When First Sgt. John Cassata, a combat medic who served in the U.S. Army Medical Corps for 26 years, retired from the service a decade ago, Veterans Affairs clinics were a lot different than they are today.

In fact, when Cassata retired, the Veterans Affairs Community Based Outpatient clinic in Clarksville where he now serves as a whole health partner, didn't even exist. The 34,000-square-foot facility operated by the Tennessee Valley Healthcare System opened a little more than a year ago. The clinic serves qualified veterans, and focuses on primary care and mental health services.

Audiology, laboratory and optometry services, nutrition, pharmacy support, social work and radiology also are provided at the clinic.

Now, the clinic's staff are innovating veterans' medical care even more by addressing veterans' concerns using a holistic approach through the VA's new Whole Health System.

"Ever since I retired, the VA has changed tremendously ... especially here in the last year or two," Cassata said.

'A proactive approach'

The patient's personal health plan is the core of the Whole Health System. To develop that plan, clinic staff partner with the veteran to discover their mission. That process begins with whole health coaching.

Todd Raley, whole health coach at the clinic, said the cultural shift is a change from the traditional model which hinges on the question "What's the matter with you?" to a contemporary "What matters to you?"

"When we just treat the medical diagnosis, that is what the veterans become to the medical provider. They become identified by that injury, illness or diagnosis," Raley said. "Oftentimes we lose sight of the whole person. Switching that paradigm seems like a subtle change, but it's huge."

Veterans are not required to participate in the Whole Health System.

"This being a proactive approach and looking to empower veterans, you can't make something mandatory and think you are empowering someone," Raley said.

All clinic patients are informed about the system and invited to engage. Should a patient be interested in participating, the process will begin with a session with a whole health coach. The Clarksville clinic employs five coaches.

During the first session, the coach will introduce the veteran to the Personal Health Inventory. The PHI addresses the following eight key components: working your body; surroundings; personal development; food and drink; recharge; family, friends and coworkers; spirit and soul; and power of the mind.

"The PHI is designed to give the patient a snapshot of where they are at health wise and where they want to go," Raley said. "It helps veterans focus on what they want to work on. The beauty of the eight key components is that each one of those overlaps."

To explain the interconnectivity of the components, Raley referenced an example of a veteran struggling to sleep.

"If that veteran isn't sleeping well, then they don't have the energy to work out. They probably also aren't eating the best. That can affect their spirit and soul, because they get down," he said. "So by teaching someone some mindfulness techniques and body scans … they can feel calm and relaxed and go to sleep … we can help them improve their health."

A veteran's surroundings also can influence their sleeping habitats, he added.

"If the veteran doesn't feel safe in their surroundings -- where they work or live -- if someone doesn't feel physically or emotionally safe, when they are trying to lay their head down at night … they aren't going to sleep," he said. "That's how everything interacts."

After completing the PHI together, whole health coaches will work with patients to develop SMART goals, which are specific, measurable, attainable, realistic and time-based, Raley said.

"The program is veteran-driven, so the veteran gets to decide what they want to work on first. They know themselves better than anyone else, and they know what's important to them," Raley said. "The veteran decides what their goal is and what the action steps are."

To help veterans achieve their SMART goals, whole health coaches can refer them to whole health clinical care.

Patients also can be referred to in-house well-being programs such as self-care and skill-building support; health coaching and health partner support; and Complementary Integrative Health (CIH).

'Get the job done'

CIH clinic services include acupuncture, chiropractic, and physical and massage therapy.

Craig Anderson, the clinic's chiropractor, said one way TVHS is innovating on a national level is by having chiropractors, acupuncturists and physical therapists meet with patients at the same time.

"When someone comes into the CIH clinic they actually see multiple providers at the same time, and that's the difference," Anderson said. "Instead of talking afterward, we are talking in front of the patient."

During an appointment, providers will network with other providers in the clinic to best serve the patients in a timely fashion, he said.

"We will even pull in more providers if we think the patient may need additional services. We will pull those providers into the room and say 'let's talk' and do it right then," Anderson said.

This approach allows providers to communicate more openly and collaborate to develop the best care plan for each patient, he said.

"Bottom line, the idea here is to get the job done and to get it done without waiting," Anderson said. "We are trying to be really flexible with that. It's a new concept we just started doing less than a year ago. It's new, but it's already working really well"

Anderson said chiropractic medicine is an important part of the Whole Health System because back pain can affect many components of a person's life.

"Let's say the lower back isn't moving very well and that causes back pain. Let's say it's not moving properly because it was injured and never properly healed. Maybe that back injury causes the person not to exercise very much, but that exercise would help you, but you can't move because it hurts," he said. "That's where we come in. We can temporarily make things better so patients can exercise better and get into the lifestyle that is going to support better health."

In the CIH clinic, chiropractors work hand-in-hand with acupuncturists to provide care. Ashley Donato serves as the acupuncture physician at Clarksville's clinic.

Donato said acupuncture has been around for more than 5,000 years and is known for treating pain safely and effectively.

"It's time-tested and true," she said. "Acupuncture is best known for treating pain naturally without drugs. Our role here is to balance out the opioid crisis. We offer treatment as a team to treat patients with complex pain … multiple complex pains, chronic and acute."

When a patient is referred to the CIH clinic, the team first performs an evaluation assessment to format a treatment plan, Donato said.

"This isn't just passive care, this is for actually going somewhere with the patient and recommending different things such as nutrition, exercise, mind and body modalities, so we can treat the patient as a whole. The role of our clinic is to treat patients in pain."

Some exercises providers can prescribe are yoga, Tai Chi and kettle bell. All are provided through the clinic. These classes are open to all patients. A prescription is not required for participation.

'Right care at the right time'

Reflecting on the past ten years, Cassata said the culture surrounding the VA has changed to put veterans more in control of their health.

"Basically, when you got out of the military you couldn't really go anywhere, couldn't make plans or start a new job … because you had to go to these appointments. The choices were very slim. It was all one way … my way or the highway with the VA," Cassata said. "The way we've been transforming now is that it opens up doors and gives opportunities for veterans to take charge of their own situation and make their health care work best for them."

The expansion of care options also is a new development, he said.

"Instead of going in to see a doctor because my back hurts, them giving me a pill and telling me to go get a X-ray and come back in a year … that's no options. Now I have the option to ask to see a chiropractor and now they are just down the hall.," Cassata said.

Clinic staff also are working to better streamline the system, he said.

"Before, I would get a letter in the mail telling me I have to go somewhere at a certain time and place months later ... now it's days later, or maybe even same-day sometimes," he said. "There are more options and choices now. Instead of putting people right on the opioids, now we have options to choose from and we can use heavy medications as a last resort."

Having smaller, community clinics also are an improvement, he added.

"The benefit that we have in the community clinics is that we are a tight organization amongst each other. All the doctors, nurses and staff talk amongst each other, so when there is a special case, it's much easier to navigate because there isn't any red tape," he said. "It's much better for the veteran, because they are going to get what they need, when they need it. It's the right care at the right time. You can't get any better than that."

Veterans seeking care also are experiencing reduced wait times, he said.

"It used to be that you would see a doc, then a couple months later you would get a note in the mail … veterans were always waiting, waiting, waiting. Waiting and not feeling any better," he said. "Now, we are changing the culture, so veterans know when they come in here they are going to get the treatment they need when they need it, and not a minute later."

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