Radical Redesign of Health Care


GAUDET: HI. I’M TRACY GAUDET, AND I’M THE DIRECTOR
OF THE OFFICE OF PATIENT CENTERED CARE
& CULTURAL TRANSFORMATION, AND I’M REALLY GLAD
TO BE WITH YOU TODAY TO TALK TO YOU ABOUT
REDESIGNING HEALTH CARE TO PROMOTE ONE’S WHOLE HEALTH,
SO THE FIRST THING I WANT TO SAY FOR CONTEXT IS THAT
THE VERY ASSUMPTIONS UPON WHICH HEALTH SYSTEMS WERE
DESIGNED ARE NO LONGER VALID. LIKE EVERY OTHER SYSTEM
THAT’S EMERGING FROM THE REDUCTIONISTIC PARADIGM AND TRANSFORMING
INTO A SYSTEMS APPROACH, HEALTH CARE NEEDS TO BE
RADICALLY RE-ENVISIONED AND REDESIGNED. THAT’S WHAT WE’RE GONNA
TALK ABOUT TODAY. THE IHI, THE INSTITUTE
FOR HEALTHCARE IMPROVEMENT, IS CALLING FOR THIS,
IN THEIR LANGUAGE, NEW RULES FOR THE RADICAL
REDESIGN OF HEALTH CARE. I THINK IT’S FASCINATING
IF YOU LOOK AT THEIR RULES. THERE ARE 10 OF THEM,
BUT I’VE HIGHLIGHTED 4. FIRST,
CHANGE THE BALANCE OF POWER. CO-PRODUCE HEALTH AND WELL-BEING
IN PARTNERSHIP WITH PATIENTS, FAMILIES,
AND COMMUNITIES. SECOND, CUSTOMIZE
TO THE INDIVIDUAL, AND I THINK THIS IS AMAZING
IF YOU LOOK AT THEIR LANGUAGE. CONTEXTUALIZE CARE
TO AN INDIVIDUAL’S NEEDS, VALUES, AND PREFERENCES
GUIDED BY AN UNDERSTANDING OF WHAT MATTERS TO THE PERSON IN
ADDITION TO WHAT’S THE MATTER. SOUND FAMILIAR? THIRD, PROMOTE WELL-BEING. FOCUS ON OUTCOMES THAT MATTER
THE MOST TO PEOPLE, APPRECIATING THAT THEIR HEALTH
AND HAPPINESS MAY NOT REQUIRE HEALTH CARE, AND FOURTH, CREATE JOY IN WORK. CULTIVATE AND MOBILIZE
THE PRIDE AND THE JOY OF THE HEALTH CARE WORKFORCE, AND THAT’S WHAT WE’RE UP TO
HERE IN THE VA, SO THE VISION IS CLEAR. WE HAVE ROBERT WOOD JOHNSON
CALLING FOR A TOTAL
TRANSFORMATION AND A SHIFT TO A CULTURE
OF HEALTH. WE HAVE THE IHI CALLING
FOR 100 MILLION HEALTHIER LIVES, LOOKING AT EMOTIONAL, SPIRITUAL,
AND PHYSICAL WELL-BEING. WE HAVE KAISER PERMANENTE, WHO
STOOD UP A WHOLE NATIONAL EFFORT THAT THEY’RE CALLING
TOTAL HEALTH. THE SURGEON GENERAL– WE RECENTLY DID AN EVENT
WITH THE U.S. SURGEON GENERAL FOCUSED ON EMOTIONAL
WELL-BEING, SO EVERYONE AROUND THE NATION
IS CALLING FOR THE SAME FUTURE STATE,
WHICH IS GREAT. ATUL GAWANDE–I LOVE HIM–
ONE OF HIS QUOTES THAT I THINK CAPTURES THIS
REALLY WELL– “WE’VE BEEN WRONG ABOUT
WHAT OUR JOB IS IN MEDICINE. “WE THINK OUR JOB IS TO ENSURE
