News Archive

Federally Qualified Health Centers (FQHC’s) are a nationwide network of federal, state, and privately-funded community health centers that historically serve more than 28 million people, both uninsured or underinsured, providing essential health services at little to no cost to the patient.  Now, with the COVID epidemic and the increase in people who have lost their jobs, the number of people served has surged to over 36 million.  Before adding the numbers associated with the epidemic, FQHCs offered care for one in 12 people in the country, one in 9 of which are children, and 400,000 of which are veterans.  There are approximately 12,000 of these community health centers across the U.S., all of which receive funding from the Health Resources & Services Administration (HRSA), within the U.S. Department of Health and Human Services.

FQHC’s have long addressed the economic and social drivers that are essential components of a comprehensive approach to population health. These issues are gaining bipartisan support under the umbrella of the Social Determinants of Health (SDOH). In 2019, Senator Todd Young (R-IN) introduced the Social Determinants Accelerator Act, a bill designed to facilitate state Centers for Medicare and Medicaid Services (CMS) funded grants for programs targeting high need Medicaid recipients using innovative Social Determinants Accelerator Plans.

The IHPC supports funding for FQHCs as fundamental to its mission to eliminate barriers to health.  Additionally, since FQHCs often benefit from more programing flexibility than other federally funded programs, they are a growing source of innovative and integrative models of care.  An exceptional example of an FQHC that is providing integrative care is the Petaluma Health Center, in Northern California, directed by Fasih Hameed, MD.  In addition to providing a full range of integrative services, this clinic is embedded in the community, with innovative features including providing care in the schools, a community garden and teaching kitchen.  Another outstanding example is the People’s Community Clinic, a federally qualified health clinic (FQHC) in Central Texas.  IHPC’s former chair, Sharad Kohli, MD, recently wrote an article about how this Texas FQHC developed an integrative model for patients with pain.
Read Dr. Kohli’s article here

Dr. Gerald Clum, DC, Director of the Center for Compassion, Integrity and Secular Ethics at Life University made a generous gift to the Board of Directors of the Integrative Health Policy Consortium–a 10-week Compassionate Integrity Training program for IHPC Partners For Health.

The Center for Compassion, Integrity, and Secular Ethics (CCISE) at Life University is dedicated to developing and promoting empirically-based programs that foster the human values most conducive to individual, social and environmental flourishing through research, dialogue, education and community empowerment.

Compassionate Integrity Training (CIT) is a multi-part training program that cultivates basic human values as skills for the purpose of increasing individual, social, and environmental flourishing. By covering a range of skills from self-regulation and self-compassion to compassion for others and engagement with complex systems, CIT focuses on and builds toward compassionate integrity. Values and concepts like compassion and integrity are based on a secular approach to universal ethics based on common sense, common experience, and science.

Compassion has been recognized as crucial to quality health care provision. Dr. Beth A. Lowen, MD, Assoc. Professor of Medicine at Harvard Medical School and Chief Medical Officer at the Schwartz Center for Compassionate Healthcare, says, “Perhaps heightened public and professional awareness of the value and importance of compassion will enable us to raise our voices together to insist that compassion is a necessity, not a luxury, in health care.”

Additionally, former U.S. Senator William H. Frist, MD, and heart transplant surgeon recognized data from the groundbreaking book, Compassionomics by Stephen Trzeciak and Anthony Mazzarelli, demonstrating how compassionate care achieves measurable improvement to patient outcomes, fiscal health, and employee satisfaction. Thus, compassion drives revenue and cuts costs. This is key to driving legislation that is good for all.

U.S. Senator Cory A. Booker, in the forward to Compassionomics said that the authors “focus on the healthcare system to show us tangible and significant ways that compassion makes a crucial difference in health care. They show us that compassion isn’t just a nice idea, it’s a practice that when put into action improves lives.”

The 10-week CIT Training for the IHPC Partners For Health will promote expanded awareness and deeper understanding of the concepts that can be employed in policy work to keep us grounded in a basic orientation toward kindness, care, and compassion. Participants will be supported in developing deeper appreciation for the inherent value and innate potential as interconnected in common humanity. Practicing discernment and critical thinking while incorporating basic human values into decisions will lend to more humane and inclusive policy making.

IHPC is deeply grateful for the kind offer and support from Dr. Clum and Life University and is eager to leverage this important interpersonal training towards its continued work to address equity, diversity, and inclusion within the integrative health community.

“This project may not bear fruit for another 40 or 50 years, and you and I won’t be here to see it. But our generation must make a start…more sensible humanity may emerge, whose leadership too will be different.” H.H. the Dalai Lama

CIT (Compassionate Integrity Training) STARTS NEXT WEEK –SPOTS ARE STILL AVAILABLE FOR IHPC PFH OR THEIR MEMBERS!

• There are still slots available for additional participants!  Please let Tracy know if you are interested or someone in your organization and she will connect you with the CIT team.
• If you signed up but have not yet registered – please look for email from
  • Kristin Norton —kristin@kristinzo.com
  • Please register as soon as possible!

A Case in Point by Nancy Gahles, DC, CCH, OIM

“The first Law of Understanding is that in general the same hopes, sorrows, joys,
troubles, fears, encompass us all. The same Destiny beckons us. The same Love
enfolds us. The same Justice educates us. “ ~George S. Arundale, Understanding is
Happiness.

A well-known axiom often used when describing policy work is that it is like “sausage
making,” a rather gruesome process. But policymaking is also relationship making.
Because the American Society of Acupuncturists (ASA) and the American Academy of
Medical Acupuncturists (AAMA), both IHPC Partners for Health, share the common
goals of supporting acupuncture as a part of the larger medical system, the two groups–
together with the IHPC–began a series of conversations this fall to see how they might
more formally work together.

Indeed, an overarching concern for appreciating the common humanity of us all and
working together to build relationships that make the world a better place was echoed
by both leaders of the acupuncture organizations. Olivia Hsu Friedman, DACM, LAc,
Chair, ASA, stated that “common mutuality arose from just talking, identifying objectives
and obstacles”. Freda L. Dreher, MD, FAAMA, President, AAMA, said that “it’s so easy
with Hsu Friedman; we were automatically in synch.” The discussions led to good faith
intentions for the two groups to work together and to a more formal Memorandum of
Understanding (MOU).

