Well, welcome to our session today on whole health and health care, realizing the promise of the biopsychosocial model for mental disorders and diversity. My name is Harold Cudler, I'm an associate consulting professor of psychiatry at Duke and an adjunct professor at the Uniformed Services University of the Health Sciences in Bethesda. From 2000 to 2005, I co-chaired VA's special committee on PTSD, which reports directly to Congress on VA's clinical, research, educational, and benefits programs regarding PTSD. I've served on the International Society for Traumatic Stress Studies Board of Directors, co-led development of the joint VA-DOD clinical practice guidelines on PTSD, and advised Sesame Street's Talk, Listen, Connect program on military families. And I say all this because it just seems like you can have a career based on the clinic and a particular diagnosis, but you can get caught up in a lot of psychosocial issues. In fact, I think if you're not, you're probably not looking widely enough in your career. I've served as the clinical director of VA's Mid-Atlantic Mental Illness Research, Education, and Clinical Center on Deployment Mental Health, and partly in that capacity, co-led the North Carolina governor's focus on returning military members and their families. And in 2014, I joined VA's central office in Washington as the chief consultant for mental health, responsible for VA's national mental health policy. I currently chair the Service Member and Veterans Initiative, the American Psychoanalytic Association, and the Military and Veterans Committee for the Group for the Advancement of Psychiatry. During my 40 years as a VA psychiatrist, working clinically, research, policy development around veterans' issues and disaster responses, I became familiar with the conventional wisdom that while there were things you could do after traumatic events that could be helpful, there could be no such thing as primary prevention of the disorders associated with traumatic stress, including, but not limited to, post-traumatic stress disorder, major depression, and substance use disorders. For example, the diagnosis and treatment of PTSD had been largely a retrospective exercise in VA, which often began months, years, or even decades after the traumatic event. And that was your focus, looking to the past. Frankly, on September 11, 2001, it occurred to me that we now had a prospective mission, and we didn't have any tools for even thinking about how do you prospectively prevent trauma, traumatic disorders, anxiety, depression. So during those past decades of war in Afghanistan and Iraq, I became involved in efforts to lessen the impact of deployment stress, both in the service member and his or her family, while they were still serving, long before they became veterans and long before they presented for mental health services at the VA. This often involved making sure that the family, left to its own devices on the home front during a warfighter's deployment, was supported. And these deployments could last six or 12 or even 18 months, and then be repeated six months later. My wife and I once met a little girl at Camp Lejeune. She was 12, I think, and her father had deployed nine times with the Second Marine Expeditionary Force in combat missions. Significant stress on the family. So was there going to be money in the bank, food on the table, transportation to school or to work, access to health care with clinicians who had the clinical and cultural competence to understand the nature of deployment stress? Did they even ask, you know, is your family involved with the military? And the answer is usually they didn't. And to think about the potential impact on these service members and their families. You know, even mundane issues like who is going to mow the lawn? Did the spouse at home know how to run the lawnmower? Did they know how to balance a checkbook? Had they ever changed a tire? These are the kind of questions, by the way, that come into the military's military one source. Not so much how do I, you know, get PTSD treatment, but I've never managed a checkbook and things are going badly and this is really bad because we didn't have money and we're overdrawn. These are things that often tear up a family. And then when you're in Iraq and you're calling back home and, you know, the people are shooting at you, yes, but you can't solve the problem that your spouse is having back home. That's actually many people report the worst stress they have in a combat area is that they can't fix things going on with their families. These issues are terribly important for the long-term trajectory of service members and veterans and their children and spouses and partners. All this called for a focus that expanded way beyond the traditional scope of clinicians to include the social determinants of health. And this was happening during a period when we were becoming increasingly aware that the social determinants of health account for more of the variants in health outcomes than do diagnoses or modes of treatment. Meeting these needs required identifying and weaving together a web of clinical and social services so finely intertwined that no one could fall through it. And for the most part, these webs do not exist. Later as our wars wound down and new veterans took up civilian lives, did they have the education and training needed to get and hold a good job? A lot of veterans could get a job, but could they hold it? Did they have housing that was stable or were they living on their mother's couch, one argument away from being homeless? Did they have opportunities to enjoy life with their families, access to good nutrition or to physical or mental health care? It was around this time that VA began to promote a new approach to health care called Whole Health, which builds on the value of integrating clinical and social services, and in particular, in terms that were focused on personal factors, local resources, and cultural competence. Recently, I was invited to take part in an ad hoc committee of the National Academies of Sciences, Engineering, and Medicine to study VA's Whole Health program and make recommendations about its future in VA and its potential value in health systems beyond VA. Alex Christ was co-chair of that ad hoc committee, and I'd like to now invite him to take it from here. And by the way, welcome to APA. But first an introduction as Alex is getting ready. Alex Christ, MD, MPH, is a professor of family medicine at Virginia Commonwealth University in Richmond, Virginia, and a practicing family physician and teacher at the Fairfax Family Practice Residency. He directs the Community Engaged Research Corps for the Wright Regional Clinical and Translational Science Award Center, CTSA, HUB, and leads multiple projects with numerous community partners in Central, Eastern, and Northern Virginia. And those are, as we were discussing earlier, immensely different areas to live in and work and seek medical care. These work to improve access to care, address health equity, and improve quality of care. Dr. Christ is the director of the Virginia Ambulatory Care Outcomes Research Network, ACORN, a collection of over 500 primary care practices throughout Virginia that collaborate and do research that matters to primary care. He's also a former member and chair of the U.S. Preventative Services Task Force. And he is a member of the National Academies of Sciences, Engineering, and Medicine, and a terrific co-chair of the Ad Hoc Committee for Achieving Whole Health for Veterans and the Nation. So, Alex, the floor is yours. Thanks, Harold, and thank you all for spending time with us here today. So, I'm going to try to make the next 40 minutes worth your while the best I can and summarize and talk about this report from the National Academies and try and put it into context about, well, what can you do with this and how can this help you, the people you serve, and your community as well. So this is the report here, Achieving Whole Health for Veterans and the Nation, and it's about the VA, but it's also about the whole nation. Every person in America deserves whole health. That was one of the conclusions of the report, and because of that, we need to make sure that every health system, every practice, every place can deliver whole health to people. And I get the joy of coming up and talking about the report and the findings and everything, but this was all of a group effort here, like all of the different national academies. There were 16 people who were involved in putting this together with really wide and in-depth experience, and that's the thing that allowed this report to come together. So the context here, the committee was assembled to try and identify and to look at the best practices from the VA Whole Health Initiative, but also from health systems and international examples all over, and to think about how do we transform health care by scaling and disseminating whole person care to the entire population. So this report, in essence, is about saying how do we redefine what it means to be healthy, and how do we redo our entire health care system? Just a small goal for the report, so nothing big. In the context of this, we all know that the U.S. lags behind other countries in terms of health outcomes. It's getting worse, too. So we have worse life expectancies, worse quality of care, greater infant and maternal mortality, and even quality of life isn't as good as it should be. It's not surprising, though, because the U.S. health care system is very reactionary. It's transactional. It's fragmented. We really don't have a coordinated approach to generating health and ensuring that people are well. And the system is really organized around fee-for-service models and health conditions, and not systems to try and make people and communities healthy. So one of the things that this committee found is that whole health is a fundamentally different chassis for delivering health care. We need to really think differently about what we're doing, what our goals are, how we're achieving it, and who we're helping and who we're serving. So the statement of task for the committee was to look at, well, where is whole health currently being implemented? What does whole health accomplish at the VA in these different systems? And then how can we spread this? And we'll introduce later the terms of scale and spread. So scale is if you're in a system where they're already doing some whole health initiatives, how do you make this more broadly accessible across your system? And spread is how do we make it go from one system or one community to another so that it is actually a national movement and not just a change within the VA? So if you're not