HEALTH AND SURVIVAL, “BUT REALLY,
IT IS LARGER THAN THAT. IT IS TO ENABLE WELL-BEING,
AND WELL-BEING”– I LOVE THIS LINE–
“WELL-BEING IS ABOUT “THE REASONS ONE WISHES
TO BE ALIVE. “THOSE REASONS MATTER
NOT JUST AT THE END OF LIFE OR WHEN DISABILITY COMES,
BUT ALL ALONG THE WAY,” AND I THINK HE SAYS IT
REALLY WELL. LET’S STOP FOR A SECOND
AND ASK WHY. WHY SHOULD WE BE ENTERING INTO A COMPLETE REDESIGN
OF HEALTH CARE? WELL, IT DOESN’T TAKE LONG
TO FIGURE OUT THAT OUR HEALTH CARE
IN THE NATION IS IN A FULL CRISIS,
EVERYTHING FROM THE ECONOMICS– THE HEALTH CARE CONSUMES
18% OF OUR GDP, AND THAT’S CRIPPLING OUR ABILITY
TO COMPETE GLOBALLY. CHRONIC CONDITIONS ARE THE VAST
MAJORITY OF THOSE COSTS, ABOUT 75% OR SO, AND WE KNOW
THAT CHRONIC CONDITIONS ARE REALLY LARGELY IMPACTED
BY PEOPLE’S HEALTH AND LIFE AND THEIR CHOICES THEY MAKE
DAY TO DAY. THE BOTTOM LINE IS THIS. THE CURRENT HEALTH CARE MODEL
DOES NOT WORK BECAUSE WE DO NOT HAVE
A CORE COMPETENCY. WE’RE NOT DESIGNED
TO SUPPORT PEOPLE IN ADDRESSING THE THINGS
THAT MOST IMPACT THEIR HEALTH AND WELL-BEING. IT’S NOT OUR FAULT.
IT’S NOT DESIGNED THAT WAY. I THINK IT’S REALLY INTERESTING
TO THINK ABOUT WHY– HOW DID WE GET HERE? WHY DO WE HAVE THE HEALTH CARE
SYSTEM THAT WE’VE GOT?– AND IF IT GOES BACK
TO THE LATE 1800s AND EARLY 1900s,
OUR WHOLE MEDICAL PARADIGM WAS BASED ON
A REDUCTIONISTIC MODEL. WE HAD THINGS LIKE GERM THEORY,
AND WE FIGURED OUT, “OH, COOL. A DISEASE IS CAUSED
BY A CAUSAL FACTOR, “SO ALL WE HAVE TO DO IS FIND
A CURE TO THAT CAUSE, AND WE’RE DONE.” IT RESULTED IN THIS
“FIND IT, FIX IT” APPROACH, WHICH, TO BE HONEST,
OUR MEDICAL PARADIGM IS STILL BASED ON TODAY. OUR SCIENCE HAS ADVANCED
THAT IN THE 2000s, WE HAD A LOT MORE ADVANCE
AROUND SYSTEMS APPROACH. WE UNDERSTOOD THINGS
LIKE QUANTUM PHYSICS, SYSTEMS BIOLOGY,
AND CHAOS THEORY. WE KNOW THAT HUMAN BEINGS ARE
COMPLEX, ADAPTIVE SYSTEMS, AND YET WE HAVEN’T REDESIGNED
OUR HEALTH CARE APPROACH FUNDAMENTALLY. IF YOU LOOK AT THIS GRAPH– AND SOME OF YOU HAVE
SEEN THIS BEFORE– IT REALLY ORIENTS
ACROSS A PERSON’S TIME, ACROSS TIME
IN A PERSON’S LIFE, AND WE SEE THAT THERE
ARE INITIATING FACTORS OF HEALTH AND DISEASE,
AND RIGHT NOW, WE PRETTY MUCH WAIT TILL YOU’RE
