Modifying Whole Health Services for Successful Telehealth Delivery: Lessons from Veterans Health Administration's Rapid Transition During the COVID-19 Pandemic.

Introduction: The Veterans Health Administration (VHA) is shifting care from a disease-oriented to health-creating approach that aims to provide whole person care. This Whole Health (WH) system combines person-centered care with delivery of WH services (e.g., health coaching, well-being education and skill-building classes, and evidence-based complementary and integrative health therapies), alongside conventional medical services. During the COVID-19 pandemic, WH services were modified for delivery through telehealth (teleWH). This article characterizes modifications to WH services made to maintain continuity during the transition to telehealth formats. Materials and methods: We conducted semistructured qualitative interviews with a purposive sample of 51 providers delivering teleWH services at 10 VHA medical centers. We examined WH service modifications as well as facilitators and barriers to those modifications using rapid coding and directed content analysis. Results: Modifications were driven by (1) preparing for teleWH service delivery and (2) improving teleWH service delivery. To prepare for teleWH services, modifications were prompted by access, readiness, and setting and resources. Modifications to improve the delivery of teleWH services were motivated by engagement, community-building, safety, and content for a teleWH environment. One-on-one teleWH services required the fewest modifications, while more significant modifications were needed for well-being, skill-building, and movement-based groups, and reconfiguration of manual therapies. Discussion: Findings highlighted the need for modifications to ensure that teleWH services are accessible and safe and support interpersonal relationships between patients and providers, as well as in group-based classes. Successfully delivering teleWH services requires proactive preparation that considers access, readiness, and the availability of resources to engage in teleWH services. Tailoring strategies and considering the unique needs of different teleWH services are critical. Conclusions: The COVID-19 pandemic catalyzed teleWH service implementation, utilization, and sustainment. The challenges faced and modifications made during this transition provide lessons learned for other health care systems as they attempt to implement teleWH services.

Promoting Whole Health and Well-Being at Home: Veteran and Provider Perspectives on the Impact of Tele-Whole Health Services.

Background: The Veterans Health Administration (VA) is undergoing a transformation in how healthcare is organized and provided. This transformation to a Whole Health System of Care encompasses the integration of complementary and integrative health services, education, and Whole Health coaching to develop Veterans' self-care skills. During the COVID-19 pandemic, these services were provided via telehealth (tele-WH). Objective: We sought to understand Veteran and provider perspectives on how tele-WH impacts Veteran engagement in Whole Health-aligned services and the impact on their well-being. Methods: Semi-structured interviews were conducted with 51 providers who delivered tele-WH at 10 VA Medical Centers (VAMCs) and 19 Veterans receiving tele-WH at 6 VAMCs. Participants were asked about their experiences with tele-WH, what they perceived to be the impact of tele-WH on Veterans, and their preferences moving forward. Interviews were transcribed, and a content analysis was performed using a rapid approach. Results: We identified 3 major themes that describe the perceived impact of tele-WH on Veterans. These include: (1) increased use of Whole Health-aligned services; (2) deeper engagement with Whole-Health aligned services; and (3) improvements in social, psychological, and physical well-being. Conclusion: Tele-WH is perceived to be a strong complement to in-person services and is a promising mechanism for improving engagement with Whole Health-aligned services and promoting Veteran well-being. Future research is needed to measure outcomes identified in this study and to support more equitable access to telehealth for all.

Telemedicine in Diabetes Care.

Telemedicine can be useful for the management of diabetes mellitus. Remote monitoring of glucose levels improves A1C levels in people with poor glucose control. When multiple daily injections of insulin are required, continuous glucose monitoring improves glycemic control and increases patient satisfaction. Telemedicine diabetes prevention programs can be cost-effective. Teleretinal screening allows for the remote evaluation of retinal photos obtained at the primary care office to facilitate the timely completion of annual screening. Telemedicine for patients who have diabetes requires administrative and patient preparation before the visit. The physical examination should focus on the skin and extremities, especially the feet. Patients receiving telediabetes care require at least annual in-person visits for complete foot examinations, sensory screenings, and to address issues noted during previous telemedicine visits.

Tele-Integrative Medicine to Support Rehabilitative Care.

Complementary and integrative health (CIH) modalities have therapeutic value in the multidisciplinary rehabilitation of chronic pain patients. Evidence of such has been seen with the Whole Health Model at the (Veterans Affairs) VA Healthcare system. CIH therapies, including yoga, tai chi, mindfulness meditation, hypnosis, self-massage, and acupressure, are significantly effective for managing chronic pain with little to no negative effects, and can be easily incorporated into telemedicine care with great potential benefit. The future of wellness in telemedicine is evolving with great potential, and needs further attention to addressing barriers of care.

The Use of Vitamins, Supplements, Herbs, and Essential Oils in Rehabilitation.

The term, dietary supplement, refers to a broad category of products, including herbal or plant-based extracts, micronutrients, and food-based nutraceuticals. The use of supplements in clinical rehabilitation requires clear communication from patients and health care providers to understand the types of products used and their effects on health. Providers should distinguish between using micronutrient supplementation for therapeutic purposes and treatment of nutritional deficiency in patients with malnutrition syndromes. Evidence supports micronutrient and nutraceutical supplementation use to improve pain, functional status, and inflammation. There is little evidence on the use of herbal or plant-based extracts in therapeutic rehabilitation; larger studies are warranted.

Impact of a 10 minute Seated Yoga Practice in the Management of Diabetes.

OBJECTIVE: We sought to prospectively evaluate the impact of a 10 minute seated yoga program added to standard comprehensive diabetes care on glucose control and cardiovascular health in the severely ill, medically complex diabetic population. METHOD: A total of 10 patients with type 2 diabetes, ages 49-77, with duration of diabetes >10 years and haemoglobin A1C >9% (75 mmol/mol) were included in the study. Patients randomized to a yoga intervention were taught a 10 minute seated yoga practice, were given an explanatory DVD and a fold-out pocket guide to encourage adherence at home, and were instructed to incorporate the practice as often as they could. The patients in the control arm were provided information and hand outs on the available yoga classes on campus. RESULTS: At 3 month clinical follow up, the mean decrease in fasting capillary blood glucose (CBG) was 45% among yoga participants (-5.2 ± 4.1 mmol/L). Heart rate (HR) dropped by 18% and Diastolic blood pressure (BP) dropped by 29% in the intervention arm, (-12.4 ± 6.69 and -26 ± 12.05 mmHg, respectively). There were no statistically significant changes in the haemoglobin A1C, systolic blood pressure, weight, or body mass index in either group. CONCLUSION: Our small pilot study reinforces the current medical evidence supporting the use of yoga, combined with standard care, to improve health outcomes in diabetes.