Rewiring the Network
Changes needed in VA healthcare
This article was originally posted in its entirety on the New York City Veterans Alliance blog.
Secretary Shulkin and his team at the Department of Veteran Affairs (VA) have been busy. From recent bills passed to upgrade Bad Paper Discharges to the extension of the VA Choice Program, VA is certainly not sitting still.
These were easy wins. Expanded access to mental health care, reducing mental health stigma with the re-evaluation of behavioral discharges for those diagnosed with PTSD, and extending Choice were no-brainers. That these wins were easy does not diminish their value; these programs and policies were needed victories. But they were easy upgrades, like downloading the latest smartphone operating system to improve performance: small changes with moderate impact.
So now I would like to see VA not just upgrade the operating system but rewire the network. I want them to take on a challenge that isn’t so easy, but one that attacks a root condition so time and money spent implementing yields huge results.
There are many such challenges to choose from: misdiagnoses, failure to receive care, conflict between compensation and pension evaluations and recorded symptoms, incorrect records, ongoing appeals… the list goes on. Each does a disservice to Veterans, and wastes VA budgets in necessitating a Band-Aid service like a new call-in line or the third iteration in two years of a benefits website.
I live in a constant quagmire of all of these challenges and more, being a severe Traumatic Brain Injury (TBI) patient. But I see TBI as a perfect way to visualize VA challenges. The symptoms of TBI are varied and complicated, and the current design of the VA healthcare system — including Choice — is ill-equipped to handle these cases. So luckily, this horrible experience of navigating multiple mazes of ineptitude gives my nerd self the opportunity to analyze the different challenges to search for a link.
The root cause of failure in complex cases: continuity of care, or rather the lack thereof.
Let’s take an example. I get the joy of seeing neurology roughly every two to four months. VA being a training hospital, that also happens to be the rotation schedule of neurology residents at the clinic (which operates one day a week and regularly running an hour late). That means every time I come in, I have to start my story from the beginning since I don’t expect someone to flip through my entire 9-year neuro record in their five minutes between patients. My follow-ups may as well be initial appointments which link directly to my multiple misdiagnoses, appointment scheduling problems, and incorrect records. Compensation and pension exams for initial and appeals are done by someone else entirely with little concern for what is already in my record (correct or otherwise), so it’s just another opinion and still no continuity. I lose track of the number of appeals and requests to correct records filed on my behalf.
It is also on me to mention key words — like “apoplexy” and “complex migraines with partial numbness” — to ensure doctors have the information they need so I don’t end up prescribed the wrong medications or procedures (again). I learned these key words after the third attending doctor in two weeks said, “That would have been nice to know. Yeah, that changes things.”
With TBI, everything is connected. Endocrine, vestibular therapy, neuro-opthomolgy, pain management, psychiatry… each feels the ripple effect of any misstep from another department. But as complex as this is, I have yet to meet someone who specializes in TBI because I always see residents.
The problem is not the fault of the residents; it’s the system. The lack of continuity creates challenges that put undue onus on us and on staff. There are so few attending doctors for so many residents they could not possibly know each case intimately, and while there are case managers to coordinate complex care they are largely ineffective as they are also not specialists. The various departments treating the same patient therefore do not meet to discuss a whole case, and gaps in care arise.
TBI can cause depression, anger and mood changes, vision and balance issues, nervous system damage, chronic endocrine problems, and so much more. Recent evidence suggests there may even be a link to ALS, enough that VA declares ALS presumed service-connected. That’s a pretty big, and deadly, deal. But VA hands TBI to a poor medical student at an overbooked clinic with no personal patient history other than the hurried notes of the previous resident. The system doesn’t even afford a way to follow-up with a patient to see if an assessment is correct or treatment is working. Lack of continuity doesn’t just hurt the Veterans; it doesn’t help the residents learn to treat complex issues, develop patient relationships, or develop longer treatment plans.
The VA as a training hospital model is a great way to develop doctors with an interest in Veteran issues, and saves money cutting back the number of attending doctors. But with over 350,000 Veterans diagnosed with TBI, the residency program needs to be supported with a full-on series of integrated, concurrent solutions. Hire researchers studying current treatment options to oversee patients. Increase attending doctors to lower the ratio of residents to attending. Since residents rotate, assign patients to the attending to enforce continuity. Complex patients necessitate an expert case manager, who must pre-brief residents a day prior to any patient appointments. It’s a multi-pronged approach that isn’t cheap, and can’t be implemented piecemeal to be successful.
However, VA makes money from research and long-term savings from quality care instead of just saving on staffing costs. The one-time cost of program implementation for care continuity would return billions in appeal reduction, speed of care, and so forth. To me, this is another no-brainer. It’s a harder one to execute than the Band-Aids, but a larger return on investment.
So props to the Secretary and his team for the upgrades they’ve made so far. Now let’s rewire the network.