familiar with how the National Academies comes out with these reports, it's a pretty intensive process. So this group of 16 people met over a two-year time period. There were six different meetings, each with kind of scheduled goals and approaches. Many of them were public, and you could join in and watch and see what happens. And that's a normal process for the National Academies. There were three commissioned papers. So if you want to learn more about this beyond what we just said, there was one about the VA's approach. There was one about patient-centeredness. And there was another one about lessons from whole health systems across the world, actually. There was a literature review to pull all this information together to identify all the evidence and all the examples. And then all of the recommendations are driven by consensus. So I'll end here with the third part of what I'm going to talk about is the different recommendations of the committee. And the recommendations are for the nations. So there's lots of call-outs, like we want HHS to do this, or CMS to do this, or HRSA to do this. But there were also call-outs to health systems and practices and clinicians. To do this, you can also do this activity. So we'll talk a little bit about this. And then it had peer review to make sure that what was put together was good. This is the report. If you Google National Academies and type in whole health, you'll find it. It's easy. The commissioned papers are there. The whole report is 534 pages long. I don't expect you to read it all. But there is a summary chapter. And to just orient you, one of the chapters just talks about the definition. And I'll share that with you. Like what is it? What are we talking about? The other was the evidence supporting the foundational elements of whole health care. The other was whole health examples. And it describes them and gives a face to them so you can see what are we talking about. And then we had the evidence from the different whole health systems. Then we talked about scaling and spreading, as I mentioned what those were. And then we come up with the different recommendations for the nation and for health systems on what they should be doing. I'm also going to talk about two other articles just as a resource. So one was in JAMA Health Forum, a much more simple 2,000-word summary of the entire report. And then the other one was in this Medical Clinics of North America. And that's talking about how practices and clinicians can implement this and put it into practice. Now, if you're not familiar with National Academy's report as well, you might be asking, well, what happens with one of these reports? What's it good for? So for starters, it's a great way where you can learn about everything. So what are people thinking about? What are they recommending? What are they talking about? In addition to that, hopefully it ends with recommendations and the actors that are called out in the recommendations do something about it. But they may or they may not do something about it. So what happens with some of these whole health care reports is what's happening with this right now. It ends up on someone's bookshelf. So that's my bookshelf. Don't judge me for the books that I read. But this is what can happen. It can just sit there. So there needs to actually be a call to action. And I think that's a much more important part about these National Academy's report. They really are a call to action. So if you're going to go back to your health system or your practice or your group or where you're working or the community you're serving, and you start talking about, well, here's this National Academy, and this is what they're talking about, that actually gives you a lot of ammunition to be able to try and make changes in your community. If you're a researcher, if you can write and cite the whole health report from the National Academies, that's going to help you with your research and moving things along. And then maybe it'll give you some direction for the future. So let me next talk about the committee's definition. And this definition was derived from the VA's program, but it was also derived from the other 13 examples that we found within the U.S. and across the nation. So the committee defined whole health as physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities. And to achieve this, whole health care is an interprofessional, team-based approach anchored in trusted longitudinal relationships to promote resilience, prevent disease, and restore health. And it aligns with a person's life mission, aspiration, and purpose. So this is an interesting definition. There's three parts to it, right? There's a statement at the beginning of sort of where are we, the statement of a statement of being. And then the second sentence talks about how to achieve this, which is very important as well. And then it's really kind of reframing health as not a state of being. It's not like the sum of your labs and are you in good health or bad health, but really much more it's a resource that allows you to achieve what you want to achieve in your life, your life's mission, aspiration, and purpose. And if you're not experiencing whole health, it's kind of hard to live your life to the full extent. So that's one of the reasons that we frame the definition this way. And this really builds on a century of efforts to say what does it mean to be healthy, where the World Health Organization and other groups have been trying to really say what this is and change it from a pure biomedical model to much more about this broader being. The report talks about how is whole health delivered. So it's built on the foundation of high quality, well-supported primary care. It's cross-sectorial spanning conventional medical care, mental health, health behavior promotion, complementary integrative health, public health, and social services. And throughout the report, we are really careful to use the term health care, two words. This is about how do we care for people to build health and not health care like our traditional health care system, which is probably not doing as well as it should be doing. So the other thing about this definition that I think is important is it talks about both a current state, so whole health is, that's what it is. And you can look at someone and talk with them about are they experiencing physical, behavioral, spiritual, socioeconomic well-being. Does it fit with their alignment? But it also gets into a future definition. So not only is the second sentence about how we deliver this in our health care system, but it talks about if we're doing this right, this is what we're going to do. We will promote future resilience, we'll prevent future disease, and we'll restore health. And I think those are important factors there in terms of both the current state and the future state of where we'd be going. This is something that gives me a little bit of anxiety. It's not in the report, and this is where I kind of talk separate from the report. But I was thinking a little bit about sort of the pyramid of, well, where are we as a nation and where are most people at? And we probably have a group of people at this top of this pyramid who are very highly symptomatic. They're not experiencing whole health. They're having a lot of problems. And in a lot of the different evidence, we saw folks who had traumatic brain injury or who had injuries from combat or other different scenarios, and these are our highly symptomatic group. This could be physical and it can be mental. Then we have our less symptomatic group, but they're still symptomatic. They're not experiencing whole health. And then we have our healthy group. And the dollar signs are sort of what this costs, and the cost is not just the cost of delivering care, but it's sort of that opportunity cost of not being able to experience whole health and achieve what you want to achieve in your life. But one of the things that got me worried is thinking about that future state, like promoting the resilience and well-being and preventing disease. There's probably a whole group of people here at the bottom who don't have the right physical, mental, social environments to continue to have whole health. They have it now, but they don't have the right substrates. It might be that their blood pressure is too high. It might be that they're experiencing chronic daily stress, and they're at risk for developing physical, behavioral, spiritual, environmental, and socioeconomic, not well-being in terms of state. So if we think about the people over their lifespan who will experience whole health all the time, it's probably much smaller than we want it to be. Not trying to be too depressed, because there is a solution, and let's move and talk about some of this solution. So based on all of the evidence of the different whole health implementations that we saw, we found that there were basically five foundational elements of whole health care. And they're necessary for an effective whole health care system to be able to help the people and the family and the communities they serve achieve whole health. So the first one's being people-centered, and this is grounded in the definition, right? We just said whole health is defined by people, families, and communities. So what's important to one group might be different than what's important to another. And the system that's helping to care for them and to generate whole health should be knowing what that is and helping them to achieve it. So it often starts with understanding people's needs and their goals in that context of where they're living and growing up and everything. So one of the examples that we saw evidence of is the NUCCA health system, which is in Alaska, and that takes care of a Native American tribe up there. And they describe the people in the health care system not as patients, but as owners. And they have community gatherings, and they say what they want and what they need from the health system. And then the health system is really, really bound to deliver that and to make sure it's caring for them. It was a really amazing example to hear about. Another is being comprehensive and holistic. So this is not just like, oh, we have to have all the parts to take care of physical and mental and spiritual and socioeconomic well-being, but the parts all have to come together into a whole so that we're taking care of whole people, whole families, whole communities. And it's not just the whole at one point in time, but it's also the whole over someone's lifespan or over the future lifespan of a community. And so this is going to take spanning conventional medical care, complementary and integrative health, spiritual