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Veterans Affairs Chiropractic Advisory Report Nears
Completion
Stephen Barrett, M.D.
In September 2003, the Department of Veteran Affairs (DVA)
Chiropractic Advisory Committee updated its draft of recommendations
to guide implementation of chiropractic services within the Veterans
Health Administration (VHA) under a law passed in 2001. The law
calls for providing "a variety of chiropractic care and
services for neuromusculoskeletal conditions including subluxation
complex." The Committee's purpose is to advise the Secretary
of Veterans Affairs on (a) protocols governing referrals to chiropractors,
direct access to chiropractic care, and scope of chiropractic
practice; (b) definitions of service to be provided; and (c)
advice in developing and implementing the program. Subluxation
is a medical term that means partial dislocation of a bone, but
chiropractors use the term to mean other things. "Subluxation
complex" is a quack concept that has been written into some
federal and state laws even though chiropractors cannot agree
among themselves about what it is. The advisory report states
that "not all practitioners agree that the subluxation complex
is a clinically definable entity." Two of the eleven advisory
committee members wanted surface
electromyography and thermography (tests used to diagnose
"subluxation complex")
added to the list of initial privileges. Neither of these tests
has any valid medical use. Noting that respondents to a recent
major chiropractic survey rated electromyography as "of
little importance" and ignored thermography, the majority
of the committee said that providers wishing to use these modalities
could seek permission to do so. The majority also concluded that
access to chiropractic care should require referral from the
patient's primary care provider or another VA clinician who is
treating the patient. It is standard practice within the VA system
that referral is required in order to see a specialist. Some
committee members have expressed concerns that allowing direct
access would quickly overload the capacity to provide chiropractic
care. Many chiropractic organizations have protested the referral
requirement.
The law establishing the Committee specifies that it will
cease to exist on December 31, 2004. The Committee is scheduled
to meet again in December 2003, March 2004, and July 2004, and
October 2004.
VA Advisory Committees make recommendations to the Secretary
for Veterans Affairs; they do not decide policy. When the
recommendations are submitted to him, the Secretary will ask
VA staff to review them and provide him with input in formulating
the agency's response. The Secretary will then communicate his
decisions regarding the recommendations to the Committee and
to the VHA management for implementation.
Department of Veterans Affairs
Recommendations of the Chiropractic
Advisory Committee
Draft #7. December 2003
INTRODUCTION:
Public Law 107-135, Section 204 established the Department
of Veterans Affairs (VA) Chiropractic Advisory Committee "to
provide direct assistance and advice to the Secretary in the
development and implementation of the chiropractic health program"
within Veterans Health Administration (VHA). The Committee is
charged to advise the Secretary on protocols governing referrals
to doctors of chiropractic, protocols governing direct access
to chiropractic care, protocols governing scope of practice of
chiropractic practitioners, and definitions of service to be
provided, as well as to provide advice in the development and
implementation of the chiropractic health program.
Secretary Principi appointed Committee members in August 2002.
The Committee has met 4 times to discuss the specific charges
to the Committee. The Committee also has extensively discussed
how chiropractic care can effectively be integrated into the
existing VA healthcare system, and this document includes recommendations
regarding implementation of the chiropractic health program.
The Committee will, in a later report, provide input on other
matters including the educational training and material required
by P.L. 107-135 as well as evaluation and quality measures for
the chiropractic care program.
This document reflects all opinions as expressed by the members
of the Committee. When the Committee did not reach complete consensus
on a recommendation or Committee members expressed concerns regarding
the recommendation, a Comment section following the rationale
for the recommendation presents the other opinions expressed.
In instances where Committee members strongly disagreed, a dissenting
recommendation follows the recommendation endorsed by the majority
of the Committee. A summary of the public comments received and
reviewed by the Committee is attached as Appendix D.
This document relates only to the provision of chiropractic
care and is not intended to restrict other qualified healthcare
providers from the use of manipulation in the care of patients
when licensed and privileged to provide such care.
BACKGROUND:
Doctors of chiropractic in private practice are responsible
for providing appropriate care within the scope of their licensure,
education and competency and for making appropriate referral
to other health care providers when necessary. Coverage of chiropractic
care by health insurance plans varies as do access requirements.
Many health insurance plans require referral by a primary care
provider, others require only that the patient use a doctor of
chiropractic within the plan, and some permit self-referral to
chiropractic care. Individuals who pay for the care themselves
may directly access chiropractic care. Collaborative professional
relationships between doctors of chiropractic and allopathic
and osteopathic physicians exist and continue to increase in
the private sector as more patients become interested in chiropractic
care and more insurance plans provide coverage.
In 1995, the Department of Defense (DoD) initiated chiropractic
care through the Chiropractic Health Care Demonstration Project
(CHCDP). CHCDP demonstrated that chiropractic care was accepted
best when the doctors of chiropractic were incorporated within
a traditional medical team housed within the main medical facility,
rather than functioning as a separate entity. As in VHA, organizational
structures in DoD vary among facilities and thus several different
organizational models have been used to integrate chiropractic
care into its healthcare delivery system on a permanent basis.
The Committee visited the National Naval Medical Center, Bethesda,
where chiropractic was organizationally placed within a musculoskeletal
service line that also included Rheumatology, Orthopedics, Physical
Medicine and Rehabilitation, Physical Therapy, Occupational Therapy,
and Podiatry. This arrangement has provided an organizational
structure that reflects functional working relationships in the
care of patients with neuromusculoskeletal conditions.
Within DoD, the Navy's experience indicated that hiring and
placement by local commanders coupled with a strong, visible
commitment to success from senior leadership resulted in a smoother
integration of chiropractic care into an established traditional
medical setting. The DoD experience may be instructive as VHA
determines how to integrate doctors of chiropractic into its
system.
VHA is a comprehensive, integrated care system encompassing
163 hospitals, 850 ambulatory care and community-based outpatient
clinics, 137 nursing homes, 43 domiciliaries and 73 comprehensive
home-care programs. VHA endorses a primary care model of healthcare
delivery, in which each patient has an assigned primary care
provider who is accountable for addressing a large majority of
the patient's personal healthcare needs, with referrals to specialists
when needed. While complete implementation of the model has not
yet been achieved, in part due to the large influx of new patients
that VHA has experienced in recent years, it remains VHA's goal.
VHA's health care system encourages an integrated, interdisciplinary,
interdependent and collaborative team approach. The composition
of health care teams in VHA varies among sites as a result of
differences in the size and configuration of VHA facilities,
staffing patterns, and local business and medical practices,
but the team approach to care serves veteran patients well, as
many have multiple health care needs that overlap and influence
each other.
The Committee has discussed extensively how doctors of chiropractic
can be integrated successfully into the VHA health care system.
While local variations in services and organizational structures
will play a role in this, the Committee believes the key to successful
implementation is a collaborative, cooperative approach
to the integration of care. Doctors of chiropractic should be
an integral part of an integrated team of providers. The composition
of such an integrated team may vary between sites, and members
of the Committee have provided several descriptions of integrated
settings that may assist VHA in its decision-making process (Appendix
B).
