As the health care field searches for better ways to provide care that improves outcomes and controls costs, organizations are seeking innovative ways to understand and respond to the full range of medical, behavioral health, and social needs of patients. Widening the lens of how we think about the purpose of health care services to include supporting and fostering wellbeing in patients and clients may be one way to get there. Wellbeing is defined by the Full Frame Initiative as “the set of needs and experiences that we all require for health and hope.” Thinking about increasing access to wellbeing as a pathway to health, rather than the other way around, may meet patient needs more effectively than traditional approaches that typically address medical, behavioral health, and social needs in separate and uncoordinated ways.

The Center for Health Care Strategies (CHCS) recently spoke with Tanya Tucker, chief of national partnerships and outreach at the Full Frame Initiative, to understand how a focus on wellbeing can help transform patient care. The Full Frame Initiative partners with communities and social service, health care, and other institutions providing coaching, technical assistance, tools, and resources to infuse their work with a wellbeing orientation in pursuit of stronger outcomes — particularly for people experiencing poverty, violence, trauma, and oppression. Ms. Tucker serves as an advisor for Advancing Integrated Models, a national initiative led by CHCS and made possible through support from the Robert Wood Johnson Foundation.

Q: Can you describe the Five Domains of Wellbeing developed by your organization?

The Five Domains of Wellbeing are the essential set of needs that are universal to humans. Every day, people strive to meet these needs, influenced by their own unique contexts, histories, and communities.

A: The Five Domains of Wellbeing are the essential set of needs that are universal to humans. Every day, people strive to meet these needs, influenced by their own unique contexts, histories, and communities. There is no hierarchy to these domains — one is not more important than another. Yet too often, our systems focus on progress in one domain, forcing difficult and unsustainable tradeoffs in other areas.

Social connectedness is about creating a sense of belonging and value. It refers to the relationships that people have in their lives to give and receive information, emotional support, and material aid. There’s a reciprocity about social connectedness that rarely gets attention. It’s not just about whom you can depend on, but who depends on you.

Stability is the degree to which people can expect their situation and status to be the same from day-to-day. Unfortunately, some patients may have their stability interrupted by well-intentioned interventions, so paying attention to routines and anchors in peoples’ lives is important. Anchor disruption can be anything from little things like not having your morning coffee, to bigger things like routines with family getting disrupted because of children being displaced into foster care, or prescribing certain treatments to patients that may interfere with a familiar routine. Our sense of stability might be measured by having the sense that small disruptions or changes won’t set off big cascades — that there’s some give and flex in life, and that we can weather what comes our way.

Safety is about how we can truly be ourselves without risk of physical and emotional harm. It isn’t about comfort — it’s about those core parts of our identity being under threat — our race, our gender, our orientation, our religion, and our trauma histories. All of the domains are individually realized, but particularly with safety, we tend to tell people whether or not their experience is “valid.” In reality, I can’t tell you when and how you should feel safe. I may feel safe in one situation, but because of who you are and your context, you wouldn’t feel safe.

Mastery is about having a sense of influence and choice in the decisions that you make about your future, your environment, and your relationships, and seeing a correlation between your effort and an outcome. It’s tied to purpose. A common misconception is thinking you have to master something to feel mastery. Making progress on something could be mastery to you, as long as it’s important to you and others recognize and value your efforts.

Meaningful access to relevant resources is how we can meet our core needs in ways that aren’t difficult, degrading, or dangerous. I get to determine what’s relevant and important to me. People may get access to resources or referrals to services, but if it isn’t something that matters to them or if they feel shame when trying to access it, that is not meaningful.

Q: For providers, how can an awareness of wellbeing change how they deliver services and potentially impact patients?

The biggest reason providers are wary of adopting a wellbeing approach is that patients will reveal more problems than providers can address. The reality is that focusing on wellbeing can actually reveal assets and strengths that patients can build on to help support them in working through issues.

A: People often seek health care when they’re in vulnerable situations and naturally, providers want to help “fix it” — and thus, get narrowly focused on the problem. A wellbeing approach helps a provider understand the significance of an illness or a condition in a person’s life and how that illness is affecting their wellbeing, which then informs a possible response. The wellbeing frame motivates providers to ask questions that focus more on the patients’ lives and what resources they are well connected to, which helps broaden their understanding of patients and their communities.

