My first patient in medical school was a 25-year-old Iraq war vet from a small farming town in Idaho. A star high school football player, he had enlisted in the Army on his 18th birthday so he could see the world and afford college. Within his first month in Iraq, a satellite pole fell on him during a brutal sandstorm. Multiple leg surgeries later, he was sent back to America battling chronic pain and dependent on narcotics. Using a cane to walk, my patient grew depressed, gained 30 pounds and became a diabetic.
I had 30 minutes with him, and my attending physician had just 15. We were already running late. But my attending calmly introduced our team’s social worker and psychologist. They booked visits for the patient with the VA pain-management clinic, the mental health clinic for post-traumatic stress disorder and a physical rehabilitation specialist. And we saw the patient the very next day to begin treating his diabetes.
This multifaceted and coordinated approach to treatment — all of it at minimal or no cost for veterans at the VA — is rarely practiced in other American hospitals and clinics. If this patient had hobbled in and found me at a private clinic outside the VA system, his lack of insurance and a job would have put him in the Medicaid ranks. Specialists might have refused to accept Medicaid, and he might have had to pay out of his own pocket — or not see them at all.
Moreover, like nearly all private patients, he would have needed to coordinate these visits on his own, carry his medical chart with him and later ensure that I received the specialists’ recommendations. To see me again, he might have needed to wait weeks for an opening.
The VA system could be a model of how to change all that. Indeed, it’s a model of changing itself.
After battling years of bad press in the 1980s and ’90s, VA hospitals have made great strides and now deliver top-notch care, according to trusted rankings. In the past few years, VA hospitals have taken the lead in implementing what is known as the patient-centered medical home (PCMH). This awkwardly named concept is now common vernacular among physicians and health-care providers, and since April 2010, it has been rolled out at VA clinics nationwide.
The PCMH is a home only in the figurative sense; patients are meant to feel at home within a health-care team — a physician, nurse practitioner or physician’s assistant; a registered nurse; a pharmacist; a social worker; and a psychologist. The result is improvements in access, chronic-disease management and coordination between primary physicians and specialists.