Passport to Whole Health: Chapter 19
Chapter 19. Whole Health and Community
Health starts where we live, learn, work and play
―Robert Wood Johnson Foundation
The Importance of Community
Encompassing all the other areas within the Circle of Health is the outermost circle, Community. All elements of Whole Health—including “Me” at the center, self-care, and professional care—happen within the context of and uniqueness of a larger community. The Community circle encompasses and underlies all the others; community is fundamentally important to all aspects of health and well-being. It is the largest ring in the Circle of Health for a reason—it has global impact.
Community refers to the spaces in which we live, the resources we have available to us day-to-day, and our relationships with others in our broader environment. Community includes our culture, our social systems, our history, and our surroundings. It is the larger framework in which health is supported or, conversely, challenged. Health does not start in the VA, though VA certainly makes important contributions; it starts in our homes, our schools, our workplaces, and our neighborhoods.
One person may be a member of many communities for many reasons. Some examples include:
- • Upbringing: family networks, spiritual practices or groups, childhood experiences (adverse or not);
- • Interests: professional pursuits, activities, or clubs.
- • Location: neighborhood, local communities, cities, counties, regions, nations, and other geographical cultures.
Our relationship with the people, places, and resources in our communities shape how we perceive ourselves and the world around us. Personal identity, or "Me" in the center of the Circle of Health, is often understood through the reflection of community, or "We."
Without the “We” aspect of healing, Whole Health—and all health care—would be very limited. The health of one’s community is essential to the promotion of health for those within it. Community shapes our ability to engage in healthy behaviors and pursue what matters to us.
It adds to the richness of the Whole Health approach if we move through the different components of the Circle of Health once more, this time looking at them through the lens of Community.
Me: Personalizing Care Through Understanding Context
Conventional care often focuses on the individual, exploring what is going wrong inside the body. This is important, but people do not exist in a vacuum; the behaviors of the molecules inside our body are affected by all sorts of things outside of us. “Personal identity” is actually defined by how we define ourselves in relationship to the communities to which we belong. Even focusing just on the innermost “Me” in the center of the Circle of Health, we begin to see how influenced we are as individuals by our context. For example, when a person is asked, “What really matters to you?” they frequently respond that it is the others in their lives who matter most. Our different communities—and the beliefs, values, and norms we gain from these communities—strongly influence our Mission, Aspiration, and Purpose (MAP).
Whole Health builds on the interconnectedness of health factors and opens the door to discuss not only Veterans’ health conditions, but the larger conditions that impact their health and well-being. Attunement to context has a significant impact on quality of care and prevents medical errors.2 It reconnects us to Whole Person care. There are some striking parallels between how the Whole Health approach can emphasize a person’s connecting with community and how the Recovery Model also does this in mental health.
Part of personalizing care is being aware of context, including the factors that shape a person’s life and what matters to them. It is not essential that we know every detail about our patients’ histories, their value systems, or their day-to-day lives, but it is important that we remain open to considering, understanding, and appreciating those factors. To attain the highest level of health for all people requires focused and ongoing efforts to address healthcare barriers.
There are countless ways one’s relationship within Community can affect how they engage in their health care. Consider these two Veterans, each of whom presents for a primary care appointment in the VA.
- The first Veteran arrives early and is accompanied by a family member, having driven from home nearby. The Veteran is retired and service-connected, and he schedules his appointments around his personal travel schedule. He has had good relationships with VA staff in the past, and he enjoys volunteering with a Veteran Service Organization.
- The second Veteran arrives a few minutes late because the second bus he took to get to the VA was running slow. He has no family support and is struggling to pay his bills. He is concerned that he will be charged a co-pay for this and future appointments. He has avoided care because his service was cut short by an injury during Basic Combat Training. He feels marginalized in the Veteran community.
Imagine how different these Veterans’ appointments could be. Each Veteran is likely to have differences in how they perceive health care, experience trust with staff, and in their willingness to partner on health goals. These contextual factors have as much impact on their engagement with and desire to follow a Personal Health Plan (PHP) as any of our health care recommendations. And as we will see, these factors impact Veteran experiences in other areas of health as well.