The biggest reason providers are wary of adopting a wellbeing approach is that patients will reveal more problems than providers can address. The reality is that focusing on wellbeing can actually reveal assets and strengths that patients can build on to help support them in working through issues. We aren’t asking providers to become experts on everything — we’re suggesting that by bringing in the richness of people’s lives, it is possible to work collaboratively with patients to come up with better solutions.

Q: Do you think using a wellbeing frame when caring for patients also supports staff wellbeing?

Wellbeing is a must-have for all of us.

A: A myth that we work hard at tearing down is the view that a wellbeing focus is just “nice to have” in an organization. Some organizations see it as something that they might get around to eventually and can kind of sprinkle on top. However, wellbeing is a must-have for all of us.

Across this work, particularly for people who are on the front lines, burnout is extremely common. Focusing on wellbeing helps providers tap back into their own sense of mastery and purpose and allows them to reconnect to why they got into this work to begin with — the mission and vision.  It also gives them permission to move away from thinking about one disease at a time, an approach that can often be alienating for the patient and frustrating for the provider. This different frame allows providers to use creativity and relationship building to find the best solutions for their patients, which could result in improvement of not only the wellbeing of their patients, but their own as well.

Q: What are practical steps that providers can take to adopt a wellbeing orientation? What are challenges to doing so?

A: Something practical that providers can do is ask new kinds of questions that don’t lead with the illness that brought the patient in. A wellbeing orientation starts with understanding how the condition impacts their wellbeing — why it matters to them to get better. Asking how this illness has affected the patient and their life helps us to understand what is motivating the patient and helps us intervene in a way that won’t cause unsustainable tradeoffs. This information gives providers the opportunity to think about patients as more than an illness, allowing them to build more trusting relationships and work with their patients to come up with potential solutions. This approach to care is not dissimilar from the Camden Coalition’s COACH Model, that also puts relationship building with the client first and foremost, and where the goal is to support a client’s wellbeing and capacity to care for themselves.

One challenge is that health care systems are set up to compartmentalize the issues and medical problems that people face and deal with them separately when they may actually be related. A wellbeing approach is about putting all of these siloed pieces together and embracing the complexity and messiness of people’s lives.

Q: Can you talk a little bit about the relationship between wellbeing and equity?

You can’t really do this work without a focus on equity, because it isn’t just about individual decisions or willpower — it’s about the structural forces that are getting in the way of people having equitable access to wellbeing.

A: Wellbeing and equity go hand-in-hand. You can’t really do this work without a focus on equity, because it isn’t just about individual decisions or willpower — it’s about the structural forces that are getting in the way of people having equitable access to wellbeing. Sometimes great interventions aren’t enough to help people progress — we also have to dismantle the oppressive structures that impact wellbeing.

This is not for one person or system to do, but it’s for all of us to work together on. It took a long time to create the systems the way they are and it’ll take a long time to shift them to be more equity-focused. We can’t stop cycles of poverty and oppression overnight, but having that collaboration between systems, staff, consumers, and leadership working toward this goal — with a focus on wellbeing as a way to get there — is a good place to start.

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Lisa N
6 months ago

I love this discussion! As I imagine sharing this insight with our community partners who work in fast-paced (overbooked?) clinics, I anticipate resistance will set in — the response will be “We just do not have the time”. But, if this is what it takes to move the needle, we have to make time and trust this process. I think we (I?) become impatient and set sights on the end-goal. But, this approach is one of the missing links to effective care coordination and building self-efficacy. Slooow down, be present, listen and observe. Watch for the unfolding as the relationship… Read more »

Paul J Nelson
6 months ago

As a basis to inform the concept of well-being, I would recommend a philosopher’s analysis of the historical antecedents that underlie an understanding of well-being. Professor Neera K. Badhwar began with the writings of Aristotle and referred to the evolution of thought that has established its contemporary understanding. Her book, Well-Being: Happiness in a Worthwhile Life, was published in 2014. It should be on the shelf of any person who endeavors to prevent, ameliorate, and mitigate the loss of social cohesion within every person’s community.