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7 Implementation and Models of Care for Veterans Who Have Chronic Multisymptom Illness
Pages 155-182

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From page 155...
... Anecdotal c evidence suggests that simply adhering to multiple CPGs often is not effective for managing chronic conditions with multiple morbidities such as CMI and can result in incomplete care and decrease patient satisfaction, and increase the likelihood of overtreatment and adverse side effects. Each personal care plan will be peculiar to the individual veteran (although crafted from the therapeutic elements outlined in Chapters 4 and 5)
From page 156...
... Building on information presented in Chapter 6, it ends with a discussion of how information about managing CMI might be disseminated to VA clinicians and patients. MODELS OF CARE FOR CHRONIC MULTISYMPTOM ILLNESS IN THE DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SYSTEM Veterans use the full array of health care benefits and systems for their care: the Veterans Health Administration (VHA)
From page 157...
... The number, specialty types, relative availability, and extent of integration into the primary care team of specialty-team members vary widely from clinic to clinic; VHA currently assigns behavioral-health clinicians to PACTs in VA medical centers (VAMCs) and outpatient clinics that have more than 5,000 primary care patients, and many smaller clinics also have behavioral clinicians on PACT teams.
From page 158...
... .2 In addition, VHA has developed CPGs for a number of relevant conditions, including postdeployment health and common c ­omorbidities and conditions that have overlapping symptoms, such as major depressive disorder, posttraumatic stress disorder, traumatic brain injury, and chronic pain (Chou et al., 2007; VA and DOD, 2001a, 2009a,b,c, 2010a,b)
From page 159...
... It also contains a section on undiagnosed and unexplained illnesses, including information about CMI. Specialty Care Access Network Although VHA has 153 medical centers and more than 900 outpatient clinics nationwide, not all veterans have easy access to VHA facilities (­ eisinger et al., 2012)
From page 160...
... . Veterans in a WRIISC are evaluated by a multi­ isciplinary team that d conducts a comprehensive health assessment and formulates a comprehensive personal care plan aimed at managing symptoms and improving functional health; the plan is implemented in the WRIISC and given to the referring clinicians (Lincoln et al., 2006)
From page 161...
... GULF WAR VETERANS' EXPERIENCE OF CARE Patient Satisfaction Despite the extensive efforts devoted to improving care for veterans who have CMI, some Gulf War veterans have expressed frustration and anger about what they consider to be subpar care from VHA (public comments to the committee, December 17, 2011, and February 1, 2012; Furey, 2012)
From page 162...
... Veterans older than 65 years old are more likely to use non-VHA health care facilities than younger veterans; this may be due to the older veterans' Medicare eligibility. Female veterans reported scores similar to those of male veterans on most dimensions of outpatient satisfaction with VHA facilities after adjustment for a number of demographic attributes (Wright et al., 2006)
From page 163...
... In 2010, nearly all primary care appointments at VHA facilities occurred within 30 days of the desired date (Walters, 2011)
From page 164...
... Group 4: Veterans who are receiving aid and attendance or housebound benefits from VA; and veterans who have been determined by VA to be catastrophically disabled. Group 5: Non-service-connected veterans and noncompensable service connected veterans rated 0% disabled by VA with annual income and/or net worth below the VA national income threshold and geographically adjusted income threshold for their resident location; veterans receiving VA pension benefits; and veterans eligible for Medicaid programs.
From page 165...
... a.  eterans eligible for enrollment: Noncompensable 0% service V connected and: Subpriority a: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/or placed in this sub priority due to changed eligibility status; Subpriority b: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less.
From page 166...
... Because of the complexity of the disability patterns and the law governing Gulf War disability rating policy, VA produced a training letter for regional Veterans Benefits Administration (VBA) personnel, explaining the rules for disability compensation for undiagnosed illness and a medically unexplained CMI (VA, 2010)
From page 167...
... Information was not found on the categories of medical conditions for which the veterans of the Iraq and Afghanistan wars are receiving disability compensation. AN APPROACH TO ORGANIZING SERVICES FOR CARE OF VETERANS WHO HAVE CHRONIC MULTISYMPTOM ILLNESS As noted above, VA, in conjunction with DOD, has already committed in principle to expeditious completion of a disability examination for soldiers who are leaving active duty (Rooney, 2012b; VA, 2012c)
From page 168...
... With respect to the disability determination, maximum symptom resolution and functional capacity cannot be reached until pending disability dispositions are resolved. Disability is a fluid phenomenon and must be reassessed periodically, but this is not an acceptable argument for deferring disability determination beyond the time when a PACT primary care clinician is expected to initiate a comprehensive personal care plan.
From page 169...
... Many lapses in quality occur during transitions of care to different settings, so VHA should monitor closely and periodically evaluate the adequacy of communication and the coordination of care among settings when care is stepped. As noted above, most veterans who have CMI can be managed in a PACT, but care in this setting will fail unless the PACT can adjust the visit schedule to accommodate extended, complex visits; access the specific team members and clinical expertise needed to follow the care plan, including nonclinic care and follow-up; and master the implementation strategies necessary to incorporate the multitude of relevant CPGs, to master teambased care, to navigate the delicate territory between team-based care and developing an accountable personal relationship with patients, and to incorporate self-management strategies into the fabric of the personal care plan.
From page 170...
... The idea that mistakes can be identified and corrected is built into the cycle. Continuous quality improvement also allows for incorporation of new models of care, such as integrative medicine and optimal healing environments, into the PACT care process when they are needed (IOM, 2009; Jonas and Chez, 2004)
From page 171...
... Implementation of multiple guidelines for management of chronic conditions is difficult, requiring complex teamwork by staff who are otherwise fully engaged in caring for patients in distress. Successful implementation has its own measures of success that are distinct from clinical outcomes.
From page 172...
... to practices as they begin their redesign efforts. Thus, implementation teams should include health coaches, integrative-medicine practitioners, and other local practice resources that can help practices to work out local changes and solutions to the problem of implementing multiple CPGs for their own unique patient-panel demands under variable local conditions.
From page 173...
... Stepped care is much harder in the civilian setting, because specialty resources are less available. Perhaps most important, primary care clinicians in the civilian setting are less familiar with the characteristics of CMI in veteran populations and therefore less adept at creating the complex personal care plans described above.
From page 174...
... Examples include evidence reviews, practice guidelines, and consensus statements. Implementation goes beyond reaching the intended audience, clinicians.
From page 175...
... System changes and support systems will also reinforce changed practice behaviors and may enable their maintenance. CLINICIANS' BEHAVIOR CHANGE: SYSTEM AND INTERPERSONAL DETERMINANTS The role of clinicians is critical in any adoption of health care innovations, and much of the adoption and maintenance of innovations requires change in clinicians' behaviors (Gunter and Whittal, 2010)
From page 176...
... SUMMARY VHA faces extraordinary challenges in caring for the burgeoning population of veterans who have CMI. It is possible to meet the challenges with adequate clinician education and support, organization and preparation of care teams that fit the needs of the veterans, establishment of implementation protocols that lead to continuous quality improvement, dissemination of these successes to other clinical teams and settings that are struggling
From page 177...
... 2011. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care.
From page 178...
... Health Services Research & Develop­ ent Service, Department of Veterans Affairs, Washington, DC. m Konnopka, A., R
From page 179...
... 2005. Patient satisfaction and use of Veterans Affairs versus non– Veterans Affairs healthcare services by veterans.
From page 180...
... War Related Illness and Injury Study Center. East Orange, NJ.
From page 181...
... 2001b. Clinical Practice Guideline for the Management of Medically Unexplained ­ Symptoms: Chronic Pain and Fatigue.


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