to fix. We have to step back and let them express where they're motivated to start and then we start to see meaningful change.

Dr. Wayne Jonas:

That's fantastic. I mean, this changes the whole opportunity and availability of resources for helping people to heal. Instead of saying, "Oh, well, I don't have anything more that I can do for you in this area, you've done everything in those areas," you basically say, "There's multiple pathways into your healing journey. Where would you like to start?" Then just begin there and that will get them into that process. The personal health inventory, or the PHI, is sort of the core tool for this discussion that goes on to help patients do this. I know on the website at the VA Whole Health, it's there and it shows how to use it and all that kind of thing, and so we're going to put the URL up there several times during this talk so people can go there. All the resources there for Whole Health are free. They're available, they can be used.

Here at Healing Works Foundation, we've taken the PHI and adapted it for non-VA environments and so if you go to our website, which we'll also put up there, clinicians or systems can get the tools adapted for that same framework, same approach that you've just talked about, and then do what we call a HOPE visit, a healing oriented practice as an environment visit, write a note about that, and not just a soap note or a diagnostic note that then begins to move people along that healing journey that you talked about. It looks for that entry point people can get into. Thank you for mentioning that and thank you for having built that that we've taken from the VA and made available more widely, hopefully.

All right. So you've talked a little bit about the why and what, both for you and for what this is. Could you tell us a little bit about the so, what? Does it really do anything? Has this been tested in the VA? Is it really producing the kinds of impact that we're looking for in terms of patient satisfaction, in terms of clinical outcomes and clinician burnout and wellbeing, cost issues and that kind of thing? Can you kind of summarize, has the VA been evaluating this program?

Dr. Kavitha Reddy:

Well, yes, and excited to share so much on what's happening. Really driven by a lot of the concern with chronic pain and opioid use, we had a significant piece of legislation several years ago of the Comprehensive Addiction and Recovery Act that allowed VA to do just that, to take this system, a whole health system, and implement implemented at 18 sites across the Veterans Health Administration, one in every network so we really had a nice diversity across the country, and part of that was evaluating how is this going to be implemented and what impact might it have on the organization and what outcomes might we see.

The exciting news is as we start to explore those outcomes with our research partners in VA, and under the leadership of Dr. Ben Kliger as our executive director, we have seen several things that are exciting to report. One, we are seeing improved patient activation, engagement and goal setting, which we said was really the cornerstone to this healthcare delivery model. The second thing we've seen is reduction in opioid utilization amongst chronic pain patients. The third thing that is interesting to note is that a lot of our chronic pain and mental health patients are using the whole health model. They gravitate towards that model and the thinking is these are complex issues that often don't respond to just only one tactic or intervention, but what's appealing in the whole health model is you're using all therapeutic approaches and so these very complex issues are finding benefit from this type of approach.

We also are looking at some preliminary and very promising data that's showing some reduction in the use of pain procedures downstream. Now we're still evaluating that, but that could really contribute to some of our thinking on cost, just like the pharmaceutical reductions. One additional point, and we can certainly share the studies, we do have one that has just recently been published, clinicians who are delivering the whole health approach to their veterans, year after year, we see a correlation with improved job attitudes, reduction in burnout, reduction in turnover intention, ranking the VA as the best place to work, their perceptions of their leaders. That's year after year. So very, very promising to see that trend continuing.

Dr. Wayne Jonas:

That's fascinating. I understand you've also done some look ... I'm going to talk a little bit about the clinician wellbeing in a minute, but you've also looked at costs, right? Does this cost a lot more?

Dr. Kavitha Reddy:

The interesting thing is it's really about doing the right thing for the veteran and so upfront there's going to be some additional resources perhaps that you use, and we're still evaluating what the impact is as far as cost of the organization. But with reductions in pharmaceuticals, potential reduction in use of procedures, that's where you're going to start to see maybe some costs downstream that we can avoid, but I think the more promising thing is the value proposition. We're seeing patients that are more activated, engaged and wanting to actually interact with the different approaches that we have in VA. We even see increased activation around use of evidence-based practices in mental health, which is fantastic.

Dr. Wayne Jonas:

You didn't address my cost question, but that's okay. I saw a report, a publication, that came out I think in Health Fair somewhere, we'll find the resource and make it available to our listeners, that actually looked at a cost offset, a reduction in cost compared to from whole health users versus non-whole health users, including pharmaceutical components and opioid use. The opioid use is really important. The mental health is really important. The pandemic has exploded our approaches to these areas and shown a lot of the deficits of just using the standard medical model to try to do that. Our opioid deaths have tripled since the pandemic compared to before the pandemic, and mental health needs have exploded way beyond the availability of mental health services.

