published Thursday, October 6th, 2011

Cleveland: Why military veterans deserve good health-care

By Cliff Cleveland

Federal agencies endure unrelenting attacks by many members of Congress, political candidates and pundits. Critics overlook vital services provided by such organizations as the Veterans Health Administration.

VHA is the nation's largest integrated health-care system, serving almost 6 million of 22 million veterans of military service. Facilities include 152 medical centers, more than 800 community-based outpatient clinics, skilled nursing and long-term-care units. Vet Centers are a new addition, offering a range of counseling services (personal, marital and bereavement) for combat veterans. A reported 300 Vet Centers will be open by year's end.

Concern for the plight of disabled veterans began with the Continental Congress which established a system of pensions. The first national medical facility opened in 1834. Following the Civil War, individual states opened homes for veterans. These offered varying arrays of care for disabled and indigent veterans.

After the World War I, veterans' services were divided among three agencies. In 1930 these services were consolidated in the Veterans Administration. President George H.W. Bush signed legislation in 1989 to give cabinet rank to the Department of Veterans Affairs (DVA). In fiscal year 2010, DVA's budget was $113 billion, of which $48 billion was directed to health services. For comparison, the 2010 budget for defense was $692 billion and Health and Human Services $879 billion.

Eligibility for VHA services is determined by guidelines based upon service-connected disability and annual earnings. Benefits for eligible veterans may include clinic and inpatient care, prescriptions and travel benefits to health facilities. When VHA facilities are distant, eligible veterans may obtain subsidized care in private clinics and institutions.

VHA has developed programs to coordinate care more effectively.

An electronic health record allows access to a veteran's chart at any point of service. Medication errors are reduced. Diagnostic reports are readily available. Illegibility is eliminated.

Increasingly, clinics are organized as patient-centered medical homes. A conversion to this model should be completed by 2015. It offers extended hours of service, urgent-care clinics, regular check-ups and preventive care. Patients with chronic illnesses are followed by a team of care-givers to coordinate care and address problems early to lessen the need for hospitalization. Protocols for phone and email communication permit easier access to clinics and faster transmission of clinical information.

Waiting times for appointments, visits to emergency rooms, and hospitalization rates have been significantly reduced in clinics which have adopted the medical home concept.

Hospital-at-home is a demonstration project that evaluates the feasibility of treating some patients with illnesses such as emphysema and chronic heart failure at home instead of hospitals.

Rural Mobile Health Care Clinics offer care to veterans who do not have access to nearby VHA facilities.

During the current wars VHA services have been stretched by large numbers of troops suffering from closed head injuries, complex wounds from explosive devices, and post-traumatic stress disorder.

Problems do exist within VHA. Quality is not uniformly good. Some hospitals have lost accreditation for certain clinical services. Waiting time for clinic appointments can drag on for weeks. VHA van services are not always scheduled to match clinic hours. Services may not be centralized so that a veteran may have to visit one site to see a doctor and then travel cross-town for diagnostic services.

I served my first assignment as an intern at the Nashville VA Hospital, a model for integrating new health facilities with existing academic health centers. Wards were integrated, unlike most hospitals in the South at that time. VHA provided a level of service that many of these veterans could not otherwise access. This tradition continues.

Veterans shared with me profound stories of service in World Wars I and II, the Korean War, and early encounters in Vietnam. These narratives should remind us of our societal obligation to honor and to provide excellent health care for those who have protected us.

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