The goals for VHA's new chiropractic care program should include:
- Patients have appropriate access to chiropractic care.
- Doctors of chiropractic, physician providers and other clinicians
develop collaborative relationships in order to provide the concurrent
patient care necessary to meet the needs of veterans.
- Chiropractic care is fully integrated into all of VHA's missions
patient care, education, research and response to disasters
and national emergencies in an appropriate manner.
RECOMMENDATIONS AND RATIONALE:
A. Qualifications for Employment
Recommendation 1: Education requirement.
Degree of doctor of chiropractic resulting from a course of
education in chiropractic. The degree must have been obtained
from one of the schools approved by the Secretary of Veterans
Affairs for the year in which the course of study was completed.
Approved schools should be:
(1) Schools of chiropractic accredited by the Council on Chiropractic
Education Commission on Accreditation or equivalent agency recognized
by the U.S. Secretary of Education, or
(2) Schools (including foreign schools) accepted by the licensing
body of a State, Territory, Commonwealth, or the District of
Columbia as qualifying for full or unrestricted licensure.
Rationale: The Council on Chiropractic Education Commission
on Accreditation (CCE) is currently the accrediting body recognized
by the U.S. Secretary of Education for Doctor of Chiropractic
programs and single-purpose institutions offering the Doctor
of Chiropractic program. CCE has been recognized by the Department
of Education since 1974 and P.L. 106-117 (the Veterans' Millennium
Health Care Act), Section 303, defines the term chiropractor
as an individual who "holds the degree of doctor of chiropractic
from a chiropractic college accredited by the Council on Chiropractic
Education." However, prior to 1993, a second organization,
the Straight Chiropractic Academic Standards Association (SCASA)
was also recognized by the Department of Education and 13 state
licensing boards. Limiting recognition to CCE accredited schools
excludes from VA employment licensed doctors of chiropractic
who graduated from SCASA accredited schools, those who graduated
from chiropractic school prior to the creation of CCE, those
who graduated from a school of chiropractic before it achieved
full CCE accreditation status, and those who, in the future,
might graduate from a school accredited by a new chiropractic
accrediting organization recognized by the U.S. Secretary of
Education.
H.R. 2414, introduced June 10, 2003 to amend title 38, United
States Code, to provide for the full-time permanent appointment
of chiropractors in VHA, states the educational qualification
of chiropractors as "hold the degree of doctor of chiropractic,
or its equivalent, from a college of chiropractic approved by
the Secretary." This language, which models that used for
other professions in Title 38, if passed, will override the current
limitation to CCE accredited schools contained in P.L. 106-117.
The language of H.R. 2414 was incorporated into H.R. 2357 and
passed by the House of Representatives on July 21, 2003
VA currently accepts graduation from an accredited school
or a school accepted by a state licensure board for several health
care professions (physician, dentist, optometrist), while the
qualification standards for other professions permit education
from a school accepted by a state licensing board only for graduates
of foreign schools.
Given the history of accreditation of chiropractic educational
programs, and the existence of a second accrediting body that
was recognized by the US Department of Education until 1993,
the Committee recommends the acceptance of the broader education
standard that will not exclude experienced doctors of chiropractic
because of variations in the accreditation of chiropractic schools
in the past.
Comment: Chiropractic state licensure criteria is not
standardized across all states nor has the same examination always
been used by all states. As a result, some members of the Committee
expressed concerns that licensure may not be adequate to assure
the same level of training as those programs meeting the standards
of a recognized accrediting body.
Recommendation 2: Licensure requirement
Current, full and unrestricted license to practice chiropractic
in a State, Territory, or Commonwealth of the United States,
or in the District of Columbia. A doctor of chiropractic who
has, or has ever had, any license(s) revoked, suspended, denied,
restricted, limited, or issued/placed in a probationary status
should be appointed only in accordance with existing VA provisions
applicable to other independent licensed practitioners.
Rationale: Doctors of Chiropractic are licensed as
independent practitioners in all US jurisdictions. While some
variation in licensure law exists among U.S. jurisdictions, doctors
of chiropractic are responsible for providing appropriate care
within the scope of their licensure, education and competency
and making appropriate referral to other health care providers
if necessary.
P. L. 106-117 (the Veterans' Millennium Health Care Act),
Section 303 defines the term "chiropractor" as an individual
who is "licensed to practice chiropractic in the state in
which the individual performs chiropractic service." H.R.
2414, introduced June 10, 2003, to amend title 38, United States
Code, defines the licensure qualification of chiropractors as
"be licensed to practice chiropractic in a State."
This language, which models that used in Title 38 for other professions,
if passed, will override the current in language in P.L. 106-117
and allow VA to use the same criteria as used for other Title
38 professions, i.e., licensure in any US jurisdiction. The language
of H.R. 2414 was incorporated into H.R. 2357 and passed by the
House of Representatives on July 21, 2003.
Recommendation 3: Other requirements
Doctors of chiropractic should be expected to meet the other
employment requirements, such as citizenship, English language
proficiency and physical requirements, established by VA for
all other Title 38 employees.
Rationale: Doctors of chiropractic should meet the
general employment criteria expected of all other Title 38 employees.
B. Scope of Practice
Recommendation 4: Scope of Practice
Doctors of chiropractic shall provide patient evaluation and
care for neuro-musculoskeletal conditions including the subluxation
complex within the boundaries set by state licensure, VHA privileging
and the doctor's ability to demonstrate educational training
and clinical competency in the areas necessary to provide appropriate
patient care.
Rationale: P.L. 107-135 states: "The chiropractic
care and services available under the program shall include a
variety of chiropractic care and services for neuromusculoskeletal
conditions including subluxation complex."
VHA Handbook 1100.9, Credentialing and Privileging, states:
"The term independent practitioner is an individual permitted
by law (the statute which defines the terms and conditions of
the practitioner's license) and the facility to provide patient
care services independently, i.e., without supervision or direction."
The VHA privileging process includes verification of educational
training and clinical competency.
Examples of neuromusculoskeletal conditions appropriate for
chiropractic care include, but are not limited to, subluxation,
back pain, neck pain, headache, and joint sprains and strains.
A more comprehensive but not all-inclusive condition list routinely
used in chiropractic education is included in Appendix A.
Comment: The term "subluxation" as used by
allopathic practitioners refers to the slippage of one bone on
another, (i.e., a partial or complete dislocation) which is measurable
on a radiograph. "Subluxation complex" or "vertebral
subluxation complex (VSC)" are terms specific to chiropractic.
These terms are used by doctors of chiropractic to describe a
joint that they judge is no longer in proper position and/or
is not functioning properly and the adjacent tissues associated
with the malposition or altered motion of the joint. Subluxation
complex may or may not be visible radiographically and may or
may not have specific symptoms associated with it. Not all practitioners
agree that the subluxation complex is a clinically definable
entity.
Footnote: "A subluxation is a complex of functional
and/or structural and/or pathological articular changes that
compromise neural integrity and may influence organ system function
and general health." The
Chiropractic Paradigm, Association of Chiropractic Colleges.
