A Whole Health Model of Care to Promote Social and Racial Justice

Purpose: Whole health models of care focus on care coordination across sectors, address the needs of older adults with multiple chronic conditions (MCC) and reduce barriers to care. These models reduce the risk of fragmented care that does not improve health care or meet patient needs.^[1] These models are complex, focus on six determinants of health recommended by the CDC (biological, psychological, individual health behaviors, access to health services, environmental and social) ^[2], and demand indicators that reflect this complexity.^[3] The FlourishCare Model (FCM) transforms primary care sites by addressing all determinants of health and focusing on helping patients to flourish. Flourishing represents adaptation to age-related changes and reduction of abilities, along with positive gains and strengths associated with old age.^[4] The FCM is delivered by an inter-professional team in primary care settings. The FlourishCare Index (FCI) was developed as a clinical measure to assess the effectiveness of the FCM to address all determinants of health. The FCM and FCI were developed as part of HRSA’s GWEP Program.

Methods: The FlourishCare team will present data on the effectiveness of the FCM serving 159 older adults with MCCs. We used a two-level longitudinal design and hierarchical linear modeling to test a multilevel growth model where measurement occasions per patient ranged between 2-5. We examined individual differences in FCI scores from baseline to their last measurement occasion and tested potential predictors, modeling a random intercept and slope model.

Results: The sample was mostly female (77%), White (64%), retired (54%), married (30%) or widowed (20%) and living in urban areas (64%). The mean age was 69 (SD=15), with 13 years of education (SD=3). The results show that patients changed significantly over time on total FCI scores (57%-72%;ß=3.80,SE=0.63). In breaking down the determinants, results show significant growth over time for individual health behaviors (58%-67%;ß=2.14,SE=0.84), health care access (71%-89%;ß=4.43,SE=1.00) and social determinants (62%-85%;ß=5.54,SE=1.02) with psychological determinants (54%-61%;ß=1.74,SE=0.95) and environmental determinants (70%-81%;ß=2.81,SE=1.62) showing a trend to significance. Biological determinants only showed significant growth for rural patients (32%-45%;ß=3.46,SE=1.68). Interaction effects with time show that the FCM was able to support patients with lower education attainment to improve at a higher rate than those with higher education attainment, both for the total score on the FCI (ß=-0.59,SE=0.24) and for health care access (ß=-0.94,SE=0.38). Receiving mental health counseling resulted in more improvement in psychological determinants than those who did not receive counseling (ß=3.43,SE=2.04). The FCM was able to support rural patients at a higher rate than urban patients to gain access to health care (ß=4.13,SE=2.02). The FCM supported Hispanic patients the most in improving their social determinants of health (ß=8.40,SE=3.93).

Conclusions: This study showed the importance of a systems approach to care that incorporates a whole health approach using measures that focus on what matters most to patients, especially for older adults who place importance on quality-of-life outcomes. Furthermore, the study showed how a whole health approach to care can address equality by accelerating the flourishing of rural, Hispanic patients with lower educational attainment, promoting social and racial justice.