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When combat is over, the fight has just begun. Wounded veterans, returning from abroad, have struggled to gain access to health care services, including treatment for post-traumatic stress disorder (PTSD), amputations and spinal cord injuries. For some, care is just out of reach; for others, it's not up to par.
With older veterans living longer and an influx of new blood from the wars in Iraq and Afghanistan, quality health care is at a premium. Rural vets want convenience, amputees want options and female soldiers just want some attention. It's a great undertaking, especially for a health system serving millions nationwide, but providers and lawmakers are preparing for duty.
Close to Home
When injured veterans return from war, they don't always get top rate care. Most VA Medical Centers are based in urban areas, but the majority of veterans live in rural towns, noted Alan Petrazzi, MPT, MPM, rehab manager for the VA Pittsburgh Healthcare System. A single physical therapy session could require a four-hour round trip. That costs time and money--neither of which the veteran may be able to afford. The travel is distressing to any veteran, but doctors are particularly concerned about patients with PTSD. "That's one population where we need to reduce frustrations across the board and not introduce any others," Petrazzi noted.
In light of these problems, the VA is exploring new ways to deliver care. In the '90s, the department launched community-based outpatient centers (CBOCs) to bring health care services, including physical therapy and rehab, closer to the patient. Today, those CBOCs continue to expand across the nation. "We're augmenting what we're currently doing at the big centers by having satellite clinics," Petrazzi explained.
For veterans who are still beyond reach, the VA contracts with external providers closer to home, ensuring that patients get the care they need.
VA Medical Centers are also taking cues from walk-in clinics. With the "express" model of care, patients can pop in when they want, instead of waiting for an appointment at an inconvenient time. "We don't commit to a schedule at a point and time and have them accommodate us," Petrazzi explained. "We flip it and have the staff accommodate them."
The greatest opportunity, however, lies in technology. The VA currently uses electronic medical records (EMR), which makes it easy to communicate and collaborate with other providers. For example, if a patient shows signs of mental distress during a therapy session, the PT can add a note to the patient's EMR requesting a mental health evaluation. The VA is also considering tele-rehabilitation, which allows providers to conduct consultations via the Web. Patients could "meet" with therapists from the comfort of their home, eliminating travel time all together. For patients with PTSD, that means the least disruption and distress as possible.
A Step in the Right Direction
Traditionally, amputees have had few opportunities to engage in the armed forces; a return to battle was unlikely. "You would get your rehabilitation, get your prosthesis, and you would go home and live your life," Petrazzi said.
Now, advancements in prosthetics have put independence in sight. "We've had military people who get injured, go through their rehabilitation and go back into the active military with their prosthesis--very high level things," Petrazzi said. "And not just a desk job; some people have gone in for combat roles."
With veterans demanding the best of the best (and "prosthesis" being just a Google search away), doctors and therapists are fighting to keep up on research. "The challenge to our staff is we have to always be one step ahead," Petrazzi said.
Lawmakers have also noticed the growing amputee population, and they've proposed legislation to meet their needs. "Many of these younger veterans are surviving wounds that would have been fatal 40 years ago," said Congressman Michael Michaud. "As a result, there are a greater number of severely-wounded warriors who need greater levels of rehabilitation for amputations and multiple traumas."
Michaud co-sponsored the Veterans Physical Therapy Services Improvement Act, which focuses on recruitment and retention of physical therapists in the Veterans Health Administration. The bill has yet to clear the House, but lawmakers seem favorable toward the veteran's cause. Congress recently passed the Caregivers and Veterans Omnibus Health Services Act, which helps veterans--including amputees--by supporting their caregivers. Under the new law, family members will gain access to training, education, health care and other assistance programs as they adapt to life with a wounded warrior.
The X Factor
While amputees are on the rise, the number of female veterans is growing at a record pace, leaving VA medical centers with an unprecedented challenge. Veterans health care has traditionally been male-oriented, but with women projected to take 14 percent of the share in the next few years, the VA is doing its best to navigate gender-specific needs.
"It's just a little bit like trying to turn the Titanic," said Melissa McNeil, MD, VA Pittsburgh's women's health medical director. "It's a very big system, and it has lots of providers who do not have a lot of experience with women."
Female veterans have far different needs than their male comrades, according to Dr. McNeil. Aside from the usual OB/GYN care, women report a high rate of musculoskeletal issues from ill-fitted gear. "What we're seeing is the boots, the backpacks, sort of all the paraphernalia that you have to take on a long march is not really designed with a woman soldier in mind," she explained.
Women often suffer from sexual trauma and related issues--Dr. McNeil said the incidence runs about 25 percent. They also have more difficulty with re-entry, as traditional roles, such as mother and spouse, are in stark contrast to their roles in combat.
Since the late 1990s, the VA has held women's health issues at attention. Officials appointed National Centers of Excellence for Women's Health, and the department continues to fund their services. The VA also requires that every medical facility have a women's veteran program manager on site, to ensure women's health needs are being addressed.
At the VA Pittsburgh, a National Center for Excellence, women enjoy a "one-stop shop" for primary and gynecological care, Dr. McNeil said. If they have a severe issue, such as one requiring surgery, referrals are available.
The VA's latest launch, however, has been a set of mini-residencies that educate providers on women's issues, from pap smears to pelvic pain. "There's a huge campaign under way to both measure quality of care and to provide education for providers," Dr. McNeil said.
One mini-residency has already been rolled out, and a second track--this time, focusing on menopause and older women's issues--is in development.
On the legislative front, lawmakers are correcting deficiencies in women's care. The Caregivers and Veterans Omnibus Health Service Act includes provisions for female veterans, including a call for more education regarding sexual trauma and a pilot that provides free child care while a female veteran is getting medical care. "For too long, the VA has not been adequately equipped to meet the unique needs of the ever-expanding, yet underserved, population of female veterans," Michaud said. ".This bill is a good start toward assessing how to better meet the needs of female veterans and working toward establishing permanent programs that bring their care up to the level of the care provided to their male counterparts."
Veterans' health services have improved; in fact, the VA has been cited as a model for health care reform. But its transformation is far from over. Like Dr. McNeil, Congressman Michaud believes the Veterans Health Administration is still taking its first steps on what will be a long road ahead--and the veterans he's met would agree. "The overall consensus is that VA continues to make strides toward providing quality care for our veterans," Michaud said, "but there is still more that Congress and the VA can do."
Cheryl McEvoy is an assistant editor/web editor with ADVANCE.
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