C. Services to be Provided (Privileges):
Recommendation 5: Minimum Initial
Privileges
Minimum initial privileges, based on the state licensure of
the doctor of chiropractic, should include:
- History taking
- Neuromusculoskeletal examination and associated physical
examination
- Ordering of standard diagnostic plain film radiologic examinations
to include spine, pelvic, skull, and rib series and chest (PA
and lateral)
- Determine appropriateness of chiropractic care for
the problem(s) for which the patient is being managed.
- Provide chiropractic care
a. Adjustment
b. Manipulation/mobilization
c. Manual therapy
- Manage neuromusculoskeletal care
- Referral to appropriate provider when chiropractic care is
deemed inappropriate or when patient conditions outside the scope
of chiropractic care are suspected or detected through examination
or as a result of diagnostic testing.
Recommendation 6: Other Initial Privileges
When permitted by the state licensure of the doctor of chiropractic
and the privileging process for the VA facility, additional initial
privileges may include:
- Ordering of additional diagnostic studies
a. Imaging studies (e.g., CT, MRI, ultrasound, bone scan)
b.Clinical laboratory (e.g., Urinalysis, SMA 24, Arthritis Panel,
CBC)
c.Other appropriate tests (e.g., EMG, nerve conduction)
- Order or provide other treatment modalities:
a. Physical modalities (e.g., heat, cold, electrical, ultrasound)
b. Ergonomic evaluation, posture management
c. Orthotics, supportive bracing, taping
d. Counseling/education on body mechanics, nutrition, lifestyle,
exercise, hygiene.
Rationale: There is some variation in licensure law
among the U.S. jurisdictions, and a doctor of chiropractic may
not practice beyond the scope of his/her individual licensure.
The Committee, in Recommendation 5, has identified privileges
that all doctors of chiropractic are licensed to provide and
recommends that these be permitted throughout VHA in order to
provide baseline consistency in practice as chiropractic care
is integrated into VHA. In Recommendation 6, the Committee has
identified additional privileges that some doctors of chiropractic
are licensed to provide, and recommends that these be included
in initial privileges when permitted by the licensure of the
doctor of chiropractic and the employing facility. The Committee
understands that having different privileges for the same category
of practitioner within a facility may be confusing, but believes
that when consistency in practice within a facility is not an
issue, doctors of chiropractic should be used to their fullest
legal capability in providing care for neuromusculoskeletal conditions
in order to reduce the degree to which patients are inconvenienced
by having to see multiple providers for ordering of necessary
diagnostic tests or treatments. The Committee also understands
that some VA facilities require prior authorization for some
diagnostic tests, such as MRIs, and believes prior authorizations
required of doctors of chiropractic should be consistent with,
but not exceed, existing facility policies.
Comment: One member of the Committee recommended that
appropriate use of laboratory tests by doctors of chiropractic
be monitored to insure that no critical values exist which do
not also reach the primary care physician and/or do not receive
appropriate follow-up. VHA does not privilege individual practitioners
to order diagnostic tests unless they are competent to manage
the results appropriately. VHA policy requires that all emergent
test results must be immediately communicated to the ordering
practitioner by telephone, face-to-face conversation or hand
carried report. Abnormal test results that are not emergent but
require attention by the ordering practitioner may be transmitted
by direct or electronic communication to the ordering practitioner
or to a designated surrogate if the ordering practitioner is
not available to review results in a timely manner. Electronic
communication includes e-mail, fax, or view alerts transmitted
to the ordering practitioner.
Although notification of the primary care provider is not
required by VHA policy, view alerts in the VA electronic medical
record system are a mechanism by which emergent values are automatically
forwarded to the patient's primary care provider, as identified
in the computer system, as well as to the ordering provider.
The primary care provider also may elect to have all abnormal,
non-emergent values automatically forwarded.
The DoD Chiropractic Health Demonstration Project initially
monitored laboratory results for overutilization and follow-up
of abnormal results, but discontinued such monitoring due to
lack of positive findings, i.e., no failure to follow-up or refer
for abnormal results.
Comment: Two members of the Committee wished to have
surface electromyography and thermography added to the list of
privileges. Respondents to the Job Analysis of Chiropractic conducted
by the National Board of Chiropractic Examiners in 2000 rated
electromyography was "of little importance" and indicated
they rarely referred patient for such studies. Thermography was
not rated at all. This type of equipment was not provided for
doctors of chiropractic in the DoD Demonstration Project. Doctors
of chiropractic wishing to use these modalities could request
them in their privileges, but the majority of the Committee does
not believe they should be recommended for inclusion in initial
privileges.
Recommendation 7: Additional Privileges
After the initial annual evaluation, the doctor of chiropractic
may request additional privileges, which may be granted by the
privileging facility consistent with the needs of the facility
and the licensure held by the doctor of chiropractic, upon demonstration
of appropriate training and competency.
Rationale: The Committee understands that the privileges
granted doctors of chiropractic will reflect not only the scope
of the doctor of chiropractic's license, but also the mission
and resources already available within the facility. In the event
that a facility does not initially grant privileges up to the
scope of the doctor of chiropractic's license, training and competency,
Recommendation 7 suggests a timeframe for consideration of additional
privileges after the facility has had experience in providing
chiropractic care. Recommendation 7 also provides for additional
privileges not included in Recommendation 6.
Recommendation 8: Publication of
Information Letter
VHA should publish an Information Letter providing guidance
to facilities regarding the recommended privileges approved by
the Secretary.
Rationale: The chiropractic profession is new to VHA
and most doctors of chiropractic practice in private practice
settings rather than in health care organizations. An Information
Letter that provides information regarding privileging of doctors
of chiropractic will assist in providing some degree of consistency
in process within VHA. An Information Letter provides guidance
rather than a mandated policy.
D. Access to Chiropractic Care
The Committee did not reach consensus on how veterans should
be able to access chiropractic care within VHA. Six members of
the Committee favored a referral only system and 5 favored a
more direct form of access. Therefore, two recommendations are
presented. The Committee also made a third recommendation (Recommendation
10) to allow direct access for newly discharged veterans who
had been receiving chiropractic care through DoD in order to
ensure continuity of care.
Recommendation 9: Access to Chiropractic
Care
Access to chiropractic care should require referral from the
patient's primary care provider or another VA clinician who is
treating the patient for the condition(s) for which chiropractic
care is indicated. The referral process should be expedited without
barriers. Veterans who have been referred to and have received
care from a doctor of chiropractic should continue to have access
to the doctor of chiropractic for the continuation of care or
treatment, consistent with facility policy for specialty care
access.
Rationale: VHA uses a primary care model of healthcare
delivery, with access to almost all specialty care through referral.
Allowing direct access to chiropractic care would create a specific
exception to that overall model. It has not been VHA's practice
to permit a patient to receive specialty care upon request; rather,
another clinician, usually the patient's primary care provider,
must refer the patient. It is felt that the patient's primary
care provider, or another provider who has evaluated the patient,
has the best knowledge of the patient's overall health status
and potential contraindications to chiropractic care.
Mandating that patients should be able to receive chiropractic
care upon request may be poorly received by VA facilities, and
may create demands for direct access to other specialty care.