PRETTY FAR DOWN ON THAT CURVE TO INTERVENE. IT DOESN’T WORK VERY WELL,
BUT WE CREATED A SYSTEM TO ADDRESS THAT. IT’S A CLINICAL CARE MODEL
WHICH PREDOMINANTLY RESULTS IN OUTPATIENT
AND INPATIENT MEDICAL CARE, AND I’M OVERSIMPLIFYING IT
TO MAKE THE POINT, BUT THAT’S OUR
DOMINANT PARADIGM. I THINK THERE’LL BE A TIME
NOT TOO FAR IN THE FUTURE WHERE WE LOOK AT THAT
AND WE THINK, “WHY DID WE THINK
ONLY HAVING THAT APPROACH WAS EVER GONNA WORK?” IF WE LOOK
AT HOW IT’S WORKING NOW, LET’S LOOK AT HEART DISEASE. HEART DISEASE
IS THE NUMBER-ONE KILLER OF MEN AND WOMEN
NOT ONLY IN AMERICA, BUT AROUND THE GLOBE,
AS YOU KNOW. WHAT DO WE DO? WE DO A LOT OF ANGIOPLASTIES. THEY COST A LOT OF MONEY.
WE DO A LOT OF BYPASS SURGERIES. THEY COST EVEN MORE MONEY,
AND IT’S INTERESTING TO REALIZE THAT ANGIOPLASTIES AND STENTS
DO NOT PROLONG LIFE OR PREVENT HEART ATTACKS
WHEN PEOPLE HAVE THEM IN A STABLE CONDITION,
WHICH IS 95% OF THE TIME, SO IF SOMEONE
IS AN ACUTE SITUATION, THEY GO INTO THE EMERGENCY ROOM,
AND THEY GET STENTED, PROBABLY SAVED THEIR LIFE,
BUT 95% OF THESE PROCEDURES ARE DONE ON STABLE PATIENTS. IT DOES NOT PROLONG LIFE,
DOES NOT PREVENT HEART ATTACKS. WHAT ABOUT BYPASS SURGERY? BYPASS SURGERY PROLONGS LIFE
IN LESS THAN 3% OF PEOPLE, SO HERE WE ARE, DOING
THESE VERY INVASIVE THINGS, VERY EXPENSIVE THINGS,
AND NOT EVEN GETTING THE OUTCOMES WE WOULD LIKE. NOW JUXTAPOSE THAT TO THE FACT
THAT CHANGING LIFESTYLE COULD PREVENT–
NOT JUST TREAT, BUT PREVENT– AT LEAST 90% OF HEART DISEASE,
THE NUMBER-ONE KILLER, BUT WE DON’T HAVE A SYSTEM
OF HEALTH CARE THAT DOES THAT. WE HAVE A SYSTEM OF HEALTH CARE
THAT DOES THE TOP STUFF, THE INTERVENTIONS,
SO WHAT DOES THIS LOOK LIKE? HOW DO WE RADICALLY REDESIGN
HEALTH CARE TO REALLY PROMOTE PEOPLE’S
HEALTH AND WELL-BEING, WHETHER THEY’RE ALREADY
HEALTHY OR SICK OR AT THE END OF THEIR LIFE? WE’RE CALLING THIS
THE WHOLE HEALTH PARTNERSHIP, AND WHOLE HEALTH IS AN APPROACH
TO HEALTH CARE THAT EMPOWERS AND EQUIPS–
THOSE ARE IMPORTANT WORDS– EMPOWERS PEOPLE
AND EQUIPS PEOPLE TO TAKE CHARGE OF THEIR HEALTH
AND WELL-BEING AND LIVE THEIR LIFE
TO THE FULLEST. OUR CURRENT HEALTH CARE SYSTEM
ISN’T REALLY DESIGNED TO DO THAT, IF WE’RE HONEST, SO WHAT DOES THIS
FUTURE STATE LOOK LIKE, THE STATE THAT VA IS PRODUCING AND DELIVERING