A memorandum of understanding is a formal agreement between two or more parties
that can be used to establish official relationships. MOU’s are not legally binding, but
they carry a degree of seriousness and mutual respect, stronger than an informal verbal
agreement or a “handshake.”

Both agreed that the timing was right for understanding and collaboration for the greater
good. Dreher explained that the MOU is a launching step: one that “takes us from a
place of good understanding to a formalized understanding.” She continued “We don’t
have to BE each other to respect each other.” Hsu Friedman commented, “As a whole,
the health care industry has to recognize that we all offer different things for the good of
the whole world.” Dreher enthusiastically explained that the AAMA will be making their
upcoming April symposium more international and inclusive: “to be together, convene,
allow ideas to bubble up…”

IHPC is proud of all that these two Partners for Health have achieved thus far and looks
forward to similar models of collaboration for advancement of integrative healthcare and
healthcare policy. The AAMA and ASA are proof that relationship building comes from
mutual respect and understanding and leads to advancement of the profession as a
whole.

Q&A with Executive Director Dale West

In an effort to create a more collaborative landscape for all members of the healthcare community, the Academic Consortium for Integrative Medicine & Health, a New Buffalo, MI-based organization comprised of universities and health systems in North America, announced in October it would open its membership to nursing schools and osteopathic medical schools. The Consortium, founded in 1999 by eight academic health centers including Duke University, Harvard University, University of California, San Francisco, University of Arizona, University of Maryland, University of Massachusetts and University of Minnesota, now includes 75 institutional members representing scientists, educators, clinicians and other health professionals who share an interest in integrative medicine and health. Because these professions have traditionally remained somewhat compartmentalized, the move is an important step to help bridge the gap. IHPC recently spoke with Executive Director Dale West about the Consortium’s decision and its potential impact on the integrative and overall health community.

IHPC: Why did the Academic Consortium make the decision to expand its membership and why is this important to the integrative health community?

Dale West:  It really was the next step in the evolution of creating a more inter-professional organization. Nurses and doctors of osteopathy have actually been involved the organization for years. They are part of our current membership through the existing members but our bylaws prohibited the schools from being part of the consortium, so we made the decision to make this change as we believe it will take all of us to make the changes we want to see in our health system. We need to widen the tent.

IHPC: What kinds of changes to the health system are you talking about?

DW: Our vision is to see a transformed health system where integrative medicine and health are available to everyone. I know that is a lofty goal and what we are working toward will take all of the integrative organizations and all of the professional groups working together to get increased access to modalities that help save and improve lives.

The thinking is that having more inclusion from different institutions and sharing of resources, in terms of how we are educating our students to include an integrated integrative approach, is important. We have to be able to educate our new medical students and nursing students in a different way to help people live a healthy, fulfilling life– that is our number one goal.

Frankly, trying to make changes in health care without our nurses is never going to happen. They spend more time with patients than anyone else and are an integral part of the system. They have really been focused on integrative health as long as the rest of us, so it made perfect sense that they should be an integral part of the organization.

Doctors of Osteopathy also bring a strong background and understanding of integrative modalities. Their training comes from a more holistic approach in that that they can do spinal manipulation to alleviate pain to help people live a more fulfilling life. So they are already taught this in school, and there is no difference in scope of practice from an MD to a DO. It is an artificial barrier whose times had come.

IHPC: So far what response have you had to this change?

DW: We had had requests coming in from these groups– in fact, it was a request from a faculty member who had a new institute that wasn’t eligible to join.  That alone showed us there was interest.  We have also seen interest from other nursing and DO schools. We will likely see the first application from a nursing school in early 2021. COVID might dampen this somewhat because the focus is elsewhere. But we think it was the right move and the response we have seen so far is good. People are excited and open to coming into a larger tent.

IHPC: Was it a difficult process to shift the organization’s thinking to include these new institutions?

DW: The changes we made this year were unanimous. We made a push to make this happen and everyone involved, who voted to make a change–the board, the membership committee, and others, were unanimous, so it was not difficult to make it happen. It is something we have been thinking about.  We have had conversations over the years, but for many years we had a different focus – the organization was young still and trying to get its footing. We are in a different place now, and we thought this was the right time.

IHPC: What will membership in the consortium mean for these schools?

DW:  It means that they have a larger network to be able to talk to colleagues across the country and around the world about education curriculum, clinical practice, and research. Having a collaborative effort to share resources opens the possibilities for these schools to have a greater network as they work to create change locally and also nationally

IHPC: Looking ahead, how do you envision the impact of this inclusion?

DW: Increasing the number of institutes providing both the education to our emerging leaders in healthcare and providing care to people around the country will allow for this great collaboration– more collaborative research projects and really looking at systems for change that are working. We do have pockets of change that are moving the needle. So as we begin to be able to share these ideas, strategies, and outcomes and bring that back locally is incredibly important.  Increasing the types of organizations that can join will expand this collaboration.

Dr. Helene Langevin, Director

NIH’s National Center for Complementary and Integrative Health

on

Research for Integrative and Whole Person Health

Speaker – Helene Langevin, M.D., was sworn in as director of the NIH’s National Center for Complementary and Integrative Health (NCCIH) on November 26, 2018. Prior to her arrival, she worked at the Osher Center for Integrative Medicine, jointly based at Brigham and Women’s Hospital and Harvard Medical School, Boston. Dr. Langevin served as director of the Osher Center and professor-in-residence of medicine at Harvard Medical School since 2012. She has also served as a visiting professor of neurological sciences at the University of Vermont Larner College of Medicine, Burlington.

 

As NCCIH director, Dr. Langevin oversees the Federal government’s lead agency for scientific research on the diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. With an annual budget of approximately $142 million, NCCIH funds and conducts research to help answer important scientific and public health questions about natural products, mind and body practices, and pain management.

 

As the principal investigator of several NIH-funded studies, Dr. Langevin’s research interests have centered around the role of connective tissue in chronic musculoskeletal pain and the mechanisms of acupuncture, manual, and movement-based therapies. Her more recent work has focused on the effects of stretching on inflammation resolution mechanisms within connective tissue. She has authored more than 70 original scientific papers and is a fellow of the American College of Physicians.

 

Dr. Langevin received an M.D. degree from McGill University, Montreal. She completed a postdoctoral research fellowship in neurochemistry at the MRC Neurochemical Pharmacology Unit in Cambridge, England, and a residency in internal medicine and fellowship in endocrinology and metabolism at The Johns Hopkins Hospital in Baltimore.