Allowing direct access for only chiropractic care may also create
animosity toward a new program and interfere with the successful
integration of chiropractic care into VHA. The successful integration
of chiropractic care into the DoD healthcare system was heavily
dependent upon support from upper management and placement of
doctors of chiropractic within a health care team where collaborative
relationships developed.
Although there is anecdotal evidence some VA physicians have
significant anti-chiropractic biases, many others do not. Some
have indicated openness and acceptance of chiropractic care as
evidenced by referrals for fee-basis chiropractic care. Still
others are unfamiliar with chiropractic care and have no experience
in collaborating with doctors of chiropractic. Integrating doctors
of chiropractic into a health care team and using existing operating
procedures for collaboration will most likely lead to acceptance
of chiropractic care within VHA. (See Appendix B for descriptions
of models of integration.) Creating a different model of care
delivery for chiropractic will tend to separate and isolate the
doctors of chiropractic, with the detrimental effect of decreasing
the professional interactions that will lead to greater collaboration
and acceptance.
While new enrollees currently experience long delays in accessing
primary care, existing patients are less likely to encounter
significant delays in obtaining routine appointments. Patients
with new acute conditions have access to urgent care or, in some
facilities, same day appointments. Because the primary care provider
or another provider who has been seeing the patient will have
previously examined the patient and know the patient's history,
the referral process should not cause significant delays.
Some members believe permitting direct access to chiropractic
care may lead to patients attempting to use that access to circumvent
the primary care backlog, with expectations that doctors of chiropractic
can then move them to the head of the line for non-chiropractic
care. One member believes that establishing a policy where veterans
may self-select chiropractic care may represent a mechanism for
doctors of chiropractic to function as primary care providers.
Some members also expressed concerns that allowing direct
access would quickly overload the capacity to provide chiropractic
care.
Dissenting Recommendation:
VHA facilities should establish processes that will ensure
patients are adequately informed about treatment options, including
chiropractic care, when presenting to urgent care with acute
neuromusculoskeletal conditions appropriate for chiropractic
care, when calling to request a primary care appointment for
acute neuromusculoskeletal conditions, or when receiving care
for difficult, chronic and otherwise unresponsive neuromusculoskeletal
conditions. Patients presenting with neuromusculoskeletal complaints
who prefer chiropractic care as their treatment option should
be referred to a doctor of chiropractic for evaluation and care.
Rationale: VHA Notice 99-02, Shared Decision Making,
dated June 15, 1999, defines shared decision making as "the
case for letting patients decide which choice is best.A process
by which patients are educated about likely treatment outcomes,
with supporting evidence, and engaging with them in deciding
which choice is best for them, taking into account their preferences,
values and lifestyles."
Patients who present to urgent care or who call for a primary
care appointment for acute neuromusculoskeletal conditions, as
well as patients with difficult, chronic and otherwise unresponsive
neuromusculoskeletal conditions should be provided with complete
and unbiased information regarding evaluation and treatment options,
including chiropractic care, and be permitted to make a choice
regarding their health care. Established patients known to the
provider and who are absent any "red flags" or overt
contraindications for receiving chiropractic care should be referred
appropriately. New patients presenting to urgent care, or established
patients who come in after normal hours and are seen by a provider
who does not know them, will be examined by the provider on duty,
provided information on treatment options, and then referred
according to their preference for treatment. Other treatment
regimes should not be required before referral for chiropractic
care when that is the patient's preference. Then, if chiropractic
care is selected, the doctor of chiropractic will conduct an
evaluation and, if chiropractic care is appropriate, provide
treatment as indicated.
Most of the chiropractic members of the Committee believe
veterans should be able to select and have easy access to chiropractic
conservative care interventions for acute neuromusculoskeletal
conditions and to chiropractic consultation for difficult, chronic
and otherwise unresponsive neuromusculoskeletal conditions. This
approach would allow patients to access chiropractic care for
acute neuromusculoskeletal conditions in a timely manner without
utilizing scarce primary care capability.
Most of the doctors of chiropractic on the Committee continue
to have serious concerns that some VA physicians have significant
anti-chiropractic biases, will not refer patients, and will continue
to impose barriers, such as requiring other treatment regimes,
before referring patients for chiropractic care. They believe
requiring the veteran to obtain a primary care appointment and
referral may result in the veteran being unable to obtain chiropractic
care in a timely manner.
While VHA endorses and is moving toward a primary care model
of healthcare delivery, with access to almost all specialty care
through referral, local variations still exist. These variations
result from differences in the size and configuration of VHA
facilities, staffing patterns, and local business practices.
Currently, patients experience lengthy delays for enrollment
for primary care and/or availability of primary care appointments.
While VHA is diligently striving to reduce those delays, they
remain a fact of life. The result is that patients may be unable
to access chiropractic care in a timely manner.
Recommendation 10: Continuity of
Care for Newly Discharged Veterans
Newly discharged veterans who have been receiving chiropractic
care through the Department of Defense while on active duty and
who have service-connected neuromusculoskeletal conditions, or
who are newly returned from a combat zone, or who have applied
for service connection for the neuromusculo-skeletal condition
for which DoD provided chiropractic care, should have direct
access for continued chiropractic care at a VHA facility.
Rationale: Newly discharged veterans who were receiving
chiropractic care through the Department of Defense while on
active duty should be able to receive continuing care from VHA
without delays resulting from being placed on a waiting list
for primary care enrollment. Any veteran who, at the time of
discharge, is receiving chiropractic care for a neuromusculoskeletal
condition, through a DoD provided source, is likely to become
service connected for that condition. Some veterans are receiving
service connected status at the time of discharge under the Benefits
Delivery at Discharge program. Newly discharged veterans who
did not have the opportunity to participate in the Benefits Delivery
at Discharge program and who have applied for service connected
status for the condition that was under treatment by DoD doctors
of chiropractic also should be allowed to continue treatment
without the delay created by the length of time required for
adjudication of the claim. Newly discharged veterans returning
from a combat zone are eligible for VA care for two years after
leaving active duty even without a service connected disability.
The President's Task Force to Improve Health Care Delivery
for Our Nation's Veterans recently recommended that VA and DoD
improve their collaboration and sharing of information in order
to improve the processes for transition from military service
to veteran status. The need to share health information and improve
continuity of care between DoD and VA has been a major focus
of VA/DoD Joint Executive Council and has been included in the
VA/DoD Joint Strategic Plan that was approved April 15, 2003
by the Joint Executive Council.
Comment: One member voiced concern that this might
create a large pool of people who would attempt to circumvent
VHA's normal referral process by applying for service connected
benefits in order to continue to receive chiropractic care without
a primary care provider.
Recommendation 11: Inpatient Care
Doctors of chiropractic may see inpatients, including patients
in VHA's long term care facilities, upon referral from another
VHA provider, but will not have admitting privileges.
Rationale: Almost all chiropractic care in the private
sector is provided in outpatient settings. If chiropractic care
is indicated during an inpatient stay, the attending physician
should request it through the consult process.
Recommendation 12: Chiropractic Care
in Community Based Outpatient Clinics (CBOCs)
Chiropractic services should be provided in a CBOC when the
parent facility determines that the need exists and when
the resources are available to provide such services. The existing
fee basis program can be utilized if staff or contract doctors
of chiropractic are not available at the CBOC.
