Giving Our Veterans the Care They Deserve

It has been a little over four years since the Veterans Health Administration (VHA) first began providing chiropractic services at select VA medical centers across the U.S.. Many chiropractors continue to have questions regarding implementation and overall, there appears to be wide interest in the status of chiropractic in the VHA, suggesting that a review is needed of both the history and current status of chiropractic services in the VHA, including significant developments and plans for the future.

To truly understand the VHA chiropractic program, it is important to appreciate the organization of the federal health care system. The executive branch of the U.S. government encompasses the VHA and 14 other departments. The heads of these departments are appointed by the president as members of the president's cabinet. Of these 15 departments, three provide health care: the Department of Defense (via the Defense Health Program), the Department of Veterans Affairs (via the VHA), and the Department of Health and Human Services (via the Public Health Service Commissioned Corps).

As many readers recall, the DoD chiropractic program started as a five-site demonstration project in 1995. Since then, it has grown to its current status of more than 49 sites across the country. The VHA program arose from legislative efforts that led to Public Law 107.135 in 2001. This required the VHA to begin providing chiropractic services at a minimum of 21 sites nationwide. The Public Health Service Commissioned Corps currently has no chiropractic program.

These three departments are related in obvious ways and there is a great deal of opportunity for collaboration. The Society of the Federal Health Agencies (www.amsus.org) is a professional organization for all health care providers working in the federal system. Membership has been opened to chiropractors and a number of DCs have already joined. The society also publishes the peer-reviewed journal Military Medicine (www.amsus.org/journal). Another peer-reviewed journal, Federal Practitioner (www.fedprac.com) is also geared toward providers within the federal system.

Although there are commonalities, the DoD, VHA and PHS are separate organizations with distinct missions, goals, administrations and cultures. Each is a large federal department with different policies and procedures. Thus, when considering chiropractic services in relation to any of these three agencies, it is necessary to regard each as an individual entity.

Implementation of Chiropractic Services Within the VHA

The article provides a summary timeline of events in the VHA chiropractic program below. As stated above, in 2001 it was mandated that the VHA introduce chiropractic clinics at a minimum of one site in each of its 21 geographic regions, known as Veterans Integrated Service Networks (VISNs). A federal advisory committee was convened to make recommendations to the secretary of veterans affairs. The workings of this committee, which included a number of prominent chiropractors, have been chronicled in past issues of this and other publications.

In 2004 the VHA issued Directive 2004-035, which established guidelines for the provision of chiropractic services. Openings were announced at 26 sites and by late 2004, the first VHA chiropractors began to be brought on board. Consistent with VHA policy, this was accomplished by hiring or contracting with licensed DCs. By late 2005, positions were filled at these initial 26 sites, meeting and slightly exceeding the requirements of Public Law 107-135.

Administration: Nationally, chiropractic services are administered through the Office of Patient Care Services, which is subdivided into strategic health care groups. Chiropractic is aligned under the rehabilitation services group. In late 2007, chiropractic services were organized as a national program, with the director reporting to the chief consultant of rehabilitation services. A field advisory committee comprised of six VHA DCs and one MD serves as an advisory body to the director and the field.

At the local (facility) level, a VHA chiropractic clinic may be administered by rehabilitation services, primary care or another service line, consistent with the given facility's needs and resources. Currently, over half of VHA DCs are full-time staff employees, whereas others are part-time employees or various contractors. Chiropractors employed by VHA are in the Title 38 employee category, which includes professionals such as medical physicians, dentists, podiatrists, optometrists and nurses.

Clinical Services: Chiropractic care in the VHA is for the diagnosis and treatment of neuromuscular/musculoskeletal conditions, including subluxation complex. Services provided are determined by privileges - hospital terminology for the types of services a given provider is authorized to deliver in that facility. Chiropractic privileges typically are a reflection of the scope of practice for the state in which the DC is licensed.

Patients access chiropractic clinics - as they do all specialty clinics in the VHA - through consultation from another provider in the system. Most chiropractic consultations originate from primary care, but can also come from specialty clinics such as physiatry, orthopedics, neurology and others. Chiropractors also consult patients to other specialty clinics as indicated. This interaction is coordinated through the VHA's electronic medical record, which allows efficient communication between multiple providers to best address a patient's needs. The consultation model, and the communication it requires, also serves to facilitate the integration of DCs with other providers in a given facility.

Academics: In a relatively short time, the VHA chiropractic program has made substantial strides in training chiropractic students. As depicted in the table at right, 16 VHA sites currently have established academic affiliations with 10 chiropractic colleges. To date, more than 400 chiropractic students have trained at VHA facilities. Students function much as they do at chiropractic college clinics, performing history, examination and treatment procedures under the direction of the supervising staff DCs. Students are exposed to a wide variety of complex cases and also learn the processes and procedures of practice in a hospital setting. We are exploring methods to improve and develop chiropractic student education, as well as new opportunities for postgraduate training.

Beyond training chiropractic students, VHA chiropractic clinics also present an opportunity to train other professionals. Many DCs have medical students or residents rotating through their clinics. Trainees from other disciplines such as psychology, nursing and even pharmacy have done this as well. These opportunities give other professionals a firsthand look at the use and value of chiropractic care, and help to further interdisciplinary relations.

Research: The VHA supports a robust research agenda administered by the Office of Research and Development. This office provides support and funding through the clinical science, health services, laboratory science, and rehabilitation programs. A call for proposals on chiropractic research has been active since late 2004.

The first (and currently only) intramural funded project has been awarded to Dr. Paul Dougherty of the Canandaigua, N.Y. facility for a randomized controlled trial of chiropractic treatment for low back pain in older adults. Dougherty and colleagues also have received funding through the Health Resources and Services Administration (HRSA) for another project examining spinal manipulation and exercise in the treatment of chronic low back pain.

Dr. Andrew Dunn of the Buffalo, N.Y. facility has published the first peer-reviewed papers describing aspects of chiropractic services in his facility. Several other funded projects are in development, and a few other peer-reviewed publications are in press. Indeed, the upcoming March 2009 Association of Chiropractic Colleges-Research Agenda Conference (ACC-RAC), features one contributed session with five accepted papers on VHA chiropractic topics.

Future Direction

Since 2006, there has been some growth beyond the initially mandated sites, resulting in a total of 33 sites at the time of this writing (December 2008), with several others in various stages of development. The addition of new chiropractic clinics has been and continues to be determined at the level of the individual facility, based on its given needs and resources. There is no nationally mandated expansion plan. Continued growth will be influenced by the performance of current VHA chiropractors in the areas of clinical care, academics and research.

DCs interested in potential future openings at VHA facilities may be well-served to consider their own qualifications in those areas and develop their professional growth accordingly. We have seen that VHA openings typically attract a large number of DC applicants. The candidate who possesses an academic background, publication in peer-reviewed journals, and medical system experience, in addition to solid clinical skills, will likely be attractive to the VHA program.

The VHA chiropractic program is committed to the VHA's mission of serving our nation's veterans. The DCs in the system face opportunities and challenges that are not commonly seen in private practice settings. Efforts to improve the quality of our clinical care, education and research are focused on improving veterans' health and well-being. These efforts may also benefit the chiropractic profession and the nation at large through the acquisition of knowledge, training of health care providers, and enhancement of interdisciplinary relations.