 

Moderator – Margaret Chesney, PhD is Professor of Medicine at UCSF, and served as director of the UCSF Osher Center for Integrative Medicine from 2010 to 2015. Prior to returning to UCSF, where she had previously worked as professor-in-residence and co-director of the Center for AIDS Prevention Studies, she was the first Deputy Director of NCCIH from 2003 to 2008, and associate director of the Center for Integrative Medicine at the University of Maryland.

 

With a focus on health promotion and disease prevention, she has served as principal investigator of NIH-funded research studies identifying pathways by which behavioral factors, such as stress, are associated with chronic disease, and testing biopsychosocial interventions to promote health. She has explored the role that individuals and communities can play in the promotion of health and maintenance of optimal well-being across the lifespan, even in the face of serious illness such as cancer and HIV/AIDS. Her current research efforts are particularly focused on the health challenges faced by women, seniors, Veterans and the underserved.

 

Dr. Chesney has served as president of the Society for Health Psychology, Academy of Behavioral Medicine Research and American Psychosomatic Society. From 2014 to 2016, she chaired of the Academic Consortium for Integrative Medicine and Health.

 

 Thank You to Our Sponsors

Byline: Laura Culberson Farr, Executive Director, American Association of Naturopathic Physicians

 Since the novel coronavirus (COVID-19) pandemic began in March, the U.S. Food and Drug Administration along with the Federal Trade Commission have sent over 300 warning letters to physicians, clinics, individuals, pharmacists, and manufacturing and retail companies reprimanding them for making false and misleading claims about the ability of products or services to prevent, mitigate, treat, or cure COVID-19. Dozens of these warning letters have gone to practitioners in the integrative healthcare space, including functional medicine physicians, naturopathic physicians, chiropractic doctors, and acupuncturists, many of whom often recommend natural approaches to care through diet and lifestyle changes, and the use of herbs and/or supplements.

The American Association of Naturopathic Physicians conducted an analysis of the warning letters and providers who received them, and found that many of the offending communications were discussions about ways to “boost the immune system,” methods for how to stay healthy, and natural protocols that may be helpful in mitigating COVID-19 symptoms or that have been successfully deployed to treat other acute respiratory distress syndromes. Most of the warning letter recipients sell products through their clinic or online dispensary or advertise services like intravenous (IV) Vitamin C therapy.

The warning letters usually begin by citing language from a clinic’s website or newsletter that regulators determine makes a misleading claim, requesting that the offending language be removed and that the FTC be notified within 48 hours that the recipient has come into compliance.

However, there can be a cascade of downstream consequences from receiving one of these warning letters. Some integrative medicine providers have reported one or several of the following:

• Negative media about the practitioner or their clinic
• Merchant service accounts frozen upon a bank learning of the warning letter, and can only be reactivated after establishing proof of compliance
• Fraud investigations by the Oregon Department of Justice for violations of the Oregon Unlawful Trade Practices Act
• Reports from recipients that their state licensing board was notified

While there are no known cases of disciplinary action by licensing boards on any practitioner, the risk is possible and the anxiety and legal defense fees are even more real for providers who genuinely thought they were sharing important information about potentially beneficial, low-cost, low-risk ways to stay healthy or mitigate COVID-19 symptoms.

Providers at the Crossroads of Commercial and Free Speech

Warning letters are triggered when the FTC perceives that there is advertising or marketing language that violates the FTC Act. For integrative medicine providers, the AANP’s research found that this is almost always the nexus of discussing treatment protocols, services, or research related to COVID-19 with either a direct or implied marketing reference to selling products through a clinic store, online dispensary, or services such as IV therapy. This is considered “commercial speech,” and is highly regulated.

In the middle of this crossroads stands the Dietary Supplement Health and Education Act (DSHEA), which strictly prohibits supplement producers and marketers from making disease-related claims. A disease-related claim, such as stating a product can be used to treat COVID-19, can only be legally made for FDA-approved drugs and medical devices.

Supplement manufacturers and marketers are limited to making what are called structure and function claims and must include a disclaimer that the statements have not been evaluated by the FDA.

Here is a simple example of the difference between a structure/function claim and a disease claim. “Calcium can help build strong bones” is a structure/function claim. “Calcium can help treat osteoporosis” is a disease claim.

Under DSHEA, marketing a product associated with a disease like COVID-19, whether directly, as in “buy my vitamin C to boost your immune system to protect you from COVID-19,” or indirectly, as in “vitamin D deficiency may increase the risk of contracting COVID-19,” is considered making a false and misleading disease claim that a supplement can prevent, cure, mitigate, or treat COVID-19.

Providers who sell products and advertise the availability of products in newsletters, websites or social media are generally viewed by regulators as marketers, but have not usually been the target of FDA and FTC regulatory actions. The combination of heightened consumer fear with the explosion of consumer scams, has led to a regulatory environment that supplement industry consultant Michael Levin has called “a radioactive recipe waiting to explode.”

Synonyms, Euphemisms and Syllogisms of COVID-19

What has been particularly confounding for many integrative medicine providers trying to communicate legitimate educational content, research, protocols, tips, and recommendations to patients and the public is the ever-growing list of synonyms and euphemisms that regulators are associating with COVID-19, and asserting that they are syllogisms to making a disease claim to prevent, treat, or cure COVID-19. For example, the term “virus” is often associated with a disease, therefore a statement that a dietary ingredient has shown promise to treat or prevent “viruses” would likely be considered a false and misleading disease claim, and may trigger a warning letter specific to COVID-19.

The legal team of a popular supplement company used by many integrative medicine practitioners has cautioned their marketing team to also avoid using phrases like “during this pandemic,” or “in this new normal,” which may be considered euphemisms for COVID-19 when viewed through a marketing lens. A statement along the lines of, “during this pandemic, we need to make sure our immune systems are strong,” that then recommends a sample protocol to boost immune resilience would be viewed by the FTC as an inference to COVID-19 and a prohibited disease claim.

In a recent call with the FTC task force charged with protecting the public against COVID-19 scams, the Assistant Director of the FTC’s Bureau of Consumer Protection remarked “there is a syllogism between immunity and COVID-19 that is not definitively supported by scientific evidence.” He explained that if there is a communication about the pandemic, immunity, and dietary ingredients that links to a store selling related products, the FTC will view this as marketing and a false and misleading disease claim about the products.