care, mental health, and social needs. A lot of different sectors of our health care systems. And that's health care with two words there. And then the third is being upstream focused. So this is extremely important in terms of making sure that we keep people healthy and we're promoting that resilience. We know that most of the health outcomes are not from conventional medical care or conventional mental health care. It's much more about addressing these upstream factors, things like health behaviors and the social and the structural determinants of health. It's addressing systemic racism. It's trying to promote equity and all these other factors. And this is an area when we looked at the evidence that probably the systems weren't as good at developing as they should be. And then the fourth element is that whole health systems need to be equitable and accountable. So if I look at who's experiencing bad health outcomes and why do we have a lower life expectancy than most other countries, it's because of the people who fall through the cracks. As a family physician, the patient who sees me for their wellness exam is probably the person who least needs to see me for wellness care. So a whole health system needs to be accountable to people and families and communities and needs to proactively engage them to be able to equitably improve whole health for the entire group and community that the system is serving. And we don't have any mechanism for doing this in the United States. One of our examples was Costa Rica. And in Costa Rica, every single clinician is assigned, well every single person living in Costa Rica is assigned a clinician team. And that clinician, usually a doctor or a nurse practitioner type person and a nurse and a community health worker, goes and visits every person in the country once a year in their home to make sure their needs are being met. And when the country implemented the service, they started doing this with the poorest people in the poorest communities and they have a life expectancy that is really outpacing the U.S. right now and saw amazing achievements with that. The last element is team well-being. So a team can't deliver whole health if they're not experiencing whole health. So we need a healthy team to be able to create health for other people. In the article from Medical Clinics of North America, just to kind of set you up if you're looking for more information, we talked about the six U.S. examples and then we went through each of these foundational elements and we said, well what did this look like for them? So it was set up differently in different systems to achieve, for example, people-centered care or how did they get holistic and comprehensive care? What did they do for equity and accountability? So we tried to explain it in this paper and give a really quick summary to give people ideas of what they might be able to do to help the communities they serve. Now looking across the evidence on the different whole health implementations and about the foundational elements, one of the key overall findings, well there was a number of key things about the evidence from the the 13 whole health implementations that are in the report. So if you looked across all of them, they improved patient experience and patient reported outcomes. They were improved access to care and reduced things like emergency room visits and hospitalizations. They improved quality. They improved specific conditions and they reduced maternal and infant mortality. They increased equity, promoted team well-being, and some of them had cost reductions. Now who wouldn't want to achieve all of those things? That's kind of the goal of our health care system to try and make these improvements that are going to do all of this to make sure that the people that we're serving are doing better. I will be honest, none of the examples that we saw did every one of these bullets. So different implementations, studied different things and talked about different things. It's not necessarily that they didn't have cost reductions, but maybe they didn't measure that. Or maybe they were more focused on addressing women and children. So different ones had different benefits across the programs, but it highlights sort of the potential of rethinking what health is and rethinking how we deliver it. So once again, in that medical clinics article, just to orient you, we had the examples of the 13 implementations and we have a column to say, well what were the outcomes that this implementation had? So that you can start to see a little bit about how the different programs had these different outcomes and what were the different outcomes. So it goes into a lot more detail than what I've said here. The other thing I circled on this slide that's important to know is that the sources of funding for all of these, none of them were the typical fee for service U.S. model. Not a single one had that. They all had some sources of financing to pay for infrastructure and support. One of the examples was Mary's Center, which is a federally qualified health center. So within the U.S., the FQHC model is probably the closest we have to a financing model that would support a whole health system. But some of these other countries had policies and other systems in place. You can imagine what Costa Rica did to have care teams go to people's houses and to care for them and to measure outcomes. It was different for these different groups. Thinking about the themes across the whole health models about, well what did they look like? So the first one was they were all different. And going back to the definition, that's probably good. We just said whole health should be defined by the people and families and communities that are served. So it should be tailored to the local environment, the resources, the preferences, and the needs. It was all based on integrated high quality primary care. Mental health was an extremely important component of all of these programs. The whole health systems engaged their communities, not just the people seeking care. As I mentioned, they had financing mechanisms to pool risk. They weren't good at the upstream factors. So that's still a big thing, you know, health behaviors, social needs, systemic racism. None of them were great at that, but many tried to address them. And team well-being was another area that they weren't great at. So it's it's easier to neglect the team. And then the other thing is systemic evaluations to implement this were scarce. I'll admit when the committee started, we focused on those five foundational elements because we did not think we would find any whole health examples in the literature other than the VA system. And we had requirements that the ones we included in the report addressed all five foundational elements, and they had peer-reviewed published evidence that was non-biased enough in its design that the committee thought that the outcomes they showed were relevant and correct. So a number of people came up to us and said, well, what about us? You know, we have a program, we've been doing this at Kaiser or Caremore or a number of other different types of programs that are like this, but most of these programs didn't have published evidence. So this is another thing. If you're going to make a transformation or practice in a system or do something to try and deliver more of a whole health model, we're really encouraging people to generate evidence to support it so that you're doing this in the right way. So there's this great diagram and two chapters that are talking about how do we scale within a system and how do we spread to other systems whole health. And at the top you'll see we have these key contextual conditions that are important. We need to think about systems change and social movement. So I'm doing studies in our primary care practices where we're looking at addressing mental health and social needs within primary care as well as health behaviors. Most of our patients in the study are picking a health behavior to address and not mental health or social needs. And when we ask them, why aren't you doing this? They often say, well, I didn't think my doctor could help me with this. So there's a big cultural change that we need to have to think about whole health and whole health care. We need to have the structures and processes in place to be able to do this and we need to think about integration. So going to the VA as an example, the Veterans Administration has two divisions. They have the Veterans Health Administration and they have the Veterans Benefits Administration. So the Health Administration does health and health care. The Benefits Administration does social services like education and disability and transportation and housing. Even within the VA that's promoting whole health, they still have these divisions that need to be addressed and need to be integrated. At the bottom you see the critical foundational infrastructure. So we need health informatics and digital health that can allow teams to work together across sectors and across time. We need workforce training. We need a whole different workforce than we have right now to achieve many of these things. And the workforce outside of health care, all one word, is actually much more disadvantaged than our health care workforce which is still disadvantaged. And then we need to be able to measure learning and accountability. So if we're going to say a foundational element is being equitable and accountable, how do we assign folks to people? How do we make sure that health systems are accountable for specific communities in a way that makes sense for everyone and that builds that foundational element the way we want it to be? And then we need to rethink financing. So we can't continue with the fee-for-service model like we have. So the committee had buckets of six different recommendations. And I'll talk a little bit about these recommendations. Each recommendation had on a national level two arms. One was to the VA because the VA asked the National Academies to look at their VA whole health program. But the other was to other federal entities nationally. So that was one arm, the VA and federal entities nationally. And then the other arm of the recommendations was really to health systems and care providers across the nation to act on this. And you can see that the six categories of recommendations were really modeled after the commitment to change model. We did that on purpose. We're asking our health care system, two words, to make a commitment to change, to rethink what it means to be healthy, and how we deliver health. And that was why we framed it this way. So the first set is about committing to a shared purpose. The second