Rationale: VHA's CBOCs vary in size and resources.
Decisions regarding provision of chiropractic care in CBOCs should
be made as a part of overall facility/VISN planning for optimum
provision of services. Chiropractic services provided at CBOCs
will use the same guidelines and protocols as the parent facility.
Recommendation 13: Fee Basis Care
Chiropractic care should continue to be available through
the fee-basis program. An evaluation may be required prior to
authorization of fee-basis care; however, the authorization mechanism
should be consistent with the requirements for all other fee
basis authorizations within the facility.
Rationale: Chiropractic care should continue to be
available to patients who live in areas distant from a VHA facility
providing chiropractic services.
Recommendation 14: Occupational Health
Programs
Doctors of chiropractic can be utilized in the VHA facility's
occupational health program.
Rationale: At the National Naval Medical Center (NNMC),
Bethesda, the doctors of chiropractic participate in the occupational
health program by providing chiropractic care for work-related
injuries, providing workplace ergonomic evaluations and recommendations,
and providing classes in back care and ergonomics. The chiropractic
staff believes that their initial involvement in treating NNMC
staff played an instrumental role in acceptance of chiropractic
care at that facility. This recommendation is offered as an option
that individual facilities may wish to consider.
NNMC is different from VA facilities in that many of the NNMC
personnel are active duty military, and receive all of their
health care there. VHA personnel are civilian employees who are
covered under the Federal Employee Compensation Act (FECA). While
VHA would be able to bill Department of Labor for treatment of
work-related injuries by VHA doctors of chiropractic, the chiropractic
services that may be reimbursed are limited by the FECA to "treatment
consisting of manual manipulation of the spine to correct a subluxation
as demonstrated by X-ray to exist."
Comment: Two members of the Committee do not agree
that this recommendation should be included, as it does not pertain
to providing services to veterans. While VA employees may receive
treatment of work-related injuries at a VHA facility if they
wish, availability of such care is limited by the capacity of
the treating service to provide services to employees without
interfering with the care of veterans. A number of Committee
members believe it is unlikely the doctors of chiropractic will
have time to evaluate or treat employees or to teach classes.
There was strong disagreement from one member regarding the provision
of ergonomic evaluations or classes by any provider, as there
is no evidence that such evaluations and classes lead to any
health gains and some randomized trial evidence indicates such
classes lead to increased back pain claims.
E. Referrals to and from Doctors of Chiropractic
Recommendation 15: Screening of Patients
The doctor of chiropractic should screen patients to identify
the following "red flags" or contraindications to manual
therapy.
a.Possible fracture from major or minor trauma in an osteoporotic
patient.
b.Possible tumor or infection in patients with a history of cancer,
recent fever, unexplained weight loss, recent bacterial infection,
IV drug abuse or immune suppression
c.Possible cauda equina syndrome noted by saddle anesthesia,
recent onset of bladder dysfunction, progressive neurologic deficit
or major motor weakness in the lower extremity (not sciatica),
unexpected laxity of the anal sphincter or perianal/perineal
sensory loss.
Rationale: The presence of these conditions suggests
the need for medical consult prior to receiving chiropractic
care.
Recommendation 16: Referral Service
Agreements
VHA should encourage the development of referral service agreements
between doctors of chiropractic and both primary care and other
specialty providers regarding the types of conditions appropriate
for referral to chiropractic care, and the pre-referral testing
that will be useful to optimize the provider's time. The authorization
mechanism for chiropractic referrals, follow-up, and recurrent
care should be consistent with the facility's business practices
for other referrals.
Rationale: In VHA models of health care delivery that
do not allow direct access to specialty care, the goal of the
referral process is appropriate access to chiropractic care for
veterans with acute or chronic neuromusculoskeletal conditions
(to include the subluxation complex) amenable to chiropractic
care. A number of VHA facilities have developed service agreements
to expedite the referral process.
Chiropractic patients typically present with a wide variety
of neuromusculo-skeletal complaints; however, the large majority
of patient complaints are related to back pain, neck pain, headaches
and peripheral joint pain. (See Appendix A.)
While VHA's electronic medical record facilitates communication
among multiple providers, development of service agreements can
be used to clarify expectations regarding coordination of care
and case management. Development of service agreements may also
assist in the joint education of doctors of chiropractic and
other VHA providers regarding the provision of care for neuromusculoskeletal
conditions and the subluxation complex within VHA.
Comment: The subluxation complex (or vertebral subluxation
complex) is an entity unique to chiropractic, as recognized by
many State practice acts. Many chiropractic techniques are designed
specifically to care for the subluxation complex, which may or
may not be associated with neuromusculoskeletal symptoms (i.e.,
the subluxation complex may not be symptom specific or symptom
dependent). Some members of the Committee do not agree that this
is a clinically definable entity.
Comment: Chiropractic members of the Committee believe
that patients presenting with vertebral malposition, abnormal
spinal segmental motion, soft tissue tenderness and compliance,
and asymmetric or hypertonic muscle contractions, are appropriate
for referral to a doctor of chiropractic. Non-chiropractic members
of the Committee believe that physical therapists, physiatrists
or doctors of osteopathic medicine also are qualified to provide
evaluation and care.
Comment: Chiropractic care often requires multiple
patient encounters over a period of time. Patient response may
range from complete recovery after a single treatment to a stabilization
of the patient's condition without total resolution of the problem.
It is the opinion of some chiropractic members of the Committee
that, in the latter case, patients often benefit from periodic
care over an indefinite period of time. They believe that while
such an ongoing treatment regime may seem counter to effective
case management, in many cases, the alternatives—no care or
more aggressive care—may leave the patient in a more debilitated
condition or involve more expensive or invasive medical care.
Other Committee members insist that there is no convincing evidence
that periodic chiropractic care over an indefinite period of
time provides any health benefit or can prevent the use of other
health care procedures for any health condition.
Recommendation 17: Referrals from
Doctors of Chiropractic
Doctors of chiropractic may make referrals to other VHA services
and/or providers as appropriate, subject to facility protocols.
Rationale: In some cases, doctors of chiropractic may
need to refer to other providers for specific services, e.g.,
orthotics or supportive bracing, if direct provision of those
services are not within the privileges of the doctor of chiropractic,
or social work service for family issues. The doctor of chiropractic
also should have the ability to request further diagnostic evaluations
and medical consultations with appropriate services (including
specialists) within the VHA facility or system if potential contraindications
to chiropractic care are identified. The doctor of chiropractic
may encounter situations in which a patient presents with a medically
urgent condition that requires immediate referral. Making such
referrals directly when the need becomes evident during a patient
visit will expedite appropriate intervention.
F. Integration of Chiropractic Care into VHA
Recommendation 18: Coordination of
Care
The doctor of chiropractic and the patient's primary provider,
in conjunction with other appropriate VHA providers,
should develop a collaborative treatment regime when patients
present with concurrent neuromusculoskeletal and non-neuromusculoskeletal
problems.