The following is a small sample of context-related questions you may ask yourself about each of the patients you serve to support them more effectively as they set shared and SMART goals:
- Does the Veteran have access to a given therapy or practitioner? Do they have transportation? Is there a long wait to schedule a visit?
- Can they afford the therapy, or is it financially covered in some other way?
- Do they have the skills or health literacy to follow through with the plan?
- Do their various illnesses prevent them from achieving their goals? (For example, substance use disorder, chronic pain, severe mental illness, and/or dementia can be impediments to success.)
- Can someone else help this person keep track of their schedule, get them to their appointments, or offer them moral support?
- What circumstances are present in the Veteran’s life that may be impacting their health and well-being? What Social Drivers of Health (SDOH) are relevant to their situation?
- How are the Veteran’s care options affected by the health care system in general?
- Do cultural, religious, and other factors have the potential to support healing or interfere with it?
- Does the PHP take into account what they have already tried?
It can help to have a sense of various facts about SDOH as you consider those questions. As defined by the US Department of Health & Human Services Office of Disease Prevention and Health Promotion (DPHP), SDOH are defined as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality-of-life outcomes and risks.”71 Examples include availability of resources, access to educational and job opportunities, transportation, education quality, public safety, social support, norms and attitudes, language, literacy, access to technology, culture, and availability of health care and community-based resources. By understanding how to address social drivers of health, you are better equipped to learn the whole story about the Veterans you serve.
Research suggests that an individual’s health is heavily influenced by their community and its impact on the individual’s behavior.72 In fact, this recognized and validated model from the University of Wisconsin Population Health Institute (Figure 19-2) demonstrates that of the factors we can control to shape health, 80% of health outcomes are determined by social, economic, environmental, and behavioral factors.69 For example, a 2019 VHA survey of nearly 44,000 Veterans showed those with earnings of less than $35,000 a year reported poorer overall physical and mental health, noted they received lower levels of social and emotional support, and said they were less likely to feel they had a purposeful and meaningful life.73 On the other hand, greater purpose in life has been associated with improved mental and physical well-being, better quality of life, and even longer life.
Additionally, those making less than $35,000 are three times more likely to smoke, have higher rates of obesity, and are less likely to meet guideline-recommended levels of physical activity compared to other adults. 73 Income and economic stability are arguably some of the most important social drivers of health. People with steady employment are less likely to live in poverty and more likely to be healthy, but many people have trouble finding and keeping jobs.74 Further, economic stability is often determined by employment which drives income and access to benefits for retirement savings, health insurance, and the ability to pay for basic necessities such as nutritious food, housing, childcare, healthcare, and transportation.74 People with disabilities, injuries, or chronic conditions like arthritis may be especially limited in their ability to work.71
As this discussion about Community applies to our patients, so too does it apply to clinicians. We bring our own experiences, our culture, our stressors, our values, and our assumptions into our therapeutic relationships. We can be more effective healers when we acknowledge the unique attributes we bring to our relationships with Veterans.
Mindful Awareness: Noticing Our Mental Models
- Approaching Veterans with cultural awareness and humility requires that practitioners be humble about their level of knowledge about a Veteran’s beliefs or values, be aware of their own personal assumptions and recognize the inherent power imbalance in a patient-provider relationship and aim to treat the whole person by learning about their background.
Social Drivers of Health and Self-Care: How Community Ties to Health Behaviors
As noted above, the DPHP’s Healthy People 2020 Initiative defines SDOH as the social and physical environments that impact a person’s health. To truly be holistic in its scope, a Whole Health system focuses on bringing SDOH into the health care partnership and PHP process. Unfortunately, social risks seem to cluster among the same people and accumulate for them over time. Strategies for reducing the negative effects (and enhancing positive ones) related to SDOH can have a profound impact. Figure 19-4 links SDOH to health outcomes, putting their influences into context with other factors that also influence length and quality of people’s lives. Note that only 20% of health outcomes are attributable to Professional Care; the other 80% are tied to social, economic, environmental, and behavioral factors. Asking about these other aspects of health can potentially enhance Veterans’ (and everyone’s) Whole Health.
Each of the eight areas of self-care is influenced by—and influences—Community in different ways. What follows are some examples related to each one. For more information, go to the specific chapters about each of these different areas (Chapters 5-12).