is preparing for whole health. The third is integrating across systems. Then delivering all elements, evaluating to generate knowledge, and designing public and private sector payment and policy. So let me share a little bit about what these mean. So with committing to a shared purpose of helping people achieve whole health, we said to scale and spread this, the VA, DHHS, other federal entities addressing whole health services, and they're named here, should make whole health a core value. And then we describe what that means. And in that medical clinics paper, we talked a little bit about it from a personal level. So if you're thinking about doing this in your practice, your system, other settings, these are some things that you can do. So like one of the first things is to say, we're delivering whole health care. That's our approach. That's what we're doing. Put it in your mission statement. Make it clear what you're trying to do. Make it, give it a name, because that has a big impact and changes things. Think about what your vision and your roadmap is for delivering this. You'll need to get leadership buy-in, but you also need to get kind of buy-in from the bottom up. And champions will be critical for this process. And think about how you instill this in day-to-day culture. On a positive level in my community, I see ads on TV now saying, we deliver whole health care. You deserve this. You should have it. And that makes me feel good. They're putting our first goal into action. I worry a little that it's whole health theater. They say they do it, but they're not really doing it. And that happens a lot, but we can make changes here. The second is about preparing for a whole health approach. So this is grounded in the idea that different systems and different practices and different communities are at different places on their journey. So not everyone is advanced as the VA is here. But even within the VA, we said, look, we want you to look at where you are, which of these elements are you doing well, and which ones could you do better. And then you need to think about what resources and services you need to take it to the next level. And we went on to say also that, you know, in thinking about preparing this, you know, think about and engage the communities that you're working with and what is it that they say they need and that they want. And as you're preparing this as well, you don't have to recreate everything. That was part of the purpose of the report, to start learning about where else other people have done well, and even to work and collaborate more broadly so that you could figure out from others and copy what they do. My research team is really big into what we call R&D, but we don't mean research and development. We mean rip-off and duplicate, because we think a lot of other people have done things well, and by looking at what they've done and applying it to our setting, we can do a lot better with that. So some local examples of actions. Think about what your readiness is. Think about what you're doing well and what you need to fill in terms of gaps. Think about who your teams are and who you're serving and what are the needs of the people that you're serving. And then include those people in those communities in your discussions, in your design, and where you're going. The third thing was integrating access systems, services, and time to support whole health throughout the lifespan. So this is that example for the VA, the Veterans Benefits Administration and Veterans Health Administration. We said you guys got to get together better. You've got to coordinate your efforts and what you're doing and how you're doing systems. But the same thing applies to like a health system. So like my community health system is not really integrated with our social care systems. It's not integrated with the community programs that are doing a lot of the things that are so needed. And we have a division between health care, one word, and our public health systems. They're both doing the same thing on different angles in different parts of this process, but it's not integrated and coordinated. So here's some of the stuff that you could start doing and that we're calling for different systems to do. So build your partnerships. Think about who is working on this stuff where you live and trying to do these things. Bring them together. Think about what your workflow is and your processes. How are you going to collaborate? How are you going to share information? So our social services programs and our health care providers, they're not on the same electronic records. They have no way of communicating and coordinating. The same applies. Just look at physical health and mental health. There's not great communication between those two sets of providers and they're still within our health care system. If we're going to deliver whole health for people, we also need whole health information systems and coordination and communication. So put those structural elements together, whether that's advisory councils, health coaches, peer support, your digital technology, all of those things are needed to make it work. And then deliver all the foundational elements. As I mentioned, things like equitable and accountable has not been done as well. The VA is kind of a nice model because the VA knows who they're accountable to. They're accountable to veterans. But how do we do this in our communities where we live? So if someone doesn't have health insurance, who's supposed to be accountable to them? But we need that model here. So we called for ways that the VA could do this and called on health care systems and community programs to start thinking about their models and how they would do it and to look towards what early adopters have done to try and replicate what the early adopters have done. We called out HRSA. If you're not familiar with HRSA, they run the federally qualified health centers. So they have a whole payment model, a whole application process, and other things that a FQHC needs to take on and submit in order to get the FQHC type payments. So that type of a model could be replicated by whole health systems in trying to think about the care for people in communities. So different ways we thought about that could be really easy, low-hanging fruit. So put good primary care in place. Put in good integrated primary care and mental health and coordinate across these two branches. Think about people-centered care. So within the the VA whole health system, Don Berwick often talked about how it's not what's the matter with you, it's about what's the matter to you. So you could start asking some of these questions, start putting systems in place to deal with this. Think about integrating health care and social services, which is poorly done. Substance use is a key thing that interferes with many people's whole health. Easy thing to start trying to start, not easy, important thing to start trying to work on, and in a low-hanging fruit in terms of everyone agrees it's so important. And then think about your hands-off, hand-off process between different systems. The fifth goal was to evaluate and iteratively refine whole health. So we found 13 examples, and that's great, but that's not enough evidence to really know how to implement and scale and spread whole health across the country. So there's no reason any system or any practice or group should be going through a lot of effort without evaluating, is it achieving what we want to achieve? And if you're going to do that, we need people to share it. So we asked people to think about getting engaged in larger national initiatives where they're evaluating the processes around whole health, and we asked for groups like AHRQ and PCORI and NIH to start funding whole health research. So what are some things that our different systems and local groups can start doing? Think about what your measure of success would be. Is it going to be cost? Is it patient experience? Is it quality of care? Is it just demonstrating coordination and processes? Think about where you want to start with this. Make sure you do it prospectively. Think about how you might have a comparison group and longitudinally track outcomes. And then think about not only measuring outcomes type data, but adaptation type data. What did you have to do with your plans? How did it change in order for it to work? And what can you share with other people around that? The last goal was to put in place public and private sector policy and payment. So I said there in all of the evidence examples, none of it was based on fee-for-service. We needed some other types of payment models to help with this. And the committee struggled a lot and tried to think about was there a simple payment or policy recommendation we could put in place. And there really isn't because this is so complex. There's a whole bunch of payment and policy changes that need to occur. And we called for a whole health innovation center to try and design some of this. Haven't seen one put into place yet. So this goes back to the bookshelf or the book being the report being a book on a bookshelf gathering desk. But the tasks that we talked about, there are some changes that we're seeing occurring at a state and a federal level. So it's doing things like disseminating and advancing the vision of whole health. Partly why we're here talking today. It's defining how to measure and hold systems accountable. It's ensuring structures and processes and infrastructure. So like how do we hold EHR vendors accountable for creating interoperability and share of information across different systems and care teams. Then we need to adapt value-based payment models that aligns with delivering whole health and whole health care. And we need to think more about equitable allocation of resources. So as an example here in the U.S., we spend 18 percent of our gross domestic product on health care. And we spend 7 percent of our GDP on social care. Social care includes education from elementary through graduate school. Every other developed country is the opposite of us. They spend 7 percent to 10 percent on health care. And they spend 18 percent on social services. So we're clearly not making good choices with how we're investing in our nation. And that's part of that call for more equitable allocation of resources. But there are things you can do locally. So as we said, think about participating in experiments and demonstration projects around whole health, whole health care. Hopefully some more of these will be happening on a national level. Thinking about using your personal whole health implementation experience to try and inform your community, your system, your policy makers at the