The proliferation of fraudulent COVID-19 cures is a real and significant problem, as is the potential for restricting open communication about potentially beneficial, natural approaches to improve health. Some natural health advocacy organizations have argued that the regulators have gone too far and are stifling the ability of providers to communicate appropriate information about natural approaches to preventing or treating COVID-19.

“Your right to learn from your doctor about natural methods of staying healthy during the pandemic are under threat,” said the Alliance for Natural Health in a May statement. “The FDA, FTC, Department of Justice, and some state attorneys general have launched a coordinated censorship campaign that prevents medical doctors and other healthcare providers from communicating their extensive knowledge about how to stay healthy…using natural medicine.”

This front is also evolving rapidly, research is changing constantly, and some providers and clinics who have received warning letters are pushing back to defend the ability to educate consumers and market dietary supplements. Ongoing dialogue needs to happen with regulatory bodies to fine-tune the line between what constitutes free speech, which is not regulated, and commercial speech, which is heavily regulated.

Providers must quickly become educated about marketing laws, DSHEA, what constitutes commercial speech, and the domains that have long been the purview of the supplement industry but are now broadly being applied to providers who have become de facto marketers.

Additionally, providers also need to understand the line between free speech and commercial speech. Author Erik Goldman provides an example in his article Words of Warning: “Saying ‘Vitamin D boosts immunity’ on your website is free speech. Saying “Vitamin D boosts immunity and you can buy it at my store” is marketing. Regulators are unlikely to object to the first statement. They very well could target the second.”

To ensure compliance with marketing regulations, practitioners are urged to analyze their marketing communications with the following considerations:

1. Educate the public about COVID-19 treatment approaches without any marketing for product sales on websites, newsletters, social media posts, etc; OR
2. Market dietary supplements/products without making prevention or treatment claims, including but not limited to COVID-19, antiviral, or other disease properties;
3. Do not make claims about COVID-19 treatment approaches with product sales or a link to an online dispensary in either a direct or implied manner;
4. Get to know laws around marketing, the FTC Act and DSHEA, and the important distinction between commercial and free speech. The AANP co-hosted a FREE webinar with Holistic Primary Care, with guests from the FTC department issuing warning letters, and several legal and practitioner experts. Please click here to watch and share Your COVID Communications Could Be Illegal: How to Avoid FTC/FDA Trouble When Marketing Your Practice.

Integrative medicine practitioners play an important role in helping consumers understand what are credible, evidence-informed natural approaches to health. Developing a deeper understanding of marketing laws and commercial speech regulations will help providers accomplish this effectively and legally.

About the Author

Laura Culberson Farr

Laura Culberson Farr is the Executive Director of the American Association of Naturopathic Physicians, the national association representing licensed naturopathic doctors, and Board of Director of the Integrative Health Policy Consortium. A health advocate for over 25 years, she has a deep knowledge of the complexities of healthcare reform, and is an expert on how naturopathic and integrative medicine doctors, conventional clinics, and insurers can work together to improve patient care and reduce healthcare costs.

Nursing may be one of the most trusted professions around, but Margaret Erickson believes it needs to be elevated and respected at a new level. Nurses and the care they provide are foundational to the healthcare system and play a prominent role in today’s pandemic crisis. Yet nursing care is usually included in hospital budgets, shockingly, as “lodging expenses.”  Erickson is uniquely qualified to discuss current and future nursing care, having practiced holistic nursing for more than 40 years and holding her PhD, RN, CNS and APHN-BC®.  Since 2000, she has been working to educate and advance the role of nurses as CEO of the American Holistic Nurses Credentialing Corporation (AHNCC).

In this interview, Erickson offers her thoughts on how holistic nursing goes beyond today’s typical nursing tasks and the role it plays in today’s shifting healthcare paradigm, on the importance of self-care for patients and practitioners, and on the mission of AHNCC.  Erickson, as the newly-elected Co-Chair of the IHPC Board of Directors, discusses her expanding role with IHPC.

IHPC: Tell me about the philosophy behind holistic nursing and how it is different from traditional nursing?

Margaret Erickson: Holistic nursing is grounded in the roots of nursing and a philosophy of holism. Holistic nurses believe that people are spirit-mind-body-emotion integrated beings, that all people are greater than the sum of the parts, and that our subsystems are constantly interacting and affecting one another.  People cannot be separated from their environments. Nursing is not something we do as tasks or based on  the policy and procedure manual but rather, it is how you show up, interact, connect with the person; and help them access resources so they can be healthy and have a higher state of wellbeing, even if they are taking their last breath. Holistic nurses are always competent in the tasks and care for the physical needs of the person but that does not define their practice.

If we go back to Florence Nightingale in the 1800s, nursing was about caring for the whole person. Florence recognized the importance of meeting patients’ basic, trust, and safety needs as well as higher needs such as growth, spiritual, and needs for beauty and nature. Care was holistically focused.  She recognized that people have an innate ability within to heal and that as nurses our goal was to facilitate them in that healing process. However, in the 1970s, nurses aligned with the bio-medical paradigm to validate themselves rather than seeing they had their own discipline, a unique perspective and something special to offer. The focus of nursing care within this paradigm is treating and curing–when possible–illness and disease and is task oriented. Again, Holistic Nursing isn’t about doing tasks. However, we do have to be competent in any work or tasks we do. You can’t try to start an IV on someone several times or the patient will be very stressed, their blood pressure and respiratory rate will be elevated, which in turn affects their immune system and ability to heal. How we approach and complete our work–whether it is as an advocate, educator, or with hands on care at the bedside–affects the entire person and their ability to heal and achieve a greater state of well-being. So, you have to be competent in tasks but again that is not what defines nursing. We believe the most important instrument of healing is ourselves. It is not about us telling patients—I call them clients– what they need to do. It is about understanding who they are and facilitating and supporting them in accessing their resources to help them have the highest quality of life they can achieve.

IHPC: How do you use these philosophies in dealing with patients?

ME: The newest research shows that we make an impression in the first 7-10 seconds when we interact with others. When I walk in a room, am present, recognizing that I am in sacred space with another, I might say ‘Mr. Jones I am here to take care of you’– I speak slowly, and quietly respecting his space. My focus is on the person not the equipment, medicine, documentation, etc.  In this first interaction with the client I tell him, he is important to me.