I saw patient two days ago, clearly needed mental health services, counseling, et cetera, could not get it, just not available in those areas. I think this is a way to help facilitate improve access to those kinds of services that are focused on enhancing wellbeing and then coordinating with formal mental health services in those areas. So you said clinicians are feeling better about this. There's less evidence that satisfaction, burnout, et cetera are impacted by that. I'm surprised by that a bit because as a clinician that worked in the DOD, I still see patients in the DOD, saw a lot of veterans et cetera, when a new thing came along and they said, "Now we want you to do this," I went, "Oh, god, another thing I got to do. I have a checklist that already I can't do in the amount of time I have, and now you want me to do another thing."

But this is different. This is different. I mean, is there enough time and resources available to implement this and does it actually help give you back more time for connecting back to the patient and doing the other kinds of things that you need to do, or is it one more thing?

Dr. Kavitha Reddy:

So a couple things in there. Really great question. So when we looked at this data, we had the same reaction you did, usually in cultural transformations, it is a burden on the people implementing, and usually you see those job attitudes go down, so even more meaningful that we saw them improve. To talk about the why. I mean, I think clinicians want to practice this way. We talk about it all the time, wanting to be very present with people that we're caring for and what really burns us out is all the other stressors around us that are taking us away from that.

So the humanizing connection piece, yes, clinicians want that. I don't think you could implement this whole model only within the clinical visit. You have to have this expanded definition of healthcare. So the fact that the clinician can send their veteran to a health coach after identifying a shared goal that's connected to their purpose takes off that burden of trying to be in your clinical visit the educator, the coach, the motivator, the support system. You can't do all that in 20 minutes. You have to also address their medical issues.

But the fact that you can refer them to a complimentary approach and instructor for yoga or acupuncture, the fact that you can send them to a health coach, the fact that you can send them to interact with their fellow veteran for a shared experience where they can openly talk about what they have in common, that takes burden off the shoulders of the provider. Now, there's still, of course, a need to take some of those administrative burdens off that. That's the same in every healthcare system, documenting this, being able to deal with the alerts coming in. But what we notice is if we can get veterans more activated and they can utilize the system more effectively, they're not necessarily having to come back and use that primary care provider, walk in over and over. They now have an extended family, so to speak, that they can lean on. Really team-based care.

Dr. Wayne Jonas:

No, that's fantastic. It's not just about the relationships, which on surveys of clinicians over and over again, they report that this is the most rewarding part of their practice is actually getting to know people and serving them personally. It's providing resources also for helping them recover. So they get help in this area and they get help by the VA investing in resources of some of these other types of services and delivering them collectively in a scalable way through group visits and this type of thing, which gets at another thing that's exploded after the pandemic that was there before, and that's loneliness. Even in the area where there are very high social needs, surveys show over and over again that loneliness and isolation is one of the major problems that prevents moving forward in accessing services even when they're available and there. So these kinds of collective visits in which peers are part of it, other people in the community are part of it with some guidance with a health coach and others is almost as a side effect addressing the issue of loneliness. Is that correct?

Dr. Kavitha Reddy:

I'm so glad you brought that up. I actually just read a recent study on this as well, even bigger than nutrition and movement is the prevention of social isolation for quality of life. I have to tell you a little bit of a story. We have this course we offered called Taking Charge of My Life and Health, and it uses the personal health inventory as a guide and it allows veterans to come together and slowly talk about each element of wellbeing around the circle of health, and during one of those sessions a veteran actually shared that she was reluctant to come to the sessions, but after going she realized that she is not alone, that she thought she was the oddball out and very different. But then once she got around her fellow veterans and understood other people are feeling this way, "I have this community of people who really get me," it really unlocked inside of her this idea that "Maybe I am okay, maybe I can share more about myself." It's interesting how deeply people will share when somebody of a common shared experience is in front of them.

It gets to what you're saying from a mental health and opioid perspective, we have to have the ability to reach people in their communities with people they trust because they're not always sharing it with us, the clinicians. There is mistrust, and we have to see that that's present, during COVID became more present and how do we use that community structure, that extension of healthcare definition to really reach people. I think whole health is really doing that effectively.

Dr. Wayne Jonas:

We certainly need that outside the VA, community based support in those areas. I had a veteran tell me once, "Yoga saved my life."

Dr. Kavitha Reddy:

Wow.

Dr. Wayne Jonas:

What I said, "What do you mean by that?" He said, "I was suicidal every day. I thought about doing it until a buddy of mine said, "Let's go to this veteran yoga class, warrior yoga class or power yoga class together." He thought, "This is crazy. Why would I ever do something like that?" But his friend said, "Come on, let's just go do it," and he started in that and not only did he like the yoga, it helped him relax, et cetera, but he had a group of like-minded folks doing it together and it gave him a community. He said, "After I started doing that on a regular basis, now I don't think about suicide at all. I actually enjoy what I'm doing in those areas."