state or the county level. And then hopefully maybe at some point we can also push some of this information at the federal level where they can start making some changes. So the committee ended their report with saying that they thought whole health is a common good. It benefits everyone. And if you talk with people, the people in the communities you serve, and you explain what whole health is, this is kind of like a no brainer here. Of course we should be doing this. And scaling and spread it is going to take pretty seismic cultural, structural and process changes. And that can start with little steps. I don't think we're going to blow up the entire health care system and redesign it all in one day. It doesn't work that way. But we can start with these little steps and make the changes in our communities and in our states to try and help people better. And we're going to have to think a little bit differently, both from our policy makers, but also from our community and from ourselves. So it's a bottom up and a top down type of an approach. And it'll take a multi sector collaboration. Once again, that's multi sector collaboration both locally and nationally. So on the local level and state level, these are areas that we can make a lot of changes. So if you think across the US, we've made a lot of big changes in how we treat disease. And if you talk with most people, even though we have the worst health outcomes in the US, they think that the US health care system is the best. I think the reason they think that is because of our breakthroughs with treating diseases. If you look at NIH, they have a $50 billion a year budget, and their mission is to find and cure disease. That's their mission. FDA is to manage safe drug safety. CDC is public health. AHRQ, the Agency for Healthcare Research and Quality, is about how we deliver health care. Their budget is $500 million compared to $50 billion. And if you look in America, Americans only get 50% of the care that we know they should get for acute care, for chronic care, and for preventive care. So we're really bad at making sure people get the care that we know works. So this report is really a call to action to say that to really improve health and well-being in a meaningful way we need to think much more about how we're delivering health care to people to be much more efficient and effective and equitable so that everyone can experience whole health. So that's the report as I said it's a call to action and hopefully listening to this and with some of these resources you all can implement some of this and make some changes and know how to deal with it better and I'm going to turn this over to our next speaker. Well you know the trick to being on a really good committee is to have a really good committee chair and Alex just you know summarized two years of intensive work in 40 minutes and it was amazing. Thank you Alex and and now it's my pleasure to introduce our discussant Dr. Dilip Chasty who I know is well known in this group. Dr. Chasty is the director of global research of the Global Research Network on Social Determinants of Mental Health and Exposomics. He's president-elect of the World Federation for Psychotherapy and editor-in-chief of the International of International Psychogeriatrics. He's a former senior associate dean for healthy aging and senior care and distinguished professor of psychiatry and neurosciences at UC San Diego. He obtained his medical education in India and in the US he completed psychiatry residency at Cornell and neurology residency at George Washington. He was a research fellow and later unit chief at NIMH before joining the UC San Diego team. He's been principal investigator on a number of research and training grants. His main areas of research includes schizophrenia, neuropsychiatric interventions, healthy aging, and wisdom. He's published 15 books and many peer review journal articles. He's past president of APA and a member of the National Academy of Medicine. He also was a member of the NIMH Advisory Council and NIH Council of Councils. He was listed in the Institute of Scientific Information's list of the world's most cited authors and has been a TEDMED speaker. Particularly pertinent to what we're doing today, Dr. Chasty served as chairperson of APA's presidential task force and on the Social Determinants of Mental Health and I strongly recommend their 2022 report to you. Very much in line with what we're talking about today and it's available on the APA website. But you know, like a lot of you, I've seen Dr. Chasty on the podium. I remember his acceptance speech as president. Frankly, I remember his introduction and I was sitting there just astounded and this was a short version of what that introduction was. But I guess it was two years ago you were giving your presentation on the Social Determinants of Health and Alex and I were in the midst of trying to finalize this report and it wasn't as articulate at that stage but I went and spoke to you after you gave a presentation here and you know just wonderfully we've had this conversation ever since and here you are as our discussant. So let me turn the podium over to you Dr. Chasty and thank you. Good afternoon and thank you Harold and Alex for inviting me here to this really important session and it has been a pleasure working with Harold for many years and Alex now for the past couple of years. This report that Alex co-chaired and Harold was a member of really is one of the most important reports to come out of the National Academies. Being a member of the National Academy I know how important these reports are. This is easily one of the best reports to come out of National Academies and what I like about it is that it has practical value. It focuses on what we can do today and not just what should happen in future. So I just want to repeat this one slide about how whole health is defined. Typically if we define health most people define by the physical health and we add mental health but this talks about physical, behavioral, spiritual and socio-economic well-being and this is also important as defined by the individuals, families and communities and whole health care is for that reason interprofessional team-based approach anchored interested relationships and team well-being ensure the well-being and whole health care of team members themselves and this is increasingly important because of the fatigue that is developing among the health care workers. I think number of them are retiring and there's a shortage now of people who provide health care. I just want to talk about one paper empirical data paper that was recently published that included all three of us plus several faculty at Yale University and the VA there. This is the study of 2435 US military veterans from the 2022 National Health and Resilience in Veterans Study mean age 63, standard division of 14 years. So this has to look at the veterans health again from these multiple domains including those that were included in the National Academy's report. So the veterans reported high domain specific well-being. The mean score was 6.7 to 8.3 out of 10 and clearly that is much higher than what we would see in non-veterans and with the highest level for socio-economic and lowest in physical domain and there were several modifiable factors like purpose in life, resilience, social support that were strongly associated with the different types of well-being that were examined. So this really supports the contention behind the whole health report that if we take into account the positive things that actually will improve the health and well-being. So given that what I want to do now is talk about whole health care as it applies to psychiatry, as it applies to mental health where there are similarities and obviously there are some differences and I'm going to talk initially about this health care at the individual level and then at the community level. So at the individual level I believe that there are number of problems with our health care system as Alex mentioned. One problem is that we treat diagnosis, we don't treat the patient and that is because our health care system, the reimbursement system is based on diagnosis. So if the treatment is not connected with the diagnosis it will not be reimbursed. So sometimes people even change the diagnosis so that they can get reimbursed. This is not what the system should be and also we treat the patient. We don't ask about the symptoms and so on related to the patient. You don't ask about social factors that are important for the patient and the social determinants of health that have greater impact on health than things like hypertension, diabetes, obesity. These are factors like resilience, social connections, racism, so on and so forth. We don't ask about them, right? And this is not our fault. This is the fault of the system because the system makes us work in a specific way. Health care reimbursement focuses on what is wrong with you, what brought brought in your illness but we don't ask about what are your strengths. When a patient comes with a relapse of depression we ask about what what caused the depression. We don't ask what prevented the depression for the previous five years. Shouldn't we know that also, right? And the system prioritizes psychopathology but not well-being or social drivers of health. I don't like the word social determinant these days because determinant is a very strong term, suggestion, causation, which you really don't know. I like social drivers more than that. But really shouldn't we ask about these factors that indeed impact health? And the social determinants of health are important in general for all people but in mental health they are even more important. Some of them. Why? One, because 75% of the serious mental illnesses begin in early life. Schizophrenia, bipolar, depression, substance use disorders, they begin in childhood or adolescence. And that is why the social factors then have impact for the rest of the life. Somebody who develops cancer at the age of 65, it will have impact for the next couple of decades. Here, we're talking about the whole life. Secondly, this is the most embarrassing, one of the most embarrassing facts about the US. We have more people with serious mental illnesses in prisons and jails than in hospitals. There's no other country in the world that is like that and that really reflects on our bad health care system as well as legal system. People with serious mental illnesses die 15 years earlier than the general population. And this mortality cap has been increasing in recent decades. We published a review some time back looking at those longitudinal studies on mortality and it is increasing not because people