Moving the Body
- Neighborhood safety, sidewalks, lighting, and accessibility features influence people’s options to walk, move, or exercise outside.
- Community green spaces and parks promote physical activity.
- Financial resources influence people’s abilities to buy gym memberships, purchase exercise equipment, and engage in organized recreational activities.
Surroundings
- Health hazards such as mold, infestations, lead contamination, poor air quality, and allergens are much more likely to be found in low-income housing.
- Low-income populations have increased risk for pollution exposure, which affects health outcomes.
- Living near a park is associated with lower obesity and other favorable health outcomes.
- Better public transportation is linked to better attendance of medical appointments.
- Members of isolated communities have higher infant mortality rates and poorer mental health.
- Crime and safety make a huge difference, as does one’s personal experience with incarceration.
- Resources such as benches, sidewalks, and ramps play a huge role in people being able to engage with their surroundings.
Personal Development
- A lack of educational opportunities has long-lasting negative consequences, including reduced earning potential.
- Without education and rewarding, stable employment, people are often ill-equipped to make healthy choices. Every year of education a person has is tied to better health outcomes and behaviors.68
Food and Drink
- 40 million Americans experience food insecurity, meaning their access to adequate food is limited by a lack of money or other resources.
- Food insecurity is linked to a higher likelihood of many health problems, including, being overweight.
- Alcohol, smoking, and other substance use disorders are more common among people who have markers of social and economic disadvantage, such as poverty, severe mental illness, or less than a high school education.
Recharge
- Home is an important place to recharge, and it can be compromised when one lacks decent, safe housing.
- Socioeconomic status affects a person’s ability to pursue leisure activities and hobbies.
- Crowded and/or noisy living conditions can limit one’s ability to find solitude or be recharged.
Family, Friends, and Co-Workers
- Social networks have a significant influence on beliefs and behaviors, both in positive and negative ways.
- Social standing impacts opportunities we are afforded and our own self-efficacy.
- Loneliness and low community involvement have a huge impact on morbidity and mortality.
Spirit and Soul
- Faith-based organizations can help inform people about prevention, promote healthy behaviors, and link people to prevention resources through programs and partnerships. They can also promote safer and more connected communities, preventing injury and violence.
- Places of worship can also provide space for organized pro-social activities .
Power of the Mind
- Repeated and prolonged exposure to environmental and social stress activates our sympathetic nervous systems, which increases risk of chronic disease.
- Social risks can be important drivers of suicide, and interventions focused on community engagement and public health actions show promise. ,
Professional Care: Healthy Health Care Communities
Professional Care only succeeds in a community if it is of good quality and if people have access to it. It takes a village to do Whole Health. That village includes health care providers and other clinical team members, as well as staff, a patient’s loved ones, and the patient. It also includes practitioners of various CIH approaches; access to these services varies greatly from one community to the next, and resources like Telehealth can help remove some of the disparities with access.
When we explore Whole Health, the scenario that first comes to mind for some people is a clinical, or one-on-one, encounter. A patient, perhaps with loved ones, visits with a clinician or perhaps several members of a team and co-creates (or elaborates upon) a personal health plan that supports MAP. However, beyond the one-on-one efforts, care becomes most effective when we can integrate community into it. Policy makers, public health officials, pentad members, and administrative leaders have a critical role in moving Whole Health forward in their facilities and local communities. Without leadership working alongside frontline staff, Whole Health cannot fulfill its maximal potential.
Leadership and advocacy. Buy-in from leaders makes all the difference in terms of whether clinicians, Whole Health Partners, Health and Wellness Coaches, and others can fully offer their expertise. Meeting with leaders in your facility is as important to promoting Whole Health as talking to a patient about healthy behaviors. If something is not going well, or if obstacles are compromising your ability to offer Whole Health, seek help and support. Write your Congressperson. Talk to your supervisor. Step up on behalf of your Veterans. Engage in activities such as voting, getting involved in your local community, and working with medical advocacy organizations to practice social responsibility.
Program evaluation. Many people shy away from quality improvement efforts but asking what can be done to improve programming or to evaluate how a program is doing in terms of outcomes measures can weave in community resources and contribute to an environment more supportive of Whole Health.