Rationale: The VHA health care system encourages an
integrated, interdisciplinary, interdependent and collaborative
team approach to patient care. A holistic, integrated approach
is essential for many VA patients who have multiple health problems.
Recommendation 19: Co-management
of Care
As a member of the VHA health care team, doctors of chiropractic
should co-manage patient care for neuromusculoskeletal conditions
as appropriate, along with the patient's primary provider,
other team members, and specialists.
Rationale: Doctors of chiropractic should provide co-management
of care when patients present with concurrent complex neuromusculoskeletal
and non-neuromusculoskeletal problems.
Recommendation 20: Placement of Doctors
of Chiropractic within a Health Care Team
Doctors of Chiropractic should be integrated into the VHA
health care system as a partner in a health care team.
Rationale: The Department of Defense Chiropractic Health
Care Demonstration Project demonstrated that chiropractic care
was accepted best when the doctors of chiropractic were incorporated
within a traditional medical team housed within the main medical
facility, rather than functioning as a separate entity.
The Committee describes several models of integration in Appendix
B. Decisions regarding placement should consider the functional
working relationships appropriate to the care of patients with
neuromusculoskeletal conditions in the facility. Teams may be
organizationally defined or exist in a functional capacity. The
doctor of chiropractic should be a part of whatever team is most
likely to deal with initial presenting complaints related to
the neuromusculoskeletal system.
Recommendation 21: Site Selection
The VISN Clinical Managers should provide recommendations
for sites they believe will be most successful in integrating
chiropractic care into a facility while meeting the needs of
veterans.
Rationale: P.L. 107-135 requires that chiropractic
care be offered at a minimum of one VHA site in each VISN. Site
selection for the initial placement of doctors of chiropractic
should, to the extent possible, be driven by the interest and
acceptance of chiropractic at facilities in each VISN, as well
as by the most advantageous use of resources.
Recommendation 22: Doctor of Chiropractic
Staffing
Each facility providing chiropractic services should have
enough doctors of chiropractic on staff to provide patient care.
Patient volume may determine whether the positions would be full-time,
part-time, or contract.
Rationale: Customarily, at least two doctors
of chiropractic are necessary to be able to provide coverage
and continuous patient care during vacations or other absences,
and to provide for peer quality review. The DoD Chiropractic
Demonstration Project provided two doctors of chiropractic at
each site. Additional doctors of chiropractic may be required
based on patient demand, subject to availability of VHA resources.
Recommendation 23: Support Staff
Personnel functioning as chiropractic assistants should come
from existing job classifications, receiving additional on-the-job
training from the doctor of chiropractic. Clerical staff for
scheduling and other administrative clinic duties will also be
needed.
Rationale: Chiropractic assistants provide assistance
in patient care, similar to that provided by nursing assistants
in other clinics. Facilities have the latitude to write new position
descriptions, which are then locally classified under existing
job series and titles. Clerical staff may be shared if the doctors
of chiropractic are co-located with collaborating providers,
but the addition of a new service and additional providers may
require additional clerical support.
Recommendation 24: Space
Clinic space assignments should be consistent with existing
provider space assignments. Ideally, each examination room should
be 12 by 20 feet and contain a sink.
Rationale: The space required for a chiropractic examination
table is larger than that required for most general medical examination
rooms and more consistent with that found in a physical therapy
or physical medicine area. The standard chiropractic examination
table is 2 feet by 7 feet 5 inches, and sufficient space must
be available on all sides for the doctor of chiropractic to move
about during treatment. Desirable clinic space requirements include
a reception/waiting area (which can be shared with other clinics)
and two examination/treatment rooms per doctor of chiropractic.
As has been noted for primary care clinics, an excess of two
treatment rooms facilitates the ability to see a greater number
of patients. Office space for the doctors of chiropractic should
preferably be in close proximity to the patient care area.
Recommendation 25: Co-location with
Collaborating Providers and Services
Where feasible, the doctors of chiropractic should be located
with or near collaborating providers or services.
Rationale: Co-location will facilitate communication
and interaction with other providers and enable sharing of reception/waiting
space, administrative support staff and space, and potentially
some equipment. It is, however, important that providing space
for chiropractic care not penalize or create hardship for other
services.
Recommendation 26: Equipment
Chiropractic adjusting tables and specialized diagnostic evaluation
equipment particular to chiropractic needs will be needed. See
Appendix C for list of equipment and supplies needed for each
examination room.
Rationale: In addition to standard office and examination
equipment, some specialized equipment is needed for chiropractic
evaluations. Chiropractic table types vary with some designed
for specific types of care. Facilities should consult with the
doctors of chiropractic before purchasing tables.
Comment: Two doctors of chiropractic on the Committee
wished to have equipment for surface electromyography and thermography
added to the equipment list in Appendix C. Respondents to the
Job Analysis of Chiropractic conducted by the National Board
of Chiropractic Examiners in 2000 rated electromyography as "of
little importance" and indicated they rarely referred patient
for such studies. Thermography was not rated at all. This type
of equipment was not provided for the DoD Demonstration Project.
This equipment would be needed only if doctors of chiropractic
received privileges to perform these tests. See Recommendation
#6.
Recommendation 27: Orientation
A standardized orientation program on how chiropractic care
is to be integrated into VHA should be developed and presented
to clinical and administrative staff at each facility prior to
the actual implementation of a chiropractic service.
VHA should develop a basic orientation program for doctors
of chiropractic that can be modified for differences in facilities.
Rationale: VHA staff will need an orientation regarding
the availability of chiropractic care, including how patients
may access the care. Doctors of chiropractic will also require
orientation to VHA, including orientation to the services provided
at the facility and care processes, in addition to the general
orientation all new employees receive. Assignment of mentors
who are accepting of chiropractic care to the new doctors of
chiropractic may assist in orientation and integration.
Recommendation 28: Ongoing Education
of Providers
Doctors of chiropractic should participate in facility interdisciplinary
educational activities in order to encourage collaboration and
gain familiarity with the care provided by other services.
Rationale: Once the chiropractic service has been implemented,
additional interdisciplinary educational encounters will need
to be provided to address new concerns or questions as well as
to encourage collaboration among staff. Observation and participation
in hospital rounds and patient care conferences may assist doctors
of chiropractic in enhancing current skills as well as continuing
to educate them regarding the variety of veteran patient conditions
and needs. In addition, these educational encounters will serve
to inform other professional staff regarding the services provided
by doctors of chiropractic.
Recommendation 29: Education of Patients
VHA will provide standardized information to patients regarding
the availability of chiropractic care. Each VISN will provide
information to patients on how to access chiropractic services
within the VISN. VISN Directors should assure the widest dissemination
possible using multiple modalities.
Rationale: VHA published a patient education brochure
regarding chiropractic care in May 2001,and distributed it through
the VISN Clinical Managers. It is unclear how widely it was used,
and many patients who have inquired about chiropractic care report
that they have never seen it. VHA should make all veterans aware
that chiropractic care is a part of its Medical Benefits Package.
The Committee will provide recommendations at a later time
regarding content and methods of distributing educational materials.