WITH OUR VETERANS? THEY NEED TO HELP PEOPLE
LEARN THE SKILLS AND HAVE THE SUPPORT THEY NEED
TO ADDRESS THEIR SELF-CARE. THIS IS HOW WE EQUIP PEOPLE
TO ADDRESS THEIR HEALTH AND WELL-BEING,
AND THAT PLUS HOLISTIC,
INTEGRATIVE HEALTH CARE CREATES THE WHOLE HEALTH SYSTEM, SO IF WE THINK ABOUT
HOW DOES THAT WORK, HOW DO YOU MAKE THAT REAL,
WE NOW HAVE 3 ELEMENTS OF THE WHOLE HEALTH SYSTEM,
THE FUTURE HEALTH SYSTEM FOR VA THAT DOES HAVE CLINICAL CARE
WITH A MORE HOLISTIC APPROACH THAT BEGINS WITH A PATHWAY
WHERE PEERS AND OTHER FOLKS WHO ARE NOT NECESSARILY
CLINICIANS ARE TRAINED TO WORK WITH VETERANS
AND THEIR FAMILIES ABOUT EXPLORING
WHAT REALLY MATTERS TO THEM TO IDENTIFY WHY THEY
WANT THEIR HEALTH AND BE VERY CLEAR
ABOUT THAT PERSONAL MISSION OR ASPIRATION OR SENSE
OF PURPOSE IN THEIR LIFE THAT THEY WANT THEIR HEALTH FOR. THAT’S THE FOUNDATION
OF THEIR HEALTH AND HEALTH CARE. THEY BEGIN TO PUT TOGETHER
A PERSONAL HEALTH PLAN IN THAT PROCESS,
AND THAT PERSONAL HEALTH PLAN HELPS INTEGRATE THEIR CARE
WHEREVER THEY’RE HAVING IT, WHETHER IT’S THEIR SELF-CARE,
THEIR LIFE IN THEIR COMMUNITY, OR THEIR CLINICAL CARE, SO THE PATHWAY
IS REALLY CRITICAL. THE HEALTH AND WELL-BEING
PROGRAMS HELP PEOPLE LEARN THE SKILLS THEY NEED,
HOW TO EAT DIFFERENTLY, HOW TO DEAL WITH THEIR STRESS,
HOW TO IMPROVE THEIR SLEEP, BRINGING IN APPROACHES
LIKE TAI CHI OR ACUPUNCTURE IF THOSE ARE HELPFUL TO PEOPLE,
AND WE GIVE PEOPLE THE SKILLS THEY NEED
AND THE SUPPORT THEY NEED TO REALLY CHANGE THEIR HEALTH
AND WELL-BEING, SO THE WHOLE HEALTH SYSTEM
ADDRESSES THESE ELEMENTS– THE HUMAN ELEMENT,
THE SELF-CARE, AND THE CLINICAL CARE,
AND COMPLEMENTARY AND INTEGRATIVE APPROACHES
ARE INTEGRAL TO SELF-CARE AND CLINICAL CARE IN THIS,
SO I’D LIKE TO JUST CLOSE BY SHARING A REFLECTION
OF MINE THAT MODERN MEDICINE STARTS
WITH THE BODY, RATHER THAN THE SOUL; THE MIND, RATHER THAN THE HEART, BUT WHAT WE KNOW IS THAT
THE SOUL AND THE HEART ARE THE DOORWAYS TO HEALING
AND HEALTH OF THE BODY AND MIND,
SO NOW WE’RE AT THIS REALLY EXCITING PLACE
WHERE WE CAN DESIGN FOR THIS APPROACH
WITH OUR VETERANS AND LEAD THE WAY NOT ONLY
FOR OUR VETERANS, BUT FOR OUR NATION. THANKS SO MUCH
FOR BEING A PART OF THIS.

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