Engagement and partnerships. A powerful ally on the team is a social worker or someone else versed in what programs, classes, and support mechanisms are available not only in the VA, but at the community, county, state, and national level. There are many communities that have programs where volunteers offer free or discounted services specifically for Veterans, such as acupuncture, yoga classes, or even house cleaning services. Your VA Medical Center’s Health Promotion and Disease Prevention Program Manager is another good resource for VA and community programs and resources. A link to a full directory of Veterans and Military Service Organizations is featured at the end of this chapter. The VA website features information about Community Care Networks, particularly important now as the MISSION Act has gone into effect. It may help to promote non-clinical services that may help to address SDOH deficits, such as Vocational Rehabilitation, and Recreational Therapy. They offer a number of resources, including fact sheets, learning series, and local data that can be useful to Veterans and health care professionals alike.
Beyond Self-Care and Professional Care: The Community at Large
In the highly varied and numerous communities in which we live, there are multiple complex systems that influence the health of individuals in those systems. The following larger-scale influences on one’s Whole Health might not be mentioned explicitly in a clinician-patient encounter but also have a profound influence:
Public health. Each of us benefits from measures to contain diseases like tuberculosis, or to vaccinate against diseases that would otherwise harm entire populations of people. For example, smoke-free laws for bars, restaurants, and workplaces reduced hospitalizations by 8-17% in a year.
Policy. Laws exist to keep people safe in any number of ways. The Whole Health approach continues to expand because of legislation, funding, and support from leaders at the national, VISN, and local leadership levels.
Wise use of resources. The U.S. is the only country in the “developed world” that spends more of its gross domestic product on health care than on social services. Consider these statistics:
- The U.S. spends more on health care than any other country, but our life expectancy and overall health rate lower than many other countries’.58
- U.S. clinicians order many more diagnostic tests than most countries, and many of these tests are not needed to determine care outcomes.
- Americans visit the doctor fewer times per year than people in most other countries (especially the wealthier ones), but care is still much more expensive.
- A 2003 study concluded that adults living in 12 metropolitan areas in the U.S. only received about 55% of the medical care that was recommended for them.
- In 2011, one-third of American households said they had trouble paying their medical bills.
- 165,000 Americans died due to overdoses of prescription opioids between 1999 and 2014. Meanwhile, 83% of the world’s population has no access to opioid pain medications, largely because they are all being consumed in the U.S.
- Lack of insurance is, unsurprisingly, linked to poorer care, poorer health status, and premature death.
SDOH-Related Initiatives in VA
Addressing Circumstances and Offering Veteran Resources for Needs (ACORN). In April 2024, the VHA Governance Board endorsed ACORN as the standardized social risk screening tool for VHA. This tool can help meet The Joint Commission Standards, and it aligns with both VA’s strategic objectives as well as the Office of Inspector General (OIG) report. According to VHA’s Office of Health Equity, “Currently, VA medical centers are not required to broadly screen Veterans for social risks and social needs beyond the existing VA clinical reminders for housing instability, food insecurity, and intimate partner violence. For facilities that do choose to screen for social risks and social needs more broadly, ACORN is the required standardized screening tool.”
ACORN identifies health-related social needs and connects Veterans to resources to support them. Teams conduct environmental scans to identify local resources for each area of the ACORN screener, to facilitate rapid connection to VA and community resources. The nine domains covered are: housing, food, utilities, transportation, legal, social isolation and loneliness, employment, education, and digital needs. A national template is available, as well as a national Community of Practice to support sites interested in launching this. Additional information is available at https://dvagov.sharepoint.com/sites/VACOVHAOHE/SitePages/Social-Determinants-of-Health.aspx
VA Homeless Programs: VA’s Implementation of the Housing First Approach
Housing First is an evidence-based approach to supporting the chronically homeless population who often also have co-existing mental health and substance use disorders. Housing First takes the approach of providing housing as a critical tool in recovery, rather than requiring sobriety or abstinence prior to gaining access to housing. Through its Housing First approach, VA has seen over 52% reduction in Veteran homelessness since 2010. This reduction is especially impressive as rates of homelessness in the general population have been significantly increasing in recent years .