I look for a randomized control trial of yoga and suicidal and I didn't find anything, so it's not going to meet the evidence-based criteria but VA has looked at what does meet evidence-based criteria in these areas, and they have a list. Won't ask you to have to go through that whole list right now. I'll urge the listeners to go to the VA website and look at their tier one and tier two evaluation because they've done extensive evaluation of what evidence there is for this and which ones sort of rise to the top so far and which ones need more examination. You'll probably never find a yoga as a suicide prevention on that list or ever will, but he clearly ... that's sort of his pathway in. That was his pathway to healing.

There's another group that's going to be looking sort of objectively at this program that, especially around the evidence and its implementation, back to your science of service here, and that's the National Academy of Medicine. They are in the process of doing a very comprehensive study of the whole health program, really looking at what's needed to help expand and implement it, what does it do, answering that so what question and also what next question in these areas. That hasn't come out yet. By the time this interview's broadcast, it may be out. It's due any time now. What's the VA going to do with that study? What are they hoping happens next after you get this information and the other information you've collected? Where's the VA going with this whole person care approach?

Dr. Kavitha Reddy:

Yeah, great. We are looking forward to that release and I brought up the 18 flagship sites, but since we did that work 2018 to '20, we have greatly expanded across all medical facilities in some capacity to start the whole health implementation process. We have policies around delivering complimentary and integrative approaches that you mentioned, and what we are hoping for is that this report really solidifies the need to implement this system across all facilities in a uniform way. What are the necessary roles that we need to implement? Also, we would be really looking forward to seeing what are the necessary barriers we need to get rid of to make this implementation more effective, maybe more rapid, and what are maybe some other outcomes we should be looking at.

Already we're looking at how the whole health system may influence different populations, like you mentioned. With the release of the recent PACT Act, any veterans with toxic exposures now might have benefits in the VA depending on what kind of exposure and when. We want to start evaluating more effectively how whole health is impacting those populations. The hope for the report is that it not only is saying yes, what you've evaluated so far really, really supports you implementing this further, but are there any other key recommendations that can help us do it even faster and gain the support from the system to do that more effectively?

Dr. Wayne Jonas:

So really looking at how to expand this and how to address some of those barriers. What's been your experience in some of the main barriers to making this type of service available?

Dr. Kavitha Reddy:

I don't think any of these will sound unique to anybody out there. So the length of the appointments, we're always trying to maintain access to our veterans, but at what cost? We can do that, but in order to do it in a very personalized humanistic way, we need time. Do the lengths of the appointments need to be longer? Do we need to be looking at shared medical appointments to allow more space for those conversations? What we're measured on, we measure what we value, and right now we measure a lot of numbers, and rightly so. Those help us manage disease, but they don't necessarily manage what we care about, which is quality of life, functionality and wellbeing. I think that that's a barrier right now. If we're measured by blood pressures and BMI, then that's what the visits will be curtailed to.

This is really where cultural transformation comes up. We really want it to be tailored, I should say, to wellbeing and quality of life. We have to look at our entire incentive structure. No big deal, right? Then we have to look at our payment models. What are we paying for? In private sector, what are we reimbursing for? In the VA system, where are we allocating our money to cover the costs of care? So big ones.

Dr. Wayne Jonas:

Yeah, those are big ones and hopefully NAM will help clarify that and the VA can move forward with that. Your last one on payment is as I take a lot of these whole person care tools and try to take them to non-VA centers around the country, that's the main question I get, "Who's going to cover this? Who's going to pay for this? Oh yeah, they can do it in the VA because they're a capitated system. They're covered, they get it covered, and I can't do that because I'm in a fee for service thing." Is that a significant challenge within the VA itself and how have you overcome that?

Dr. Kavitha Reddy:

So within the VA system, we are in a different payment model, but interestingly, even within that payment model, it's based on services delivered often. I think still a challenge in that we want to move more to how can we develop a system that's looking at wellbeing and using that as a way to incentivize people to do this work. But I will say when people do bring that up, that we're in a different model, but the work we're doing in VA absolutely helps inform how policies developed outside VA. We had a great partnership when we looked at acupuncture and acupuncture reimbursement and thinking about that for Medicare and low back pain. We are working in partnership with the National Board for Health and Wellness Coaching as we speak to look at how we can help the CPT codes for health coaching in the future become something that can be reimbursed.

I think our ability to collect data and to understand the impact of this system can help inform how things happen on the outside and now everything we create is free for use, so you don't have to go through that struggle of trying to recreate it. The videos, the documents, the courses we use to teach. What I would say is in healthcare systems as we start to look more to value-based care and bundled payments, how you're incorporating CIH and coaching into your thinking I do think is the way of the future and we have a model that could work for people as they're developing that.