On the other hand, if I hurry into the room and do tasks like checking the IV, foley, or charts it shows that that is what is most important. The patient is then less likely to feel safe and trust you. Consequently, they often don’t share the important information you need to help them get well. When they don’t trust you, they won’t tell you the real story, what their needs are, and what brought them into the hospital or healthcare system. When we focus on tasks and decide what peoples’ needs are, we have a problem. No one knows someone better than they know themselves. Yet, we decide what their problem is, develop a plan of care in which they are not engaged and then we call them non-compliant. This contributes to treating the symptom rather than the root of the problem and then we have clients having multiple admissions for the same problems.

IHPC: Can you give me some examples of how this might have an impact on patient care and treatment?

ME: In most programs, we currently teach nurses to focus on the presenting symptoms, but that is only part of their care. For example, as a Case Manager in South Dakota, I had a patient admitted with severe respiratory distress. He was medicated and put on oxygen. The physician wanted to intubate him. He demanded that they call me. He told me between gasps that a blizzard was coming and his dog, who was the only person in the world who loved him, kept his home safe from others, would die if left out in cold. He refused to be intubated until I got back from taking care of the dog. I told him I would check on the dog and make sure he was safe. I asked him if while I was taking care of his dog if he could try to slow down his breathing and let the medications he had received begin to work.  I spent a couple of minutes with him, talking quietly, and working with him so he could breathe easier and deeper. I told him I would be back shortly after taking care of his major support system (his dog). I contacted a neighbor and asked him if he would go over and care for the dog. When I got back, and told him his dog was inside, he was better and we didn’t need for him to be intubated. He was so anxious about the dog that it was making his symptoms worse. Some people would have said don’t worry about the dog, you must get intubated first. As holistic nurses we try to listen, understand, and then address a person’s needs as we know that their emotional, spiritual, social, cognitive subsystems all affect their physical wellbeing. People cannot be separated into parts. So, in a biomedical paradigm, nursing and medicine focus on physical health, the body; treating illness and disease. The difference in holistic nursing is we recognize that people are unified beings; we can’t separate them into pieces or systems.

Listening to people is very important. It is essential if we want to understand what is really going on and be able to treat the root of problems versus the presenting symptoms.

I had a gentleman who was a revolving-door patient coming in and out of the hospital, nothing was working for him. His angina was getting worse, and he was identified as a financial problem for the hospital as well as an “impending cardiac event.” I was asked to see him as “he is spending too much time in our hospital and he is getting worse, not better.” I entered his room quietly and respectfully, focusing on his face and eyes.  I didn’t say anything about his admitting symptoms, but rather introduced myself, and asked why he came in?  He told me to check with doctor, and I responded, ‘I don’t care what the doctor or anyone else says or what the records say, I want to know why you think you are here? No one knows you as well as you know yourself.’ His. eyes filled up with tears and he told me his wife of 60 years had died six months ago and that he was broken hearted. He shared that he was a rancher, who lived a long way from town, that he had COPD after decades of dust and exposure to his environment from working outside. Although he had COPD he had managed as his wife had taken care of him, and they had had each other.  He was dealing with unresolved loss, and it was affecting his physical, emotional, and social well-being. I asked him how I could help and what he needed. Then I listened. He said he missed his wife terribly and was very lonely. He needed to be with other people, to talk to someone about his wife, and to have help with his activities of daily living. I worked with him, made some referrals, and he moved into town to assisted living. His chest pains went away, and he no longer needed his medication.

Understanding peoples’ life experiences is another important factor. As a case manager I was asked to follow up with an elderly gentleman who lived on the Pine Ridge Sioux Reservation. I was told I needed to talk to him after the nurse educator (NE) provided his ‘diabetic teaching’ and before he was discharged. I was asked to see him because he was diabetic and non-compliant with his medication and diet. He and his niece came to get instructions before going home. Due to his poor vision and hearing, the niece, as his caregiver, was watching and listening close to the nurse educator. He was very respectful and trying to listen but watching him I was reminded of Snoopy in the Peanuts cartoon, where all he would hear was “blah, blah, blah.” It looked like the ‘education’ was going right over his head.

After the session I asked him if he had any questions. He quietly responded, ‘no,’ at which point I gently said, ‘I noticed when she talked about eating fresh fruit and vegetables that you might have a question.’ He said ‘well yes, I guess I do. I was thinking that fresh fruit and vegetables only come to the reservation once a month. If I am not there, I don’t get any, so what am I supposed to eat?’  Then he asked ‘Did you say insulin must be kept cold?  I don’t have electricity for a refrigerator.’ His healthcare providers had never heard about his real-life experience. For the last 20 years the system had treated him based on their perceptions and assumptions, never understanding his needs or his lived reality. I was really upset. He’d been identified as non-compliant for the last 20 years when in reality the system was neglectful and let him down. Now he was nearly blind and had chronic renal failure. It was outrageous!’

IHPC: Sounds like this comes down to education and training of nurses?

ME:  That’s right. The focus and philosophy that guides nursing education and the curriculum taught determines what the nurse focuses on in their practice. Is the focus tasks or is it holistic, relationship-based care of all aspects of the person’s care? Wholism with a ‘w’ is what is currently taught in most nursing program. In these programs, nurses are taught that people have different subsystems which need to be care for. That people are the sum of these different parts. This is different that the belief that all of our subsystems, are in constant interaction, affecting one another. With “wholistic” care we look at the different parts of the person and treat them accordingly. The focus is usually dealing with the physical domain. For example, when a nurse takes a history and assessment, they focus on the physical or clinical health–they assess the body; whereas in holistic nursing, we do a holistic assessment and include an emotional, cognitive, psychosocial and spiritual as well as the physical assessment. We look at how the spiritual aspects of the person affect the emotional or the emotional aspects/subsystem affect the person’s physical health. Most nursing education programs teach that you must consider the different subsystems, but they don’t teach a holistic approach, where the nurse learns to assess the person holistically.  Nurses need to look at the whole person, not just the heart attack in room 225, the post-surgical hip replacement in room 5, etc.  Nursing education must change if we expect to have nurses provide holistic care vs. focusing on the person’s bio-medical needs and issues.

IHPC: How does AHNCC work to address these issues?

ME: –AHNCC is the national credentialing body for Holistic Nursing and Nurse Coaching. We work closely with the American Holistic Nursing Association (AHNA), which is our membership organization. AHNCC’s mission is to provide rigorous, valid examinations that test holistic nurse and nurse coaches’ knowledge, skills, expertise, attitudes, and values. Although our nurses may use healing therapies/interventions such as massage, aromatherapy, or healing energy, it’s not what defines them.  They are just additional tools that they carry in their tool box.