VA’s approach has included rapid expansion of HUD-VASH but also increased Veteran access to programs such as Health Care for Homeless Veterans (HCHV) Contracted Residential Services emergency shelter, Grant and Per Diem (GPD) transitional housing and Supportive Services for Veteran Families (SSVF) rapid rehousing. Indeed, the emphasis on eliminating enrollment preconditions and expediting placement into housing is generally considered within VA to have contributed to shorter lengths of stay among transitional housing providers, maintaining or sometimes improving the rate of exit to permanent housing and increasing access to SSVF for Veterans who may not have income or may still struggle with minor substance use disorders or moderate mental health conditions.
Link: VA’s Implementation of Housing First Over the Years - VA Homeless Programs
Additional examples of SDOH-related efforts:
- Be Connected. This program enlists a web of community support to help reduce Veteran deaths by suicide with three components they refer to as Call, Match, and Learn. The 24/7 Be Connected Call Program offers access to a support line. The Match program links Veterans and their families to different resources. The Learn program trains VA and community providers, including first responders and legal professionals around building networks of care, services, and support.
- Joining Hands, Feeding Veterans. This program, offered by the Central Texas Veterans Health Care System, works to address food insecurity, noting that the Supplemental Nutrition Assistance Program (formerly the food stamp program) doesn’t always fully meet people’s needs. The VA system partnered with the Central Texas Food Bank and has provided food to over 400 Veteran households in Austin and Temple. The project involves mobile food pantries and brings together an array of food suppliers and financial donors in the region.
Engaging in our local communities, as well as at the larger state, national, and even global levels can bring Whole Health to all levels of care. Clinicians can bring awareness to these different levels, and Veterans must do so as well. When all is said and done, we are all patients and we are all members of the larger community. We all benefit from a healthy system and we all suffer under a broken one. On the positive side, as individuals, our own Whole Health favorably influences the health of others in our community. Truly, as the Irish proverb puts it, “It is in the shelter of each other that people live.”
Putting It All Together: Personal Health Planning Using the Power of Community
During a Whole Health encounter, when Veterans focus on what matters most to them, the power of Community can become highly relevant. Consider how you might explore this with them—and for yourself—more fully. Often, it is simply changing the conversation in particular ways. Here are some examples of questions you could ask and suggestions you could make, when you are discussing Community in relation to someone’s MAP:
- How do you define Community? What community or communities do you identify as belonging to?
- How well are you integrated within your different communities?
- What potential opportunities do you have to connect more broadly? What barriers do you experience?
- Which community resources do you think you might benefit from tapping into? Would you be interested in learning about more options?
- What particular knowledge, experience, skills, or interests do you have that you could help others by sharing? How might you give back to your community or communities?
- What are some challenges faced by a community you belong to? How do you personally experience these challenges?
- Do you have the basic things you need, like clothing, heat, food, clean water, shelter?
- Tell me about the struggles in your life. How have they affected your health, or your family’s health?
- What would be important for me, as your clinician, to know about you, given that my background may be different than yours?
- What are some barriers to you achieving your health and well-being?
- What is one small change you would like to make in your life? The self-care chapters in this Passport (Chapters 5-12) feature subtopics to consider, and all of them feature one called “Make One Small Change.” If it feels appropriate or empowering, is there something related to Community that you would like to make one small change?
As with all the elements of Whole Health, these questions are also relevant for your own self-care—for care of the caregiver. Spending time with them can deepen your own Whole Health journey, too.
Wrapping Up
On that note, we have reached the conclusion this final chapter, and of our journey around the Circle of Health. Best wishes as you bring the various elements of the circle into your practice, and best wishes as you enhance your own personal Whole Health as well. May this Passport to Whole Health point you in new and valuable directions, so that you and the Veterans in your care can achieve things you previously did not think were possible! May you and all those you serve steadily move forward with all of your “MAPs” as you continue on your Whole Health Journey.
Special thanks to Codi Schale, PhD and Adrienne Hampton, MD for their significant contributions to the content of this chapter, as well as to Greg Serpa, PhD for guidance around mindful awareness research.