with mental illnesses are dying more, it is because the general population is living longer. Why it is living longer? Because the health overall, you know, our nutrition has improved and other environmental factors have improved. Not for people with mental illnesses. And so we really need to think about social drivers. These include early life adversity, social connection, food insecurity, housing instability, social discrimination. So that's why I have been interested in positive psychiatry. I was the president of the APA in 1913 and my main job was to get the DSM-5 approved and published. And we did get it done but and people said that DSM is a Bible of psychiatry. DSM is not a Bible of psychiatry. Psychiatry is not just mental illnesses. Psychiatry is mental health. And we should talk not only about mental illnesses and psychopathology but also about positive mental health, well-being. And this is again what I like about the report from the National Academy. They talk about that. So positive psychiatry is the science and practice of psychiatry that focuses on study and promotion of mental health and well-being through enhancement of positive psychosocial factors like social relationships, wisdom and resilience. What is wisdom? This is an area that I've been interested in for the last 15 years. Wisdom is a unique personality trait. Wisdom is defined differently by different people. But I should mention that wisdom has been a part of all religions and philosophies. Empirical research on wisdom started in the 1970s at the Max Planck Institute in Berlin and University of Southern California. And the empirical research has been growing since then. Much of it is done by sociologists, gerontologists. But I actually my focus was among on biology including neurobiology of wisdom. The components of wisdom are compassion, self-emotional regulation, self-reflection, humility, decisiveness and spirituality. And the main areas of the brain that are involved are prefrontal cortex, especially dorsolateral, ventromedial, anterior cingulate and amygdala and the ventral striatum. Wisdom is different from intelligence. Some people with the highest IQ are not the wisest people. Sometimes they're the most unwise people. Wisdom is different because it has more than intelligence. It has these other components like compassion, emotional regulation. And wisdom has a purpose. It enhances the person's well-being and also helps the society's welfare. I'm a geriatric psychiatrist and you know people often think about aging as something that is just gloom and doom. Especially in the modern Western culture there is so much ageism. You know people talk about increasing number of older people as a silver tsunami. As if this is a disaster that is happening because of more older people are living. That's so wrong. It is not just for moral reasons but actually there are two faces of aging. There's no question physical health declines with age. Mental health improves with age overall, not in everybody. But it improves overall even in people with mental illnesses. Even people with schizophrenia, number of them start getting better as they get older. If you have seen the movie Beautiful Mind, that's a story of John Nash who got the Nobel Prize. He was diagnosed with schizophrenia in his 20s. For the next 30 years he was in and out of hospital, got ECT, insulin, coma, medication, psychotherapy. 50 started getting better. At 60 he went back to Princeton to do research. He published a paper for the first time, started teaching and there are several other example of people like that who are less famous but still they have sustained remission. And the correlates of that are resilience, optimism and other positive traits. And these are what I call beautiful minds. You know John Nash, you all know of. And then Eileen Sachs, professor of law and psychiatry at University of Southern California. Diagnosed with schizophrenia when she was an undergraduate at Yale. Now she's in her late 50s, has become a major advocate, researcher, educator, writer in advocating for mentally ill persons. Okay, so this is for at the individual level. This is even more important at community level. So when you talk about social determinants, usually we talk about the adverse social determinant. But there are also positive social determinants or social driver. The most important one is social support and positive social connection. This factor has greater impact on health and longevity than any other factor in entire medicine, period. And this is based on meta-analysis that included hundreds of studies all over the world consistently shown. Yet we really don't do much in our healthcare practice about improving, for assessing, let alone improving the health connection. Other factors that are related to social connection, being married, having a partner, parental care, school connectedness for kids, religious group activities, family resilience, community resilience, own ethnic density, especially for immigrants and minoritized groups. And then there are some community movements like compassionate community and age-friendly community. I just want to talk about social well-being. Some of you have heard of Emil Durkheim. He was a European sociologist philosopher. He, hundred years ago, more than hundred years ago, he described something called social anomie. It talks about the state of society and the state of mind that are characterized by disruption, disintegration, resulting in loneliness, depression, and suicides. So the very nice study that was published a couple of years ago, five and a half year follow-up study of UK Biobank database, which included nearly half a million UK residents. It found significant association between the local stock market index fluctuations and the participants mood, alcohol intake, and blood pressure. Not only that, but also volumetric measures of effective brain regions on MRI in a sub-sample, even after adjusting for potential confounder. So these things affect our brain and our health. And in recent decade, the big problem we are having is loneliness. Surgeon General Vivek Murthy talked about epidemic of loneliness. Actually, it's a pandemic. It goes beyond US. There are new ministries of loneliness in the UK and Japan. And they said for the last 25-30 years, the world has become much more lonely. The number of suicides in the US has gone up by 33%. The deaths from opioid abuse have increased 10-fold in 15 years, 10-fold. And these are all deaths of distress that are caused by... In the US, average lifespans fell before COVID. It fell before COVID because of loneliness-related conditions. There is some good news here, which is that we have published several papers that suggest that actually wisdom, especially compassion and loneliness go in opposite directions. People who are more compassionate, more wise, they're less likely to be lonely 5-7 years later, which means that loneliness-associated conditions will be less common in them. And again, one of the nice things that the VA is doing, as mentioned in this report, they have started something called Compassionate Care Core project. So what they do is they recruit some volunteers and teach them how to spread compassion. And then these volunteers call the veterans who have problems at least once a week and improve their compassionate relationship. I think that's a great way of handling this. This is my last slide. So we really today are living in a highly stressed, polarized, angry, anxious, depressed society. Gallup poll studies show that the average level of anxiety, depression, stress, anger, hatred has gone up 25 to 40 percent in the U.S. in the last about dozen years or so. And it's only going to get worse unless we do something different. And that something should be assessing, teaching, and rewarding soft skills of wisdom like compassion, self-reflection, acceptance of diverse perspective in the fields of education, as well as health care. And you know, there's a compassionate communities movement I mentioned. That is something also highly to be encouraged. And this is my last slide. I think we don't have a choice but to do something about that. Because then only we can transform today's lonely, distressed, polarized world into happier, healthier, and wiser society. So again, I want to thank Alex and Harold for this session. I really think it is important that we all focus on whole health. And in psychiatry, especially, I think it is even more important because of the social anomie that we are seeing. So let me stop here. And again, thank you for your attention. Well, this is a panel discussion. And I want us to apologize. Our co-presenter, Jeanette Southpaw, who was going to join us, was a co-chair. But unfortunately, she has to preside over graduation at her college. She finally took a good look at both schedules and couldn't be in both places. But we want this to be interactive. We wanted to reserve plenty of time for interacting with you folks. And let you come up to the microphone. There's one here. And we'd ask that you speak to the microphone, because the session will be recorded. But let me say, while people are maybe making their way there, and I've got a few questions also for my colleagues I might like to pose. But you may see this as visionary, chaotic. But in fact, after two years of work on this, it is not only practical, it is not only important, it's necessary. People are suffering and we're clinicians. And our system is not addressing the core elements of what is responsible for their suffering. And we can say, well, you know, but I'm a hell of a scientist and a hell of a doctor. You come in my hospital and I'll, you know, do all kinds of things. But it's not going to make you well. We have to change. And I think, going back to the title of our presentation about the biopsychosocial issue, I remember as a resident having tremendous respect for Engel's view of biopsychosocial, but not knowing how to fill out the grid that my preceptor was telling me in the social. And none of my colleagues could either. We could do the bio very well. We could do the psycho kind of well. We couldn't do the social at all. As I became a doctor, working in a clinic with hundreds of veterans that I saw over the years, it was the social issues that often kept them from even getting to the office. It was the social issues that they suffered from and that their families suffered from. Eventually, we got the Vietnam veteran readjustment study, the largest epidemiologic study ever done of a single mental disorder in its time. And what did it show? The most powerful predictor of whether someone would have PTSD after Vietnam or continue to have it was their perceived social support from their