Comment: One member of the committee stated that the
information provided to patients should provide a "balanced
perspective on the evidence" of the effectiveness of chiropractic
care to insure patients are able to make informed decisions.
Recommendation 30: Quality Assurance
Chiropractic care should be incorporated into each facility's
quality assurance program.
Rationale: Chiropractic care should conform to VHA
quality assurance processes in a manner that is consistent with
other providers/services and the requirements of the Joint Commission
on Accreditation of Healthcare Organizations.
The Committee will provide recommendations at a later time
regarding quality measures for the chiropractic care program.
Recommendation 31: Performance Measures
VHA should develop performance/outcome measures for chiropractic
care.
Rationale: VHA's experience has shown that the use
of performance/outcome measures is useful in improving the quality
of care provided to veterans.
The Committee will provide recommendations at a later time
regarding performance measures.
Recommendation 32: Evaluation of
Chiropractic Care Program
A formal evaluation of the challenges and benefits of providing
chiropractic care within VHA should be completed by the conclusion
of the third year of implementation. Formal progress reports
should be completed at least annually.
Rationale: This evaluation should include the variations
in organizational placement and models of delivery utilized across
the VISNs and a determination of how these variations impacted
the implementation of the chiropractic service. Data to be analyzed
should include, at a minimum, the number and characteristics
of patients receiving chiropractic care, waiting times for access
to chiropractic care, and the impact on the use of the fee basis
program for chiropractic care.
It is essential that evaluation factors be established and
data collected in a prospective manner so VHA managers and doctors
of chiropractic will be able to use the data for program improvement.
Mechanisms should be established to enable the sharing of information
regarding successful implementation strategies as well as lessons
learned. The Committee anticipates that Members of Congress will
request such data. Therefore formal progress reports should be
produced at least annually.
Recommendation 33: Medical Staff
Voting Privileges
All doctors of chiropractic, once credentialed and privileged
by a VHA facility, should be members of the Medical Staff and
have full voting privileges.
Rationale: To fully integrate chiropractic care into
the VHA healthcare system, doctors of chiropractic should be
full voting members of the Medical Staff. In most VHA facilities,
both podiatrists and optometrists are voting members of the medical
staff.
Comment: Two members of the Committee stated that medical
staff voting privileges should be at the discretion of the local
facility and consistent with existing VA guidelines.
Recommendation 34: Continuing Education
Doctors of chiropractic employed by VHA should be expected
to obtain continuing education as required for the maintenance
of licensure and competency. VA should fund such training in
accordance with existing VA policy.
Rationale: VHA expects all professional staff to maintain
and enhance competency through continuing education programs.
Doctors of chiropractic should be able to access funding for
educational programs in the same manner and to the same degree
as other staff.
Recommendation 35: Oversight and
Consultation for the Chiropractic Program
VHA should create a mechanism for providing oversight of and
consultation on the implementation of chiropractic care.
This may be accomplished through the appointment of a chiropractic
advisor, similar to the position of the physician assistant advisor
or the directors of podiatry and optometry, or a field advisory
committee.
Rationale: All other professions have representatives
to provide advice and input to the Chief Patient Care Services
Officer and the Under Secretary for Health. A structure for obtaining
input from practicing doctors of chiropractic is essential to
the success of the chiropractic care program within VHA. All
current occupational representatives within Patient Care Services
are field-based and perform these duties on a part-time basis.
A full-time chiropractic advisor/director position could occur
only as a VACO position, and there are distinct benefits in having
a field-based practicing clinical doctor of chiropractic in this
position. As a profession new to VHA, it will be important for
the person in this position to have a hands-on working knowledge
of VHA operations. In addition, field-based positions allow for
the recruitment of the best-qualified individuals rather than
just someone who is willing to move to Washington, DC.
Comment: Two members of the Committee recommended a
field advisory committee with a rotating chair. Two members of
the Committee suggested that, given the challenges associated
with the system-wide implementation of a new and somewhat controversial
program, an office for chiropractic oversight and advisement
at the Central Office level should be considered.
Recommendation 36: Committee Membership
Doctors of chiropractic should be included in the membership
of appropriate facility, VISN, and national clinical and administrative
committees, work groups and task forces in a manner consistent
with the participation of other providers.
Rationale: Doctors of chiropractic should provide input
through membership on committees, work groups and task forces
that discuss, evaluate or make recommendations regarding or otherwise
impact the provision of chiropractic care.
Recommendation 37: Academic Affiliations
VHA should provide opportunities for educational and training
experiences for senior chiropractic students and recent graduates
from chiropractic programs, consistent with graduate preceptor
programs sponsored by chiropractic educational programs. These
educational experiences should expose the student to a wide range
of services provided in the VHA facility to broaden the participant's
understanding of clinical care and to help the student to experience
chiropractic care in a multidisciplinary setting.
Rationale: Health professional training is one of VA's
missions. VHA is noted for its leadership in providing clinical
experiences for a variety of health care professions.
Recommendation 38: Research
VHA, in conjunction with its chiropractic providers and chiropractic
educational programs, should conduct clinical research relevant
to the type of conditions and services provided by doctors of
chiropractic. Emphasis should be placed on common service connected
conditions. Research related to integration of multidisciplinary
providers into teams should also be undertaken.
Rationale: Neuromusculoskeletal conditions are among
the most common reasons for service connected status. VHA has
a unique opportunity to develop research programs to evaluate
the efficacy of chiropractic care in the treatment of these conditions
as well as to evaluate the dynamics of developing and integrating
multidisciplinary teams.
APPENDIX A
CONDITIONS COMMONLY SEEN BY DOCTORS OF CHIROPRACTIC
(Not all inclusive)
Chiropractic patients typically present with a wide variety
of neuromusculo-skeletal complaints; however, the large majority
of patient complaints are related to back pain, neck pain, headaches
and peripheral joint pain. Doctors of chiropractic commonly manage
the conditions on this list, which is provided as information
for persons not familiar with the scope of chiropractic practice.
This list does not imply that only doctors of chiropractic can
manage these conditions or that other health care providers are
not trained to manage these conditions.
One Committee member stated that there are no evidence-based
studies to support the therapeutic value of spinal manipulative
therapy for some of these conditions. A doctor of chiropractic
on the Committee pointed out that a doctor of chiropractic may
manage some conditions, such as osteoporosis, with dietary and
exercise recommendations, rather than spinal manipulation.
The DoD Demonstration Project limited the doctors of chiropractic
to treatment of "spine-related neuromusculoskeletal complaints
or problems". Since completion of the Demonstration Project,
DoD has expanded the scope of practice for the doctors of chiropractic
to "neuromusculoskeletal problems."
