The Department of Veterans Affairs (DVA) is the second largest of the 15 Cabinet departments. It potentially can provide services to 62 million people, including 24 million living veterans and 38 million survivors and dependents.
That health care is delivered by the Veterans Health Administration (VHA), the largest direct health care system in United States. The VHA administers a network of 21 geographic regions called Veterans Integrated Service Networks (VISNs). Throughout these VISNs, the VHA operates 154 hospitals, 136 nursing home units, 43 residential rehabilitation facilities, 875 outpatient clinics, and 206 veterans centers. In 2005, the VHA provided care to 5.4 million unique patients, with a staff of over 200,000 involved in medical care and research. The VHA also operates the largest medical training program in the U.S. Through its affiliations with 107 medical schools, 55 dental schools and 1,200 other allied health schools, the VHA trains more than 83,000 health professionals each year.
These national numbers are so large that they may be difficult to comprehend. To appreciate the context on a local scale, consider the characteristics of my own facility. The VA Connecticut Healthcare System serves a region of 330,000 veterans and sees 53,000 unique patients per year. It operates a tertiary care, Clinical Referral Level I facility with 190 operating beds and a medical staff of over 800 providers. It also is the academic affiliate for the Yale University School of Medicine and the University of Connecticut Schools of Medicine and Dentistry. Through these academic affiliations, the VA Connecticut Healthcare System trains over 675 physicians and dentists each year. Through affiliations with more than 150 additional schools, it also trains over 685 allied health students each year.
The size of the VHA notwithstanding, it historically has had a reputation for providing poor-quality care. However, many readers may be surprised to learn that recently, the VHA's care has been lauded for its exceptionally high quality. As U.S. News and World Report stated, "Criticized for decades for indifferent care the VA health system has performed major surgery on itself. The care provided to 5.2 million veterans by the nation's largest health care system has improved so much that often it is the best around."1 In January 2006, a report from the American Customer Satisfaction Index demonstrated that the VHA outpaced the private sector in patient satisfaction for both outpatient and inpatient services.2 It was the sixth consecutive year that the VHA had done so. More favorable comments came in a January 2006 article in the New York Times that stated, "The transformation of the VHA is clearly the most encouraging health policy story of the past decade," and that the VHA "represents the true future of American health care."3 Most recently, in an article on the VHA's use of medical technology,'Fortune magazine declared, "Veterans hospitals used to be a byword for second-rate care or worse. Now they're national leaders in efficiency and quality."4
This is the landscape to which chiropractic services recently have been introduced. As is probably known to most readers, the implementation of chiropractic care in the VHA is in response to legislation. Public Law 107-135, the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001, required the VHA to provide chiropractic care at a minimum of one facility in each VISN. The first VHA chiropractors were brought on board in late 2004. Currently there are 28 VHA facilities providing chiropractic care; each of the 21 VISNs has at least one site, and seven VISNs have two. Ten of the 28 facilities have hired a chiropractor as a full-time employee, nine have established part-time positions or contracts of 16 to 20 hours per week, and nine have established part-time positions or contracts of 10 hours per week or less. The decision as to whether a given chiropractor would be a staff appointment (employee) or contractor, full-time or part-time, was made at the VISN and facility level. This is consistent with VHA practices for other providers.
Clinical Practice
The VHA directive specifies that chiropractic care shall be for "neuromusculoskeletal conditions, including subluxation complex." In practice, the VHA chiropractors are seeing a wide variety of nonoperative musculoskeletal and neuromuscular cases. The majority of these cases are very complex, with multiple comorbidities. There are a number of relatively simple cases, to be sure, but most are rather complicated, with longstanding advanced pathology. Most of the VHA patients are age 55 and older; however, we see a range, from 20-year-old Operation Iraqi Freedom veterans to nonagenarians from World War II.
Each chiropractor's scope of practice is determined by state licensure and facility privileging. This also is consistent with VHA policy for other providers. I was involved in writing my privileges, which essentially mirror the Connecticut chiropractic scope of practice. This includes physician-level evaluation and management, ordering diagnostic imaging or laboratories, all chiropractic treatment methods included in my state license, and the ability to refer patients directly to other providers as indicated.
Patient access to a chiropractic clinic is through consultation from the patient's primary care provider or other VHA provider. Access to all specialty clinics is by consultation request from another VHA provider, PCP or specialty. Thus, chiropractors are treated the same as all specialty providers: physiatrists, cardiologists, neurosurgeons, etc.
This process may seem anathema to those field chiropractors who have experienced exclusion from typical medical referral patterns, and subsequently cannot rely on local physicians to send appropriate patients for consultation. However, the situation in the VHA is quite different. There is an atmosphere of collegiality and cooperation for the patients' best interest, which leads to a willingness among providers to consider chiropractic treatment for their given patients. This is evidenced by the fact that virtually every chiropractic clinic in the VHA is fully booked well in advance. There has been no shortage of patients reaching the chiropractic clinics. The majority of these patients are sent from primary care; however, VHA chiropractors are receiving consults from many specialties including orthopedics, physiatry, neurosurgery, neurology, rheumatology, pain management, dentistry and podiatry.