families. And, you know, I read that report. I actually reviewed it for one of the journals and I was thinking, gee, I was ready to work on their amygdalas, I was ready to give them all sorts of medications and we were doing a lot of the research, but I didn't know what to do for perceived social support from their families and that seemed to be more important than anything else we were doing. So I want to invite people up, if only to challenge us to say, well, is this really possible? Is this really necessary? I'm glad to welcome John to the podium. Great. Thank you, Harold and the entire panel. Great presentation, really enlightening. Thank you for the report and the discussion. John Bradley, I am a veteran myself and I receive all of my healthcare at the VA Boston Healthcare System where I serve as the Director of Mental Health. We've implemented the whole health model and it has been a tremendous boon in the care that we deliver and how we deliver it and I'm a recipient of it myself. My question is, what changes do we need to make in how we finance healthcare in order to make this model feasible at a population level that starts way upstream in childhood and families and communities through the school years and through a person's life to make this cost effective because prevention is the best treatment, right? And the VA is not perfect, as you point out, right? We don't treat the families. We don't necessarily address the social ills from homelessness, which we do a terrific job with, but there are many gaps that exist that have to be closed and so somebody has to pay for this, right? Great ideas, great reports don't get implemented without incentives. So I was wondering about your thoughts on how we can spread this model. Thank you. That's a really easy starting question, so I'll share that the committee spent a lot of time discussing that. It's partly why we came up with the Innovation Center idea because it probably needs many different changes depending on the location, the community, the population, the group. The VA's figured something out with how they're doing it and I think one of the things the VA has started with is identifying in that pyramid I showed at the beginning, the top more highly symptomatic people, it's easier to show return on investment in that population up front. I'm worried about that big block at the bottom, which I heard in your question there, and I'll say at least on a personal level, some of my thinking is we need to flip some of our national social spending. We need to invest in education. If we have an educated, informed population, we do better. We need to invest in the infrastructure of our communities and where we live and work and play. This includes, you know, in communities that build environmental health and can address climate change and can promote resilience and well-being and create connections and reduce loneliness. That's a really big goal. But like as an example, within Medicare, they have their Innovation Center. They already have opportunities for innovation models on alternative payments and if you can show budget neutrality, which is part of a problem with the legislation, then you can, then CMS can diffuse it nationally. That might be a lever to start with. The HRSA model on paying for federally qualified health centers, you know, could we think of HRSA-type payments that could go not just to federally qualified health centers, but other health programs that are serving communities that would benefit from whole health and whole health programs? I think the VA has done a great job of advancing the evidence, and I got to thank you and everyone else at the VA because I think you've led the way and can kind of create that culture of change where people might be willing to make those investments, but it's not an easy answer. I don't know. Well, I had a couple of different responses, too, and first of all, you know, Alex was saying we had these great two chapters. They were going to be one chapter, but they got so big on scaling and spreading they became two. I would highly recommend they were written by Harvard medical economists and Stanford medical economists and systems experts, and they actually drill down and give examples of how this could work, but, you know, during these 20 years of war that we've all been through and that you served so well in, John, and helped lead Army mental health through, in North Carolina, we set about connecting the dots between all sorts of programs, large and small health practices, major health systems, the VA, DOD health, but then we started to look into jobs and who would mow the lawn for the people when their spouse was deployed. This idea of communities of care for military children, it spread far and wide, and we brought in as disparate things as Sesame Street and just people who would drive, pick up and drive you to work because you didn't have a ride to work, and you know that not being able to get to your health appointment for transportation is the number one obstacle to, you know, compliance with care. It's not taking your medicine. It's not getting to the doctor at all. We did connect the dots. We didn't have to create the dots. We just had to connect them, and I see, you know, organic growth in this is possible once people say let's get together and connect them, and I'll mention one other thing. I think there's a hunger for this among the American people. We watch much too much CNN at home, and every other commercial is for Medicare Plus. I don't want to get into Medicare Plus, but what they're selling is very much what we're talking about. We'll get you to the gym. We'll make sure you've got good food on the table. We've got all kinds of supplements for the way you live, not just for, you know, your x-rays and how you're going to pay for them. People want this. They understand the need for it, and actually corporate America is offering them something far less than we're talking about, but I think that that demand will drive this, and the dots do exist, but I'll stop there. Great. Thanks. Really terrific presentation, both about the report and any time I get to hear Dr. Jesty talk, it's amazing. So my name is Doug Sedonis. I'm a psychiatrist focused on addiction, but in my role at work, I'm the CEO of the University of New Mexico's health system. So my question is, we have a great VA all over New Mexico, but I want to talk about the non-VA. So I was curious in the report, as you put it together, how does Kaiser fit in? So that's one model where people think there's a prevention and perhaps whole health. So I wonder how that fit in in your criteria. And then second, probably more realistic for me and others, is the partnership with the state, because the kind of social factors you're talking about, as well as the things I think about in the health system, really going to take the whole village, and so I'm curious if you saw any states that seem to be doing a better job at partnering with their health systems in it. And then I had a last question, because I did appreciate the burnout that we all see amongst our workforce, and that seemed to be the weakest link in what you described, and I don't know if there is anything you might add on that issue. So Kaiser, state, and teams. Thank you. I'll start and turn to Harold, and maybe you have ideas too, but the Kaiser we actually looked closely at, and I think the Kaiser model is a wonderful potential opportunity where you have the, already the insurer is aligned with the health care delivery. We didn't find any evidence that they had published, and some of it might also have been they're not naming programs, Whole Health, or even talking about the foundational elements of what they're doing. Kaiser is one of the insurers in my community that has advertisements now about Whole Health. They've adopted that over the past two years. So we looked there, but didn't exactly find it, but to your point, I think this idea of having setups where there's alignment between the payers and the care delivery process, that is a great opportunity to see a potential win, and I hate to wait until people hit Medicare. The Medicare advantage is great, but we need to start, to your point, much earlier in life. So I actually think thinking about how we maybe even address Medicaid, going to your statement about state alignment, Medicaid's a great opportunity since Medicaid cares for so many of the children, or is the insurance for many of the children in our states. The second one about state examples, Vermont's Blueprint for Health was one of our 13 examples. So they did a lot on a state level, and it did take state action to make it occur. It wasn't in our example, but I know Massachusetts has done a lot as well, but that's been much more around the CMS Innovation Centers and those types of payment models. Both Vermont and Massachusetts have also run into roadblocks more recently, and those roadblocks are probably something that we can learn from, where their programs are not being able to stay implemented the way they implemented it. So failures are just as important as the successes that we experience. The third one was, what was the third one again? Burnout? Oh, burnout. I'll leave that to others, but I will say there was a whole National Academy report on burnout as well, too. It was all about systems, and personally, I would even go on to say that I think one of the things that many clinicians get frustrated with and have moral injury over is not being able to care for people the way they want to. So if we could put someone in an effective whole health system, I actually think it would help a lot with burnout, but that's creating a lot to be able to deal with things. And a big finding of the National Academy report on burnout is that the biggest factor, it is our systems. It's the inefficiencies. It's the workload. It's all the things that make us have to do extra, and if you can address the system, that fixes things. Thank you for a great question, and I also worry about systems outside the VA. How can we improve the health care? I think some of the better systems are in other countries. For example, in the UK, there is social prescribing. So you refer the patient to what is called a link worker, a community worker who has knowledge about things like how to improve the transportation for the patient. It's a very specific question. Internet access, for example, is a big problem for our patient. They don't have internet access. Even if they have one, they don't know how to use internet. Somebody needs to spend some time with the patient, especially mentally ill patient. This becomes a far bigger problem. We need to help them use it, and so this needs to happen on a continual basis. Not