To apply for holistic nursing certification, AHNCC applicants must complete educational programs and courses that focus on holistic nursing theory, research, practice, spirituality, health, wellness, wellbeing, etc. Many of these educational programs are offered by AHNA or by other accredited institutions or organizations. Recent, active nursing practice is also required. AHNCC also offers nurse coaching certification which is geared toward the skills, knowledge, expertise, values, and attitudes utilized when practicing in the role of nurse coaching. Our nurses work in all settings and with people throughout the lifespan. At this time, we credential only RNs; we don’t have programs for other disciplines.

IHPC: You have been involved with the organization two decades. How have you seen it evolve?

ME: AHNCC started with one exam in 2000: we now have 5 and two certification programs (holistic nursing and nurse coaching). We are very proud of that.  In addition to the two certification programs, AHNCC has acquired national accreditation from the ABSNC, and our examinations are ANCC Magnet approved. Both of these recognitions validate the rigor and value of our certifications. AHNCC also works with universities around the country to create holistic-based nursing curriculum because how we educate nurses is so important. If we educate only about symptoms, illness, and disease then you have nurses prepared to work within and support a sick-care system.

We believe that self-awareness, self-reflection, self-care, and ongoing growth and development is essential to holistic nursing practice. What I learned 20 years ago is not sufficient for what I need to know now. As a holistic nurse, one is expected to continually commit to learning experiences and educational opportunities to support the lifelong learning process.  With that in mind, we have built a repository for current educational programs that will support our certificants’ lifelong learning needs. We have seen a lot of growth and many changes in the last 20 years, but it is not happening fast enough.

IHPC: Nurses are under a lot of pressure in the current COVID-19 crisis. How do you see their role changing as a result?

ME: Self-care is something we have been talking about for 40 years, but COVID is bringing it forward full force. Self-care is not just for patients. It means caring for yourself as a nurse so you can care for others.  You have to have balance and a sense of harmony to do that.  I also facilitate self-care for my patients so they have resources to do what they need to do to get well. It’s a big problem now, as we see nurses and other healthcare providers who are stressed out; nurses leaving the profession or retiring earlier than ever before. But we are making progress. The importance of caring for self and how it impacts a nurse’s or other care providers’ resiliency and decreases compassion fatigue and the need for care providers to have the support and resources so they can care for others is being recognized and valued.

The role of holistic nursing is also becoming more prominent in the COVID era. The ability to be present, hold a hand, support families and people who are dying has often been absent during this pandemic, and these services have been missed. Nurses and those they care for expect and need to have their physical needs met, but what has been missing and is often shared by distraught nurses is their ability to address the client’s spiritual, emotional, and social needs. We need to pay attention because viruses don’t go away. We need to learn to live with them. One of the things we can do is to help people build stronger immune systems and seek higher levels of wellbeing. How we feel and think, what we eat, the stress we experience, toxic relationships, etc. all impact on our ability to stay well and fight off viruses or other health challenges. We also know that the healthcare system we have is broken, and we need to make changes. A paradigm shift is required which moves our focus from illness and disease to health, wellness, and wellbeing. COVID has challenged and highlighted what isn’t working and given us the opportunity to keep what is working, and make the necessary changes that will better serve all of us.

IHPC: You have an expanding role with IHPC. What do you hope to accomplish?

ME: One thing I am encouraging IHPC to do is to continue think about who we are as organization.  Are we a collection of integrative practitioners who practice separately or a holistic integrative organization working together, grounded in our values and philosophy. Who do we serve? We need to dialogue more about the intent of our work and our mission, collectively, as an organization.

The challenge in healthcare is to get out of our silos while respecting and validating what each profession offers and to recognize the expertise, skills, and knowledge each profession can share with the collective group. Traditionally in healthcare we have had a linear, patriarchal system. Our system is top to bottom with clients at the bottom and that needs to change. I believe that all of healthcare providers are my colleagues. We work and collaborate together to empower and facilitate the client in healing. That if anyone is in the driver’s seat, it is the client. I know I have a different perspective than some of my colleagues. We often talk about patients being noncompliant. I believe that is because we are approaching it the wrong way. We need to be empowering the client–who by the way has the most invested and the most to lose–to co-create a plan of care with them that they buy into. When people are supported–given control and choices–they engage and healthcare outcomes become very different.

IHPC: You are also working with IHPC to address issues of equity, diversity and inclusion in health care. How can this lead to a change in the system?

We have systemic problems in healthcare, the government, and education. As an organization, IHPC’s intent is to address making healthcare accessible for all. I think we need to become more educated and informed if we are to work towards our goal of equal access and health care services for all people, especially the vulnerable and disenfranchised populations. Our communities, society, and even globally is only as strong as our most vulnerable populations. Learning about equity, diversity, inclusion, and social justice (EDISJ) issues and how we change systemic racism will impact on not just who sits on the Board, but on how IHPC presents ourselves, our policies, and procedures, our committee work, etc. We all have blind spots, so we have to commit to learning opportunities that present themselves and recognize that this is an ongoing process.  Working with Tracy Bowen, Executive Director at IHPC, is helping me to realize some of my own blind spots. The more blind spots we uncover, the more of a holistic understanding and perspective we will have to address these critical issues.

As a starting point, I believe that IHPC needs to begin our EDISJ education, so we will be better able to do our work. Currently, we have a fairly homogenous organization, our diversity is not great. More diversity will broaden and strengthen our world view. Diversity makes us stronger and allows us to have more resources to do our work. As our organizational worldview expands and we have fewer blind spots, we will be better able to serve our stakeholders.

Going back to my American Indian patient, if we had had someone there who could have bridged that gap, we would have been more attuned to his needs. So that is one of the areas I am working on: to see that our world view is expanded. The broader it is, the more effective we will be in supporting health, wellness, and wellbeing for our clients and society at large.

IHPC is a great model for interdisciplinary work, and I believe a team approach is the future in health care systems. IHPC is one of the few organizations I have worked with that sets the intent to honor and respect each other. It has great potential for helping change the paradigm. We just have to get past the growing pains, like all organizations. It is a wonderful inclusive model, and I would like to see this idea accepted, valued, and implemented in all health care systems. By elevating, recognizing, and validating the significance and worth of integrative practitioners like acupuncturists, naturopaths, or chiropractors, we are better able to serve our clients and communities.

