The Department of Veterans Affairs (VA) administers the largest integrated health care system in the United States. Although its image has been tarnished following last year's turmoil surrounding problems at some VA facilities,1 other VA facilities have received high performance ratings,2 and the implementation of reforms and new measures to improve access across the whole system is underway.3-4
Due to its size and scope, the VA's performance in delivering care to veterans is highly relevant to the broader U.S. health care system. Through its 150 hospitals and more than 1,400 other health care facilities, the VA provides care to over 8 million veterans each year, including more than 86 million outpatient visits and just under 700,000 admissions. The VA also operates the largest health care provider clinical training program in the U.S., encompassing approximately 120,000 trainees annually through partnerships with hundreds of medical and associated health schools.
VA chiropractors are committed to a common goal of providing the best care to improve veterans' health and well-being. Through the commitment to that goal, there emerges another important aspect to the work of VA DCs. Because of the VA's significance in U.S. health care, the success of the VA Chiropractic Program is important not only to the patients we serve, but also to the chiropractic profession at large.
Growing Participation by Chiropractors and Patients
Many readers will remember that the VA began providing chiropractic services after the passage of Public Law 106-117 in 1999.5 This allowed the VA to begin sending patients to private sector DCs through a process used for all health care disciplines known as fee-basis or non-VA care. However in 2001, Public Law 107-1356 required VA to begin providing chiropractic services on-site at select medical facilities.
In late 2004, the VA started implementing its initial group of on-site chiropractic clinics, and by the end of fiscal year 2005 there were 22 DCs providing care at 24 VA facilities. As of Feb. 2015, 72 DCs were providing care at 59 VA facilities.
The number of patients seen in VA chiropractic clinics has increased steadily each year. In fiscal year 2005, over 4,000 patients received chiropractic care on-site at VA facilities, and in fiscal year 2014, more than 29,000 patients received such care.7 There has also been an ongoing increase in the use of off-site private DCs to supplement the chiropractic care delivered at VA facilities. In fiscal year 2005, the VA referred approximately 1,000 veterans to private DCs; in fiscal year 2014, that number increased to 13,000.7
It is worth noting that the 1999 and 2001 laws mentioned above have been the only congressional mandates relative to VA chiropractic services. Other bills and resolutions that would have required additional expansion of VA chiropractic services have been introduced, but none has moved on to become law. Therefore, any expansion or development seen from 2004 through today represents the organic growth of this new service in a very large system, and reflects the positive influence resulting from the ongoing work of VA DCs.
In VA facilities across the country, these DCs are collaborating with other medical colleagues in team-based patient care, with each provider doing their part to deliver the best services for our patients. DCs are also part of interdisciplinary work groups and committees addressing issues including quality assurance, patient access, and administrative matters. The performance of VA DCs in the various roles at their facilities leads to improved interprofessional collaboration as other medical providers gain firsthand experience working with DCs.8
Advancing Research & Education
The VA Chiropractic Program has made important strides in research activities. Two major federally funded clinical trials have been conducted, as well as two projects with joint federal and private foundation funding, and numerous additional locally supported projects. More than 20 papers authored by VA DC investigators have been published in Medical Care, Spine, VA Journal of Rehabilitation Research and Development, Geriatric Orthopaedic Surgery, Military Medicine, JMPT and other peer-reviewed journals. Moreover, VA DCs have developed partnerships with researchers in other disciplines, both within and outside of the VA. This increases the overall research capacity, and strengthens the resultant work through the inclusion of additional research expertise.
The VA chiropractic program has also been responsible for key advancements in chiropractic clinical education. Since 2004, VA facilities have partnered with chiropractic schools to provide advanced clinical training rotations for chiropractic students. Currently, 19 VA facilities have affiliations with 11 chiropractic schools, and in total, more than 1,200 chiropractic students have been trained in the VA since the program's inception.
In July 2014, the VA implemented a historic educational innovation: the first federally funded graduate training program for chiropractic residents.9 Through this program, the VA provides one-year residency training in chiropractic integrated clinical practice, focusing on advanced clinical care, scholarship, and interprofessional collaboration in hospitals and other medical settings. The interprofessional education provided through these chiropractic student and resident training programs is a key underpinning for interprofessional collaboration between DCs and other health care providers.
We know there is more work to be done to ensure the optimal provision of chiropractic care to veterans. We also know that the chiropractic profession's historical exclusion from most mainstream medical systems poses a barrier to integration, both in the VA and in the private sector. Yet the accomplishments of the past 10 years in the VA show that with appropriate demonstration of competence and willingness to collaborate across professions, barriers can be overcome for the ultimate good of the patients we serve.
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Opportunities To Care For Veterans
Chiropractors across the U.S. continue to have strong interest in VA chiropractic services. The two most common questions encountered are:
Open VA chiropractic positions are announced and recruited by the given local VA facility. Vacancies are posted at www.vacareers.va.gov. There is no mechanism for an individual DC to apply to a VA facility unless an open position is posted. Cold calling or otherwise soliciting contact with a facility does not produce positive outcomes. Positions are very competitive. High clinical acumen, experience in integrated practice, command of evidence-based medicine, a track record of scholarly activities, and collegial interpersonal skills are some of the traits of strong candidates. Private DC Participation in the Non-VA Medical Care Program Non-VA medical care is care provided to eligible veterans outside of the VA when VA facilities are not feasibly available. All VA Medical Centers can use this program when needed. The use of non-VA medical care is governed by federal laws containing eligibility criteria and other policies specifying when and why it can be used. A preapproval for treatment in the community is required for non-VA medical care, unless the medical event is an emergency. As with all medical services, the initial request for non-VA chiropractic care is made by a VA provider who is managing the patient. Determination of eligibility is made at the local VA facility. General program information can be found on the U.S. Department of Veterans Affairs website. More information on provider participation in the Patient-Centered Community Care (PC3) Program and the Veterans Choice Program can be found via the Chief Business Office Purchased Care (CBOPC). Editor's Note: The online version of this article includes direct links to the valuable VA web resources referenced above. |
References
- Kesling B. "VA Approval Sinks in Wake of Turmoil." The Wall Street Journal, Jan. 22, 2015.
- Burton TM. "VA Halted Visits to Troubled Hospitals." The Wall Street Journal, June 9, 2014.
- Klimas J. "900 Employees Fired Under New VA Leadership." The Washington Times, Feb. 15, 2015.
- Veterans Choice Program. Available here.
- Public Law 106-117: Veterans Millennium Health Care and Benefits Act, 1999.
- Public Law 107-135: Department of Veterans Affairs Health Care Programs Enhancement Act, 2001.
- Fact Sheet for Chiropractic Services. Available here.
- Lisi AJ, Khorsan R, Smith MM, Mittman BS. Variations in the implementation and characteristics of chiropractic services in VA. Med Care, Dec. 2014;52(12 Suppl 5):S97-104.
- VA Chiropractic Education and Training. Available here.
Dr. Anthony Lisi is an associate professor at the University of Bridgeport College of Chiropractic. Prior to being named national director of VHA chiropractic services, Dr. Lisi became the first staff chiropractor appointed to the VA Connecticut Health Care System (2004), where he is now chief of chiropractic services. He has published numerous scientific papers in areas such as chiropractic integration, interprofessional education, and low back pain.