Measuring What Matters Most

Traditionally, the US health care system has focused on improving disease outcomes for individuals and populations. Yet more recently, we have become aware that the absence of disease or disease-state symptoms does not always translate into benefits for individuals’ broader lives. Thus, a shift is occurring where the relevant outcome is the extent to which the health care system improves individuals’ Whole Health, well-being, and functioning in their daily lives. The National Academy of Sciences, Engineering, and Medicine defines Whole Health as “physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities…[which] aligns with a person’s life mission, aspiration, and purpose.¹

A number of other institutions and government agencies have begun exploring this “new frontier.” At the National Center for Complementary Integrative Health at NIH, developing Whole Person outcome measurement approaches is a core component of the current Strategic Plan,² and several other NIH Institutes are now collaborating on this effort. Moreover, as we focus on Whole Health, there is a growing call for changes in metrics to account for individuals’ well-being. For example, the US Department of Health and Human Services has established an interagency working group to inform strategies for measuring well-being as part of the Healthy People initiative. The Surgeon General has called for a “Whole Person” approach to address the many serious public challenges we face in the United States, including the epidemics of obesity, substance use, suicide, depression, and loneliness.³

For the past 10 years, the Veterans Health Administration has been developing, implementing, and evaluating a “Whole Health” approach to care.⁴ The Whole Health approach aims to expand the mission of the health system beyond an exclusive focus on disease management and disease prevention, to a focus on the whole Veteran and what matters to them most in their life. The Whole Health System, as it is being deployed in the VHA, incorporates peer-to-peer support, health coaching, evidence-based complementary and integrative health approaches, and a commitment to incorporating what matters most to the Veteran into all aspects of clinical care. As this philosophy of health has taken root across the Department of Veterans Affairs, the concept of “well-being” has come more and more into focus as a system priority, to the degree that the VA Strategic Plan for 2022–2028 mentions the term “well-being” a total of 34 times.⁵

As a consequence of this expanded focus and mission, the Department has now taken on the task of defining well-being and developing a strategy to measure our progress in supporting Veterans in improving their well-being over time. As a first step in that process, VA Health Services Research sponsored a State-of-the-Art Conference on “Measuring What Matters” in March 2023, bringing together experts and thought leaders from the VA, other research institutions, government agencies, Veterans Service Organizations (VSOs), and Veterans themselves, along with their caregivers and families. This special issue of Medical Care outlines the discussion and conclusions from that meeting.

The perspectives and original research contained in this special issue begin to solidify and expand our understanding of efforts to measure and enhance the whole health and well-being of the whole person. Measuring well-being in health care is a relatively new field, and as described by Vogt et al,⁶ our SOTA identified key directions for well-being measurement in the context of clinical care, research, and population health. The importance and complexity of well-being measurement in a wide range of settings are reflected in several perspective pieces. Langevin⁷ elaborates on the intersection of health and well-being, identifying both aspects of well-being that are central to health and those that serve as determinants of health and situating the expansion of Whole Health at NCCIH and NIH. Britch et al⁸ provide a veteran perspective on the importance of attending to the social well-being of Veterans within the VA health care system. Perspective pieces also reflect on the value of shifting away from the measurement of deficits in favor of the measurement of well-being. Blonigen et al⁹ discuss how to assess well-being in the context of Maslow’s hierarchy of needs, particularly when thinking about vulnerable individuals with high levels of social needs. They argue for prioritizing whole-person growth needs as essential aspects of well-being for these populations. Tsai and Jones¹⁰ reflect on the movement toward age-friendly health care systems, which take more of a life course perspective on the whole person’s health and well-being and what constitutes successful aging. Herman et al¹¹ discuss the difference between Whole Person health and Whole Person determinants, emphasizing the former as the goal and the latter as potential points of intervention. At a broader policy level, Hoyer et al¹² describe the inclusion of well-being in Healthy People 2030, elevating this as a national priority. They call for a common national framework for measuring domains of well-being. Hooshyar and Bruton¹³ continue the conversation about well-being measurement in policy by focusing on the need for revision of the International Statistical Classification of Diseases and Related Health Problems (ICD)-1 to include both social determinants of health and the well-being of the whole person. Finally, Parr et al¹⁴ present a scoping review of what is already known in the literature about whole-person outcomes in clinical care.

In addition to these thought-provoking perspectives, this issue contains a group of research papers that use well-being measurement in a wide range of clinical contexts. These include Galovski et al,¹⁵ who describe a study of a peer intervention for Women Veterans and argue for the inclusion of belongingness as a key component of well-being. Chera et al¹⁶ describe how the Age Friendly Health Systems initiative can be incorporated into the emergency department. Etingen et al¹⁷ describe the challenges with implementing a new measure of well-being in clinical care, reflecting the issues and opportunities involved in incorporating well-being measurement into the health care system. Other papers examine different ways of assessing well-being. McQuade et al¹⁸ explore the use of a personal care planning tool, the personal health inventory, as a way to assess changes in well-being in the context of a wellness intervention for Veterans with Gulf War Illness. Vogt et al¹⁹ introduce 2 well-being measurement approaches that have been specifically designed for use in clinical settings. Reed et al²⁰ explore the relationship between the PHQ-2, a common screen for depression, and measures of well-being, demonstrating the limited ability of clinical measures to capture information of the broader context of patients’ lives. Weber et al²¹ explore how patients respond to questions about well-being in the context of PTSD treatment, documenting the importance of goals related to enhanced functioning and well-being as well as reduced symptomatology. Finally, Elbogen et al²² focus on a different aspect, financial well-being, discussing how financial well-being affects physical health among Veterans.

This special issue thus begins the conversation about how, through measurement, health care systems can begin to ensure that they do not only address disease but also focus on what matters most to the individuals suffering from those diseases. Finding optimal ways to address well-being requires that we measure it so that we can turn our focus toward improving the lives of individuals.