Perhaps now, COVID, the continued highlighting of systemic racism, our sense of being disconnected from our loved ones and support systems, extreme economic upheaval, and other issues that have changed how we live our lives as we knew it, etc. are creating a perfect storm which will mandate systemic changes. We need to embrace this opportunity. Change is hard, but we can do it.

“Pain-demic” – Fallout from COVID-19 Congressional Briefing
The Opioid Epidemic and Recommendations for Non-Drug Approaches to Pain Management

WASHINGTON, DC – July 30, 2020 – The “Pain-demic” bi-partisan virtual briefing hosted by the Integrative Health Policy Consortium (IHPC) and the Congressional Caucus for Integrative Health and Wellness highlighted how COVID-19 has exacerbated the nation’s raging opioid crisis and amplified the need to remove barriers to essential cost effective, non-opioid, non-drug pain treatments.  “Unfortunately, the measures we have taken to control  the spread of the Corona Virus have only exacerbated our fight against another crisis, the Opioid epidemic,” stated Congresswoman Judy Chu (D-CA) Co-Chair of the Congressional Integrative Health and Wellness Caucus.

This briefing identified current highly effective Federally sponsored programs that are proving the effectiveness of non-opioid, non-drug pain management.  U.S. Department of Health and Human Services (HHS) Task Force Chairperson and pain management expert, Vanila Singh, M.D. presented the groundbreaking findings and recommendations of her 29-member, inter-agency Task Force, in their exceptional Best Practices in Pain Management report. “The Congressionally mandated Pain Management Report establishes a 360-degree strategy to effectively address the various chronic painful conditions in a patient-centered, individualized manner that presents all the various treatment modalities utilizing non-pharmacologic and pharmacologic integrative health solutions.  The recommended best practices present effective and compassionate approaches to acute and chronic pain with the aim to improve clinical best outcomes with an improved quality of life for the millions of Americans suffering from chronic pain,” stated Dr. Singh.

Federally Qualified Health Centers (FQHC) are leading the way in implementing the HHS Task Force best practices to address the opioid crisis.  FQHC’s are the nation’s largest public healthcare safety net caring for 30 million children and adults who are part of our rapidly growing Community Health Center population.  Sharad Kohli, M.D., a FQHC family physician, detailed his experience “in the trenches” bringing non-drug, innovative pain management programs to some of the hardest hit communities in Austin Texas.  Dr. Kohli shared that a major challenge is that these effective non-drug approaches are not reimbursed through insurance programs.  “If we can figure out how to make the non-drug treatments reimbursable, then we could widely expand our services and would not be dependent on limited grant funds.”  Dr. Kohli also stated that he is uncertain how many FCQHC’s are currently using these effective non-drug pain approaches as there has not been a survey to assess how many Clinics are adopting the recommendations as yet.

“We are working to expand access to non-opioid alternatives to pain management, and committed to educating patients and providers about these innovative options,” stated Congresswoman Jackie Walorski (R-IN), Caucus Co-Chair and supporter of recent key language in the 2021 Appropriations Bill to that effect. Indeed, the U.S. House of Representatives included language in a report accompanying its version of the Fiscal Year 2021 Labor, Health and Human Services and Education Appropriations bill requesting that the Department of Health and Human Services develop a plan for disseminating and implementing the Task Force Report’s recommendations. “It is essential that as we look towards recovery, we ensure that Integrative Health policies are included.  We need to ensure that patients have access to non-opioid, non-surgical options like Acupuncture, to treat their chronic pain.  These therapies are non-addictive and do not carry similar risks of overdose,” stated Congressmember Chu.

To view the recorded briefing/slides: http://www.ihpc.org/the-congressional-integrative-health-and-wellness-caucus/

To access HHS Task Force Report & toolkit:  https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html

About the Integrative Health Policy Consortium:

The Integrative Health Policy Consortium (IHPC), a trusted voice on Capitol Hill, is comprised of 26 professional organizations and institutions representing more than 650,000 state-licensed and nationally certified healthcare professionals.  IHPC champions the Congressional Integrative Health & Wellness Caucus and functions as a critical watchdog of the federal agencies overseeing America’s health and health

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FOR MORE INFORMATION CONTACT:
Tracy Bowen, Executive Director
Integrative Health Policy Consortium, IHPC
(202) 746-1663 / Tbowen@ihpc.org

Reevaluation, vision and opportunity

In times of trouble or when crisis strikes, what is most important to us usually becomes crystal clear. The global pandemic and the surging movement to finally end systemic racism have sharpened that clarity for IHPC through its mission to eliminate barriers to health for All.  Over the last four months that has translated into increasing our advocacy with lawmakers to meet the immediate needs of the integrative health community, to elevate the efficacy and fiscal importance of a wellness approach to health, and to seize new opportunities to impact the healthcare debate during this time of extraordinary change.

This week, as a result of these efforts and the leadership of the Congressional Health and Wellness Caucus co-chairs, Congresswoman Judy Chu (D-CA) and Congresswoman Jackie Walorski (R-IN), as well as Congressman Tim Ryan (D-OH), the House Appropriations committee added language directing the U.S. Department of Health and Human Services (HHS) and the Veterans Affairs Administration (VAA) to implement measures that will expand the availability of integrated health services and open new opportunities for integrative health providers.  Specifically, HHS is to implement recommendations of the HHS Pain Management Best Practices Inter-Agency Report and VA is to expand its ground-breaking Whole Health System of Care program.  You can review specific language of Labor, Health and Human Services and Education Appropriations Bill here and the Miliary Construction, Veterans Affairs and Related Agencies Appropriations Bill here.

IHPC Executive Director, Tracy Bowen, stated, “The inclusion of this language is a major step forward toward meeting our larger objective of having integrative health recognized as a cornerstone of our nation’s healthcare system.”  The early days of the pandemic saw Bowen and the group’s Capitol Outreach Team shifting their focus to aggressively address integrative health issues relevant to the pandemic such as telehealth, insurance reimbursement and inclusion in legislation for healthcare pandemic relief. “When the COVID crisis came into full swing, our first concern was to get support for integrative health professionals during this difficult time,” said Bowen.  “We also recognized that this crisis presents a unique opportunity to raise awareness about the critical importance of integrative health professions and a wellness approach to healthcare.”