Dr. Wayne Jonas:

No, that's great. I've encouraged a lot of the civilian practices that would like to do some of this to create a sort of a test unit, a practice improvement effort, and bring these principles into that and make it part of their quality improvement component. If they're really ambitious, they can actually create an integrated practice unit and they can actually formally test it there where all of the things are put together, but even without that, they can do program improvement and that type of thing. The Healing Works Foundation is about to release a CME module to help people implement integrative healthcare in their own practice and go through standard type of practice improvement components so that they can test out and improve some of these and address these kinds of challenges and barriers when they come out so they can fix them, and it's very doable.

We ran a network around the country doing this over the last couple years, even through the pandemic. A summary of that's going to be published in the Annals of Internal Medicine pretty soon, and they can do it using those kind of standard practice improvements. I know the VA has a lot of support for practice improvement in those areas, but you don't have to have that kind of a Cadillac of improvement for a huge system like that as long as you're doing that on a sort of a routine basis.

I know that you're looking at pain in a much more rigorous way. I think you have something called W HOPE. The HOPE stands for something different than the HOPE note that I mentioned before, but it's actually a rigorous evaluation of the use of these approaches and these models and this thinking in the management of pain and opioid more formally. Can you talk a little bit about that? I know you're leading that program or helping lead that program.

Dr. Kavitha Reddy:

Well, I'm super excited to be involved. I am the PI for St. Louis. It's a multi-site NIH funded trial led by Dr. Karen Ziel and Dr. William Becker. I feel really privileged to be a part of it. We are looking at three arms really, so primary care as usual, primary care group education using a modified CBT, so cognitive behavioral therapy approach, and then the third arm is whole health, and we have a protocol around delivery of whole health that very much looks at it as a system. How are they partnering with veterans, how are they using wellbeing approaches, and then receiving integrative medicine clinical visits. We're about halfway through that trial right now, and I'm so eager to see. We'll be looking at a lot of different variables, not only impact on pain, but cost resource utilization, so I think this is going to be a really exciting study to follow and really looking forward to seeing what data we're able to produce.

Dr. Wayne Jonas:

That's fantastic. There's very few places and the VA is one of them where you can do studies like this where you can actually randomly allocate people to the key questions that you need to know in pragmatic decisions that clinicians and administrators need to make. Should I just keep doing what I'm doing? Should I add something that we know works or should we enhance it in some way with something we think is better? Having that direct comparison will be extremely valuable for knowing both what to do, how to do it, and how to adjust it in those areas.

Great. Well, I really appreciate it. I want to know if there's any additional things you'd like to add. I know you're on the board of the Academic Consortium of Integrative Medicine and Health and have a good relationship with them. That's academic centers that are out trying to do this both in VA, non-VA centers. We'll put the URL on that and point people to that. But is there anything else you'd like to talk about or mention to our listeners before we close out here?

Dr. Kavitha Reddy:

Well, thank you for having me. This is a wonderful ongoing conversation I know that we have. I think one other thing that I'll say is in doing this transformational work, we really discovered a need to have the employee themselves understand the approach and clinicians, non-clinicians, everybody, because it's really hard to do this work if you don't understand it for yourself. What are your goals? What are your values? Why do you come to work? What is your mission? We spend a lot of time within this model focused on the employee themselves and I think for anybody doing this work at their site, really from a change management perspective, investing in that employee so that they feel really bought into the process and it becomes second nature to talk this way with the people they're caring for, I think is really important.

As an organization, we've really tried to invest in looking at wellbeing and burnout, and we have a few resources we can share with you on that work if of interest. Again, many of the resources we can share that we've developed, everything ranging from mindfulness, self-compassion for clinicians, real skills that we need to do this work day in, day out. It's not easy, so I'd just like to share that with the audience as well.

Dr. Wayne Jonas:

Thank you so much for mentioning that. It wasn't on the list of questions I was going to ask you, but in many ways it's a perfect way to end this. It's about heal the healer, isn't it? I mean, look inside and make sure that you're practicing what you preach. As I say, you can't become a neurosurgeon by practicing on yourself, but you can learn how to heal and become well by doing that, and that's sort of an important way to do that. This applies beyond healthcare. This is employees of any type. If they're taking care of their employees, of their families, of their communities in a whole person way, they rise to the top of Maslow's hierarchy and the transformation in cultural transformation that you have that occurs.

I know the National Academy is talking about the need to transform healthcare after the pandemic to build back stronger and fairer in this country, and this last part of focusing on and making available these kinds of services to employees is probably in many ways at the heart of doing that. So thank you for all of the things you've made about, thank you for what you're doing for our veterans and for the country, and look forward to talking to you again in the future and more things to come.

Dr. Kavitha Reddy:

Great. Thank you so much for having me.

Dr. Wayne Jonas:

Okay, take care. Bye-bye.

Dr. Kavitha Reddy:

Bye.