Our Veterans: Navigating in a Chaotic Health Care System

Posted on May 4, 2013

I recently read an editorial written by a nursing school dean describing her husband’s frightening experience with poor hospital discharge coordination and follow-up care after a stroke. If a well-connected health care professional struggles to get quality care coordination for her family, what does this mean for the care management of vulnerable populations with special needs? Many of whom are already at high risk for health care failures.  Specifically, given the populations I have served, what this means for at-risk veterans is especially troubling.

As the former Nursing Director of Palliative Care Services at a VA Medical Center, I deeply understand the complex needs of our veterans. Many individuals who have served in the military share a number of risk factors for poor care coordination including: multiple chronic illnesses, numerous medications and limited social support systems. The need for providers to identify the veteran status of patients is critical, as is the need for strong care coordination, especially during transition from hospital to home.

Complicating their medical illnesses, veterans have special psychosocial needs. Often coping with traumatic issues from their military service and mental health diagnoses such as Post Traumatic Stress Disorder (PTSD) and addiction. Even if there is no past history, serious medical illnesses, such as cancer, can often cause PTSD symptoms, and can reactivate past losses, hampering the ability to adapt to the illness.

The Veterans Health Administration is America’s largest integrated health care system serving 8.3 million veterans each year. For veterans who have a health problem like diabetes, chronic heart failure, depression or cancer, getting treatment can be complex and fragmented. However, most veterans are receiving care in the general health care system — only about 15% of veterans get their care through the VA system (VA Data). For the majority of veterans who receive care in the private sector, veteran status is, for the most part, invisible and many veterans report a number of unmet needs when coping with medical illnesses.

Further complicating care coordination, almost 90 million American adults lack the needed literacy skills to effectively use the US health care system. Health literacy is “the ability to obtain, process, and understand health information and services to make appropriate health decisions” (Healthy People 2010). According to research published in the Clinical Journal of the American Society of Nephrology, limited health literacy is quite common and is independently associated with African-American race, lower educational level and veteran status. Since illness, stress and aging also tend to lower literacy ability, the veteran population is even at greater risk of suffering the consequences of low health literacy which include; medication errors, misdiagnosis due to poor communication between providers and patients, hospital readmissions, unnecessary emergency room visits, longer hospital stays and fragmented access to care (Center for Health Care Strategies, 2012).

Why is it that care coordination is so critical? Readmissions to the hospital (and emergency room visits) — often a direct result of poor care coordination — are common and costly.  In a recent study, veterans and their health care providers were interviewed to better understand the reasons for re-hospitalizations. Veterans identified 3 common themes that led to their re-hospitalization: (1) knowledge gaps and powerlessness; (2) difficulties navigating the health care system; and (3) complex psychiatric and social needs. On the other hand, their medical providers identified different themes that led to re-hospitalization: (1) substance abuse and mental illness; (2) lack of social or financial support and homelessness; (3) premature discharge and poor communication; and (4) non-adherence with follow-up.

The results of this study show that re-hospitalized veterans are incredibly vulnerable and have little voice in a confusing health care system. The veterans have complex care needs that are not well understood by their own medical providers.

What can be done to improve care transitions? Despite increased attention given to improving the quality and safety of care transitions, the problems persist. Hospitals are motivated now to search for viable alternatives to improve transitional care as encouraged by the Affordable Care Act.  On a program level, there are research-based transitional care initiatives, such as the Naylor Transitional Care Model, serving as a national model for effective transitional care. On a practice level, for both providers and veterans, there are several strategies that can be employed to improve communication, increase health care knowledge and enhance veterans’ active participation in their health care management.

Strategies for Providers and Veterans:

Assessing for veteran status in private hospitals. Veteran status ought to be identified as part of the patient health assessment.  Providers should ask patients, and veterans need to initiate discussion, about their military service, active combat duty, exposure to chemical agents and diseases, and any injuries or illnesses related to their service. There are a number of clinical assessment tools that can be useful.   One such tool is the Patient Health Questionnaire (PHQ-Brief), a questionnaire used to screen and monitor patient status in the areas of, depression, anxiety, alcohol abuse and physical symptoms.

Evaluating health literacy. A simple provider question; “How confident are you filling out health care forms by yourself?” can be useful in identifying patients with limited health literacy.  As well, veterans and their families should speak up if they do not understand the health care information.  Patients are not expected to be familiar with medical jargon and have the right to receive understandable health care information.

Assessing the adequacy of veterans’ support systems. Providers should identify the    primary caregiver and evaluate for understanding of care management and necessary medical follow up. Assess for caregiver burden and target high-risk veterans to provide enhanced support services. Veterans and family members need to be candid about their needs and ability to care for the veteran at home. Request additional services when needed.

Improving communication, including a greater emphasis on language barriers and cultural differences. Providers should ask veterans to describe the health care challenges they are facing. Assess veterans understanding of their illnesses; their medications/treatments and plan for follow up care. Kleinman’s health assessment  “Eight Questions” can be useful as a guide to understanding veterans’ clinical reality.

As well, veterans and family members need to make known to the providers their health care beliefs, cultural/religious values and care preferences to help medical providers understand their personal views, and work in partnership with providers to make important health care management decisions. Effective communication between providers and veterans is essential to improve care coordination.

In general, more continuing education opportunities for health care professionals in the private sector should be provided to learn about veteran specific care issues and resources. This education should include familiarity with military culture and combat experiences. An important area of health care training that is often neglected. Veterans are more likely to speak about their concerns when they know that the health care providers are familiar with their unique needs.  Additionally, partnership with the Department of Veterans Affairs and Veterans Service Organizations is needed to improve providers’ knowledge of veteran benefits, veteran specific-referral sources, and available community resources. Check the VA health benefits link for more information. (http://www.va.gov/healthbenefits/vhbh/)

Health care professionals have the primary responsibility to improve coordination of care for our veterans through evidence-based care. Improved awareness of veterans’ health care needs and development of veteran specific initiatives are critical to provide effective transitional care coordination and to help prevent dangerous and costly hospital readmissions.