“The pandemic has highlighted many of the deficiencies of our current healthcare system, which has prioritized acute and reactive care instead of prevention, lifestyle modifications and wellness for chronic disease,” noted David Fogel, MD, CEO and co-founder of CHI Health Care, and an IHPC at-large board member and co-chair of IHPC’s Policy Committee. Because IHPC has now established a place at the table for emergency relief, Fogel said, it will help the group remain relevant for further dialogue and opportunity in the future. “We are advocating for language and strategies that will affect the larger footprint of health and wellness for years to come, and our current engagement with congressional leaders is establishing momentum for our long-term core policy agenda,” Fogel added.

As the group developed new strategies and priorities, Bowen and the IHPC board kept coming back to one essential truth. “We realized that our COVID efforts must reflect our mission of eliminating barriers to health — to provide access to wellness approaches to health.”  The brutal murder of George Floyd and the subsequent national upwelling to end systemic racism elevated IHPC’s dialogue about health disparities and structural inequities, sharpening the focus on eliminating barriers to health for All. “We are deeply committed to our own internal work of equity, diversity and inclusion and to elevating our policy focus on access to wellness care in underserved populations.” Bowen noted.

An Enduring Mission in a New Normal

IHPC continues to watch and advocate for inclusion of the integrative health community in future Congressional COVID-19 economic relief packages, but the group is also redoubling their efforts on their core policy agenda.  IHPC believes that its mission to eliminate barriers to health by championing systemic change to U.S. healthcare and prioritizing health creation over reactive disease management is now more meaningful than ever. IHPC’s 2020 four key focus areas continue to be relevant:

• Expand awareness of the nation’s pain and opioid crisis, which has been severely impacted by the COVID-19 crisis, and advocate for accessible, non-pharmacological approaches to pain management.
• Elevate a whole person model of care that champions a patient-centric and interdisciplinary care team.
• Advocate for veteran’s health by promoting the Veteran’s Whole Health program, a federally funded systems-approach to healthcare.
• Support the nation’s Federally Qualified Health Centers (FQHCs), a system of Community Health Centers which provides health services to more than 29 million uninsured or underinsured people nationwide, and advocating for their use of integrative health professions.

As the world shifts to a new standard of social engagement through virtual events, IHPC is finding that it can actually access a much larger audience than ever. “Because we are no longer limited to physical space and time to go from one office to another, we can reach a lot more people at the same time, and it makes it easier for staff to tune in or watch a recording later,” Fogel said. As a result, IHPC, in collaboration with the Congressional Integrative Health and Wellness Caucus, will host a virtual congressional briefing on July 24^th (see the invitation here). “What always gets the attention of staffers on the Hill is an event that will impact a member’s constituents,” said Fogel. These virtual events, he explained, are “gaining momentum because they offer the possibility of a much broader audience interested in these issues, who will be writing, calling and emailing their members of Congress.”

As IHPC continues to adapt to the immense challenges brought about by COVID-19 and to respond to its enhanced mandate to eliminate barriers to health for All, the group has discovered new energy and meaning in the tasks at hand. Even though things are changing at lightning speed, the challenges are fueling the IHPC membership’s passion and energy to support the mission of IHPC.

House Appropriations Committee Supports IHPC Priorities

July 14, 2020

The Integrative Health Policy Consortium (IHPC) praises the U.S. House of Representatives Appropriations Committee for including language in two recent reports accompanying the Fiscal Year 2021 Labor, Health and Human Services and Education Appropriations and the Fiscal Year 2021 Military Constructions, Veterans Affairs Appropriations bills addressing priorities of the integrative health care community.

Specifically, reports accompanying these essential annual funding bills include language urging:

1. The U.S. Department of Health and Human Services (HHS) to widely disseminate and to create a strategic plan to implement recommendations in the HHS Pain Management Best Practices Inter-Agency Task Force Report; and,
2. The Veterans Affairs Administration to support and expand the Whole Health System of Care (WHS) program.

The language, as it appeared in both reports, is listed below.

IHPC is very grateful to the co-chairs of the Congressional Health and Wellness Caucus, Congresswoman Judy Chu (D-CA) and Congresswoman Jackie Walorski (R-IN), and to Congressman Tim Ryan (D-OH) for their leadership and for championing the inclusion of these provisions in both appropriations reports.

IHPC looks forward to working with Congress and the Administration to achieve the ambitious goals articulated in both reports.

LABOR, HEALTH AND HUMAN SERVICES AND EDUCATION APPROPRIATIONS BILL, 2021 (click for full Bill)

Chronic Pain.—The Committee remains concerned about the public health epidemic of acute and chronic pain, including its interrelationship with the opioid crisis. The Committee is pleased with the release of the HHS Pain Management Best Practices Inter-Agency Task Force Report in May 2019, but remains concerned over delayed dissemination and implementation of the Report’s recommendations. A strategic plan to disseminate the report and implement recommendations is needed, and the Committee strongly encourages the Department to widely disseminate the Report to health care providers and other public health stakeholders, and to update relevant pain management policies and educational tools to reflect Task Force recommended best practices across all relevant HHS agencies, including the CDC, CMS, SAMHSA and other relevant agencies. The Committee also urges the Department to coordinate with the Department of Defense and Veterans Affairs to launch a public awareness campaign to educate Americans about acute and chronic pain and the evidence based non-opioid treatment options that are available, including non-opioid medications; interventional procedures such as nerve blocks, injections and surgical devices; behavioral health approaches such as cognitive behavioral therapy; and complementary and  integrative health therapies such as massage therapy and acupuncture. (page 204)

MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES APPROPRIRATIONS BILL, 2021 (click for full Bill)

Continued Support and Expansion for Whole Heath.—As of October 2017, 18 VA medical centers have received funding to implement the Whole Health System of Care (WHS). WHS, a three-year pilot program, meets the intent of the Comprehensive Addiction and Recovery Act by delivering patient-centered care and complementary and integrative health approaches to our nation’s Veterans especially those who are struggling with opioid use disorder and chronic pain. In January 2020, VA released an evaluation of the WHS, which concluded: (1) the program had a positive impact on reducing opioid use among Veterans; (2) Veterans who used WHS, compared to those who did not, experienced greater improvements in perceived stress indicating improvements in overall wellbeing; and (3) comprehensive WHS service revealed potential savings in pharmacy costs. The Committee is pleased by the results of this evaluation and urges VA to continue supporting the WHS and to expand it beyond the 18 flagship sites in fiscal year 2021. (page 65)