In the VA system, the future of primary health care

Yogesh Khanal is a resident in internal medicine at Yale-New Haven Hospital and the VA hospital in West Haven, Conn.

At the height of the debate over the Affordable Care Act three years ago, I was in my last year of medical school, juggling rotations at private hospitals, a large university hospital and charity county clinics.

But it was my rotation at the local Veterans Affairs health system that showed me the future of primary medical care and taught me the virtues of attacking illness on many fronts. It’s a lesson that will be acutely needed nationwide once the Affordable Care Act goes into effect and sends legions of newly insured patients into clinics and hospitals.

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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.

One VA clinic in Memphis has reported reducing appointment wait times from 90 days to same-day access, decreasing emergency room visits from 52 percent to 12 percent and improving the condition of a third of its poorly controlled diabetics in just three months.

Just two years after adopting the PCMH, early research shows that VA outpatient clinics have higher rates of provider and patient satisfaction — a model that may entice more medical school graduates into primary care. When I chose to go into primary care, my med school classmates wondered why I would sign up for a life of endless paperwork, lower earning potential and patients with chronic problems often rooted in social hardships. But the PCMH harnesses non-physician team members to deliver preventative health and chronic disease education.

Now in my first year of internal-medicine residency, I’ve seen this firsthand. My clinic is at one of five national VA Centers of Excellence, a primary-care training program that emphasizes interdisciplinary, team-based care.

When the PCMH approach works, it relieves stress for doctors and patients. I recently had to break the news of a Type 2 diabetes diagnosis to a veteran, who then tearfully described his father losing both his sight and a limb to the disease. While consoling my patient, I struggled to explain that he should start taking metformin, an initial diabetes medication. Diabetes is the prototypical bio-psycho-social disease, requiring a comprehensive and potentially bewildering array of medications and lifestyle adjustments.

Ordinarily, this patient might have slipped through the cracks of the medical system until he came back in more serious condition. But after he left, our team health tech coordinated future appointments with a nutritionist, a weight-loss specialist and an optometrist. A week later, the patient came to see our team nurse, who explained how to control diabetes and how to use a finger-stick glucometer to monitor blood sugars. Without the help of my PCMH team, I’d be alone and overwhelmed in coordinating all of this vital care.

VA hospitals, providing care to more than 5 million patients annually, have shown that adopting the PCMH model of care can bring needed change. Redesigning our nation’s primary-care systems is now vital because the Affordable Care Act will soon flood clinics with up to 30 million more Americans. This will require clinics outside the VA system to adopt ways to deliver efficient, less costly care.

It’s a matter of survival.

yogesh.khanal@yale.edu

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