- Subluxation
- Chronic pain
- Strain/Sprain (traumatic)
- Lumbosacral strain/sprain
- Intervertebral disc syndrome
- Sacroiliac syndrome
- Cervical strain/sprain
- Symptomatic Scoliosis
- Thoracic sprain/strain
- Torticollis (acquired)
- Myofascial pain syndrome
- Acute cervical pain
- Osteoporosis
- Osteoarthritis
- Peripheral neuropathies
|
- 16. Migraine
- 17. Posterior facet syndrome
- 18. Chronic daily headache (tension)
- 19. Vertebrogenic headache
- 20. Scheurman's disease
- 21. Carpal tunnel syndrome
- 22. Rotary cuff tendonitis
- 23. Mechanical disorders (thoracic)
- 24. Chest wall syndrome
- 25. Tendonitis (traumatic)
- 26. Disc syndrome (cervical)
- 27. Bursitis (traumatic)
- 28. Compartment syndrome
- 29. Patellofemoral syndrome
|
APPENDIX B
MODELS FOR INTEGRATED CARE DELIVERY
The following models of integrated care delivery may be useful
to VHA administrators and clinical staff in planning to incorporate
chiropractic care into VHA facilities. The Committee believes
chiropractic care should be integrated into existing multi-disciplinary
care delivery models, in a manner consistent with current business
processes and the privileging and use of other health care providers.
While the different organizational structures and functional
processes found among VHA facilities will influence how chiropractic
care is integrated at any given facility, the Committee believes
the following principles should be used:
- The systems and structures used to integrate doctors of chiropractic
should facilitate the timely, efficient provision of care to
veterans.
- Decisions regarding care delivery should focus on the provision
of care, not the location of care.
- Decisions regarding care delivery should focus on the skills
a person needs to provide that care, not the profession of the
person.
Model 1: Integration into primary care setting or service
line.
This model replicates a method used for integrating psychiatry
into the primary care setting at the West Los Angeles VA and
other facilities.
A doctor of chiropractic (DC) would be physically located
within the primary care area. The DC would see patients on referral
from primary care providers, usually on a same day basis for
initial evaluation. The DC also would be able to provide immediate
evaluation and care for patients who call or walk in with acute
neuromusculoskeletal complaints when it is the patient's choice
to see a DC. Patients would be referred back to their primary
care provider with specific recommendations if chiropractic care
is not indicated. When chiropractic care is indicated, the patient
would be scheduled for visits with the primary care clinic chiropractor.
The patient's neuromusculoskeletal condition may be co-managed
by the primary care provider and chiropractor, or for patients
whose chief complaint is neuromusculoskeletal, the DC may become
the principal provider of care with collaboration with other
team members as needed. Organizational placement for administrative
purposes may or may not be under primary care, and would depend
on the overall organizational structure of the medical center
(i.e., traditional services vs. service lines.)
Advantages:
- Doctor of chiropractic is available in the primary care area
for short, informal consultations, which may obviate the need
for a formal consolation, thus increasing efficiency.
- Allows quicker access to chiropractic evaluation and initiation
of care.
- Improved patient satisfaction as a result of immediate referral
during one visit.
- Care is viewed as continuous over time rather than as discrete
treatment episodes, improving coordination of care across disciplines.
- Allows more efficient utilization of the primary care providers.
- The doctor of chiropractic becomes a functional member of
the primary care team, and as such, is present and provides appropriate
input during educational sessions and patient care planning conferences.
Disadvantages:
- Finding space in existing primary care areas.
- The chiropractic area within the primary care setting would
become the de facto chiropractic clinic with additional patients
being referred from other providers (e.g. orthopedics.) increasing
space needs.
- Need for duplicate equipment (e.g., chiropractic tables;
other modalities such as electrostimulation, ultrasound, hot
packs, if DC is privileged to provide these modalities) if there
is a separate chiropractic clinic located elsewhere.
- Need to coordinate chiropractic visits with physical therapy
if DC is not privileged to provide the modalities mentioned above.
- Staffing needed to maintain availability of DC if/when patient
load increases.
Model 2: Integration into a specialty service or service
line with liaison to primary care.
This model replicates the method used for integrating physical
therapists into primary care at the VA Salt Lake City Healthcare
System.
When veterans present to primary care, the emergency department,
or call with an acute neuromusculoskeletal complaint, the provider
would be able to page a DC who is available to evaluate the patients.
Both providers might examine patients collaboratively and discuss
options for care with the patient. When the patient chooses chiropractic
care, the DC could then take the patient to the chiropractic
clinic to provide care, and schedule follow-up appointments as
necessary.
Advantages:
- Allows quicker access to chiropractic evaluation and initiation
of care.
- Coordinates care.
- Allows more efficient utilization of the primary care providers.
- Enhances education of the providers involved.
- Improved patient satisfaction as a result of immediate referral
during one visit.
Disadvantages:
- Need to move patient to chiropractic clinic for care.
- Staffing needed to maintain availability of DC if/when patient
load increases and after duty hours.
Model 3. Integration into a specialty service or serviceline
without specific liaison to primary care.
This model is similar to that used at the National Naval Medical
Center.
Doctors of chiropractic would be organizationally placed in
a specialty service or service line that provides the majority
of specialty care to patients with neuromusculoskeletal conditions.
Specialty services such as Rehabilitation or Orthopedics involve
the coordinated work of numerous professionals, including physical
medicine and rehabilitation physicians, physical therapists,
occupational therapists, nurses, and others. Doctors of chiropractic
would become a part of such a team. Patients would come to the
specialty service/serviceline by referral. In some instances,
veterans would be evaluated and treated using a team approach,
individualized to the specific needs of the patient.
Advantages:
- Placement of personnel is organizationally and functionally
congruent.
- Uses existing specialty referral process.
- Enhances education of providers in specialty area.
- Can share some equipment if located near physical therapy.
Disadvantages:
- Referral process will delay care unless same-day appointments
are available.
- Less patient satisfaction due to wait for care if same-day
appointments are not available.
- Coordination of care and collaboration with patient's primary
care provider more difficult.
- Does not enhance education of primary care providers regarding
options for care of neuromusculoskeletal conditions.
APPENDIX C
CHIROPRACTIC EQUIPMENT REQUIREMENTS
Recommended equipment and supplies for each chiropractic examination
room:
- Stethoscopes
- Sphygmomanometers
- Ophthalmoscopes
- Dynamometers
- Goniometers
- Tape measures
- Percussion and reflex hammers
- Penlights
- Scales with height measuring apparatus
- Tuning forks (126 HZ and 512 Hz)
- Pinwheels
- Plumb lines
- Disposable gowns, gloves and table covers
Depending on the privileges of the doctor of chiropractic,
electrostimulation and ultrasound equipment and heat and cold
application devices may also be needed.
APPENDIX D
DEPARTMENT OF VETERANS AFFAIRS
CHIROPRACTIC ADVISORY COMMITTEE
SUMMARY OF PUBLIC COMMENTS
The Department of Veterans Affairs (VA) Chiropractic Advisory
Committee accepted public comments to assist in identifying issues
and concerns regarding the development and implementation of
a chiropractic health program within Veterans Health Administration
(VHA). While some comments were received early in Committee deliberations,
the majority were received after draft recommendations were provided
for public review and comment. The recommendations were posted
on the Committee's Intranet site (www.va.gov/primary)
on July 24, 2003 and were announced August 4, 2003 in the Federal
Register notice of the Committee's September meeting. The comments
were provided to the Committee. This report summarizes the comments
as they relate to each recommendation and identifies the persons/organizations
who have provided comment at any time during the Committee's
work.
Comment
Summary (PDF)
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