just at baseline, because these social factors are dynamic, they change, right? So we need to have, I like what you said about Costa Rica, that everybody has a primary worker who supports, and that worker may be a social worker, any, I really think in this country we need that, and that person then should be a part of the health care system. The person should be paid for by health care system, because whatever that person finds and does should be reported to the primary care doc, and in case of psychiatric patient, the psychiatrist. They need to know what is happening, because then they can do something about that. And again, psychotherapy becomes something that must be related to the social determinant, the social factors that are occurring. So I think our current system is really very bad, especially when it comes to mental illness treatment, and we can't change it overnight, but let us start with some small models that we can. VA is a really good example, Kaiser is another good example, something like that. Let us start with some small models, see how they work, and then expand. One quick thing, though, too, like a big thing that was successful at the VA are health coaches. As far as what I've heard, whenever I talk to the VA folks, going to your question about the state involvement, like why ask every health system or every clinician or practice to create a health coach workforce? Why can't that be a statewide resource that we can all work with? There's some great things that we could think about carving out at the, that's a terrible term, because we want an integrated system, but there's some specific things that we could do at the state level that would help everyone. And you know, it's nice about a giant federal bureaucracy like the VA, is that we had to create job descriptions and credentialing descriptions and even salary descriptions for health coaches. We had to create a new discipline and standardize it across the country, and anybody else can take those and get them into their own healthcare system now, you know, the credentialing system, some of the hardest personnel issues in getting that new workforce that Alex mentioned can happen. A few quick words, a story about burnout and the whole health system. During COVID, there was, as you will remember personally, a great deal of burnout in our health systems across all disciplines. And because the whole health program had already been launched and was being piloted, people were doing better immeasurably in terms of burnout if they were working in whole health. And an interesting thing happened. At some of the medical centers, as medical center leadership, we're trying to figure out what do I do about burnout, my staff's exhausted, I'm exhausted. And they would go to the whole health program and find out what they were doing. They learned things about dealing with burnout that they then put to their entire health system with good effect. And what was nice about that is that senior executives who maybe thought burnout, maybe I should open a gym, you know, really began to understand what it takes to deal with burnout and appreciate the cost of burnout and know efficiently how to deal with burnout. What happened is that not only drove anti-burnout, but it drove whole health implementation across the medical center. Because now senior leaders who did it because my mentors in Washington are watching me and make sure that I did this, did it because it was working for them. Quick word about states, you know, I think you got some good answers and some good examples. Connecticut, I would add, Arizona, North Carolina, at least in terms of veterans, did a really good job. But think about a real problematic example, substance use in West Virginia. And where did that come from? The lack of jobs in West Virginia. Bring work back to the people of West Virginia, you'll do, I mean, buprenorphine, really important. But if you really want to deal with substance use in West Virginia, bring good jobs to West Virginia. And it's not really going to be solved until people do that. And that's employing the way of looking at things that we're urging. Hey, everyone. My name is Jeff. I'm a psychiatry resident at Cambridge Health Alliance in Massachusetts. Thus far in this conversation, I've noticed we've talked a lot about like statewide policies or Kaiser systems or like VA systems. Very much top-down solutions and big picture policy solutions. I wonder if you could comment on or talk about any bottom-up solutions that you have thought about as like a psychiatry resident with like not a lot of leadership experience or ability to change things from a top-down level. I wonder what your thoughts are on kind of bottom-up solutions. A quick response to that, for my friends. The fact is that we say over and over in the report that this level of change requires top-down and bottom-up. They're both absolutely essential. And we tell a few stories. In fact, I was criticized for telling history stories. And when we sent the thing out for review, they said, tell more history stories. So I felt very good about that. But these include the story of the most important mental health innovation in American history, which was the mental hygiene movement of the early 20th century, which led to community guidance clinics, which led to the mental health associations, now Mental Health America, led to the development of combat stress control in World War I, and led to the founding of many departments of psychiatry in America, Columbia University, for example, the New York State Psychiatric Institute come out of this. And so these were all bottom-up movements. They actually started with a man who had a psychotic illness and ends up in a psychiatric hospital writing his autobiography. This is Clifford Beers, A Mind That Found Itself. It became a national bestseller. People realized, well, it's what Clifford Beers wrote his book to say. If this could happen to me, this could happen to anyone or someone you love. So what are you going to do about it? And people got together at every level of society in America and decided there were things they were going to do about it. And Clifford Beers, William James, and Adolph Meyer together started the National Committee and the world changed, bottom-up movement. Maybe I'll give one simple thing, thinking for residents. And I was at a conference a couple weeks ago talking about this, and I saw this wonderful poster a woman did in her practice where she started asking people what matters most. And she taught her partners how to ask that. And one interesting thing about this committee, so I'm a family doctor and I was asked, hey, will you serve on this whole health? I'm like, of course, I know whole health. I'm a family doc. I do whole health. I didn't really know whole health. We changed a lot over these two years in putting the report together. And I went and I started asking my patients what mattered most. Most of my patients are my neighbors. I thought I knew it, but I didn't. And it's a hard question to ask, but thinking about that person-centered element and how do you really tailor what it is, even on that one-on-one. I know we're talking about big systems changes, but sort of making that goal and the mission and adopting it, making the personal cultural shift on how to think and act differently, asking more about social needs and other factors that we might not always think about asking, or even talking to someone about, well, okay, so you have issues with transportation. What does that mean for you? Is that a problem? And what do you need to do to address it and other things? So there's a number of these different cultural shifts that you can even implement on an individual level, even if your system or your practice or your state or the federal government doesn't do anything. I agree with you that really the bottom-up is really important. And as you said, of course, both are, because I think the top-down is much less likely to happen in very near future. That's a big problem with the social determinant. I mean, ideally, if we could eliminate poverty, racism, homelessness, food insecurity, we'll be a happy society. Will that actually happen? I doubt it, because of the various other political, economic issues that are there. We need to do something at the bottom level. We need to do something to an individual patient that we see in our practice every day. A patient deserves care and not wait for the next five years until the socioeconomic system changes. And so we need to really listen to what the patient is saying. At the same time, I think one difference between sort of other patients and psychiatric patients is that if you're looking at severely mentally ill patients, what the patients themselves say may not be useful. A person with schizophrenia doesn't have insight, says, I don't want treatment. Then really the patient should, we should decide whether he gets treatment or not based on what the patient is saying. So here we need to take into account what the family says. So the family also becomes an important part of that. But really we need to find some solutions at that level. And there's not one permanent solution. It will change because of the changing circumstances. But I agree that this kind of bottom-up change is what we must do as clinicians, as patient carers. We don't have a choice and not wait for the top-down. And you know, we'll have to stop in a second. But just to say, if when you get back into your offices later this week or next week, if you were to start asking your patients about, oh, you know, you're here, I can tell you some numbers and check your meds. But I want to ask you, in your life, what really matters to you in terms of your health? You know, what are the most important things in your life right now? What concerns you? You start with that. If they need something and you don't know how to get it, you can call 988. You can call, check the United System, Unite Us system online. You can go to the National Resource Directory, find employment, housing, education, training. But if those people can't help you, you should write to them or work with them and find out, why couldn't you help me? That was a question you were supposed to know the answer to. How do we create these networks? It can start with each of you. And the more you learn about it, I think the more you'll join us in advocating for it. So thank you very much. Thank you to the panel. And let's see where we are a year from now.

whole health

biopsychosocial model

integrated care

mental disorders

PTSD

trauma prevention

social determinants

VA Whole Health program

health care transformation

resilience

positive psychiatry

social connection

workforce burnout