Aside from the fact that patients are being sent to VHA chiropractors, there are many reasons that "access via consultation" is good policy. First and most important, is it best for the patients. The model employed in the VHA ensures that all patients have a primary care provider to address primary care issues, allowing specialty clinicians the ability to focus on their specialties. I cannot imagine any specialty clinician in the VHA who feels that he or she can and should be providing primary care; conversely, I cannot imagine any PCP who has the desire or training to handle all aspects of specialty care. The providers communicate freely, patients are delighted that their various doctors are coordinating care, and the quality of care is improved.
Also, from the individual VHA chiropractor's perspective, the consultation system facilitates integration between the DCs and other providers. We are often asked, via e-mail, telephone or hallway conversations, for an opinion on the appropriateness of a potential chiropractic consult and ways to optimize patient management. The VHA's computerized patient record system (CPRS) allows consultation requests, initial reports, questions and updates to flow freely and securely between providers. This contributes to making us part of the team, not a separate entity playing by different rules. Through my conversations to date, I have not heard from even one chiropractor in the VHA who would want it otherwise.
Finally, from a chiropractic profession perspective, it is interesting to consider the potential effect that consultations to VHA chiropractors may have on future interprofessional relations. Remember that a great many medical physicians train at VHA facilities. Think of an internal medicine resident currently at a VHA facility, where it is common for the attending physician(s) to send consultations to the staff chiropractor. Upon entering private practice in the community, might he or she be more willing to include chiropractic care as a patient management option? The performance of the current VHA chiropractors may likely play a role in this scenario.
Integration
There is some variation in the manner that VHA chiropractors have been integrated into their facilities, but a number of common themes emerge. All DCs have in place service agreements, documents used by most specialty clinics in the VHA to streamline the consultation process between providers. These agreements specify the types of cases appropriate for chiropractic consult, workup the chiropractor requires before consultation, services the chiropractor will provide, channels of communication between providers, and other aspects of case management. In addition, we have all given numerous talks, from formal Power Point presentations to smaller conference-room discussions, in which we have explained chiropractic care to our respective staffs. At various facilities, we have been included in interdisciplinary teams, medical staff committee meetings and formal patient education presentations.
On a national level, the VHA has chartered a Chiropractic Field Advisory Committee (FAC), which serves as an advisory body on clinical and administrative issues relating to chiropractic care, reporting to the Deputy Chief Patient Care Services Officer in the VA Central Office. It assists in the assessment of (and provides advice on) clinical care, formulation of clinical policy, monitoring program performance, program development, patient education materials, and other aspects of the program. The committee includes six VHA DCs, one physiatrist, and a central office program manager. The Field Advisory Committee has been working on a number of items; we communicate regularly via conference calls and e-mail, and our first in-person meeting will take place soon.
Academic Affiliations
At this time, four VHA facilities have established academic affiliations with three chiropractic schools. The Western New York Healthcare System at Buffalo and the Canandaigua VA Medical Center Rochester Outpatient Clinic have affiliated with New York Chiropractic College; the St. Louis VA Medical Center has affiliated with Logan College of Chiropractic; and the VA Connecticut Healthcare System with the University of Bridgeport College of Chiropractic. Through these relationships, some 50 chiropractic students to date have taken part in a clinical rotation at a VA facility. Students function in a similar capacity as interns at a chiropractic college outpatient clinic, and also may rotate through other departments and attend grand rounds or other educational venues. My students and those I have spoken to from other facilities have found the experience to be an invaluable enhancement of their clinical education.
Research
The VHA is committed to fostering research that advances health care for our veterans and the nation. The Office of Research and Development has issued a special solicitation for chiropractic research proposals, spanning the four research services: biomedical laboratory, clinical science, health services and rehabilitation. This represents another opportunity for chiropractors to contribute to the scientific knowledge base for the good of the patient. At the time of this article, two chiropractic research proposals have been submitted for funding consideration, and a few other projects are currently in development.
In summary, the VHA chiropractors have been given a unique opportunity to contribute to the VHA's mission of serving veterans through patient care, education and research. Although this was initiated by legislation, the performance of the current participating DCs, both individually and collectively, will hopefully show that there is value in integrating chiropractic care into this large health care system. Various aspects of programmatic assessment and improvement are underway, and in less than two years there has already been some expansion in terms of additional sites being added and individual providers' hours being increased. The chiropractors in the VHA are committed to providing the highest quality care for the men and women who have served our country. Furthermore, the program has the potential to benefit the chiropractic profession at large by improving interprofessional relations, increasing chiropractic research and enhancing student education.
References
- Gearon CJ. "Military Might: Today's VA Hospitals Are Models of Top-Notch Care." U.S. News & World Report, July 18, 2005.
- American Customer Satisfaction Index. www.theacsi.org/overview.htm.
- Krugman P. "Health Care Confidential." The New York Times, Jan. 27, 2006, section A, p. 23.
- Stires D. "How the VA Healed Itself." Fortune, May 15, 2006;131-6.
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.