The long effort to implement doctors of chiropractic into the Veterans' Health Administration (VHA) is coming to fruition. On Sept. 16-17, the Chiropractic Advisory Committee met for the final time to draft its recommendations to Secretary of Veterans Affairs Anthony J. Principi. These recommendations will set the stage for chiropractic care to be included in the 163 hospitals and 1,100-plus outpatient and other facilities that make up the VHA health care system.
The 38 recommendations cover all aspects of chiropractic involvement in the system and address specific issues such as required education and licensure, staffing of the chiropractic offices, and equipment required. One of the more interesting aspects of the recommendations is the inclusion of voting and committee membership privileges, which makes chiropractors full team members. In addition, chiropractic is included in the inpatient care, outpatient facilities, fee-basis care and occupational health programs.
Below is an abbreviated list of those recommendations that are most critical to understanding the role chiropractic doctors will play in the VHA health care system. (The entire report, with all of the Advisory Comittee's recommendations, can be found at www.chiroweb.com/va.)
Rec. 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.
Rec. 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, determine appropriateness of chiropractic care, provide chiropractic care (adjustment, manipulation/mobilization, manual therapy), manage neuromus-culoskeletal care, referral to appropriate provider.
Rec. 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 (imaging, clinical laboratory, other appropriate tests).
- Order or provide other treatment modalities (physical modalities, ergonomic evaluation, orthotics, supportive bracing, counseling/education on body mechanics, nutrition, lifestyle, exercise, hygiene).
Rec. 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.
Rec. 9: Access to Chiropractic Care
Access to chiropractic care should be by consultation with the patient's primary care provider or another VA provider who is treating the patient for the condition(s) for which chiropractic care is indicated. 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 neuromusculoske-letal 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.
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.
Rec. 15: Screening of Patients
The doctor of chiropractic should screen patients to identify the following "red flags" or contraindications to manual therapy:
- Possible fracture from major trauma or minor trauma in an osteoporotic patient.
- 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
- 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.
Rec. 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.
Rec. 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.
Rec. 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.
Rec. 19: Co-Management of Care
As a member of the VHA health care team, doctors of chiropractic should co-manage patient care for neuromuscu-loskeletal conditions as appropriate, along with the patient's primary provider, other team members, and specialists.
Rec. 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.
Rec. 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.
Rec. 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.
Rec. 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 and provided to the Secretary, the Under Secretary for Health, the Deputy Under Secretaries for Health, other members of the National Leadership Board, and made available to interested stakeholders.
Rec. 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. (See table.) Emphasis should be placed on common service-connected conditions. Research related to integration of multidisciplinary providers into teams should also be undertaken.
CONDITIONS COMMONLY SEEN BY DOCTORS OF CHIROPRACTIC
(Not all-inclusive): - 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
- Migraine
- Posterior facet syndrome
- Chronic daily headache (tension)
- Vertebrogenic headache
- Scheurman's disease
- Carpal tunnel syndrome
- Rotary cuff tendonitis
- Mechanical disorders (thoracic)
- Chest wall syndrome
- Tendonitis (traumatic)
- Disc syndrome (cervical)
- Bursitis (traumatic)
- Compartment syndrome
- Patellofemoral syndrome
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