“Caring for our veterans is the duty of a grateful nation.”
—Senator Patty Murray
The United States Department of Veterans Affairs (VA), the second largest of the 15 Cabinet departments of the executive branch of the federal government, was established in 1989, succeeding the Veterans Administration. It operates nationwide programs for health care, financial assistance, and burial benefits. As the most visible component, the Veterans Health Administration (VHA) is one of the largest integrated health systems in the world, providing a variety of services to veterans in every state and Puerto Rico. Funding for VA services is provided through congressional and presidential authorization and is managed via submissions to the Office of Management and Budget. As opposed to private sector organizations, VA budgets are disbursement models rather than expenditure budgets. Additionally, it serves as an important venue for training the next generation of health care professionals in a variety of disciplines, with approximately 90,000 health professionals receiving clinical education in VA facilities each year. The VHA provides clinical learning sites for the majority of nurses and physicians in the country. Advances in care and policy implementation at VA facilities have wide-ranging effects on health care throughout the nation, since so many patients are served by so many providers and learners from all of the health care professions.
Mission and Organization
The VHA provides services to almost 8 million enrollees (Department of Veterans Administration Information Technology Center, 2008) in 153 medical centers and over 800 community-based outpatient centers (Department of Veterans Affairs, 2010). Staffed by almost 300,000 employees, services provided include outpatient primary care; social services; inpatient medical-surgical care; acute and chronic psychiatric care; specialty services such as audiology and dialysis; and tertiary care such as emergency services, transplant, neurosurgery, and the full range of cardiovascular services.
Veterans Administration Medical Centers (VAMCs) are categorized according to complexity and acuity of services. For instance, a level 1A facility will provide the full range of acute medical, surgical, psychiatric, specialty, critical care, long-term, and outpatient services, and generally includes tertiary/subspecialty care, as well as supporting community-based outpatient centers and affiliating “vet centers.” At the other end of the complexity spectrum, a level 3 facility may provide only long-term or outpatient services.
Veterans must enroll to receive VA health care benefits. They are then placed in priority groups that determine which specific benefits they are eligible for, and which co-payments they are required to pay in relation to their income levels. Veterans who have a service-connected disability rating of 50% or greater are not required to enroll. Veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are eligible to receive VA health care for five years following separation from the military, regardless of disability rating.
Patient Population and Changing Demographics
A look at current VA patient demographics reveals a changing portrait. While the World War II veteran population is well advanced in age and close to 1000 die each day, less than 40% of the population of veterans is 65 years of age or older. Currently, the veteran population is composed of growing numbers of those who have served in the Persian Gulf War, Iraq, and Afghanistan, as well as those who have served in Korea and Viet Nam. As of 2008, the projected total veteran population was 24 million. It is expected that many of these veterans will choose to receive their care at VA facilities for the rest of their lives, thus the system has a lifelong relationship with these individuals.
Women veterans have been a numerical minority in VA settings for many years, reflective of the limited role that women were allowed to play in the military in the past (Yano, 2008). However, it is expected that the number of women seeking VA care over the next several years will double, with the greatest proportion from the influx of women recently deployed and discharged from service in OEF/OIF, where the active duty military is 14% female (Hayes, 2008). Further, more than 42% of all discharged women have utilized VA health care at least once, with over 45% having visited 2 to 10 times (Kang, 2008). It is expected that women will comprise a continuously growing component of both the military and the subsequent veteran population.
Given this significant increase in women in the eligible population, VA leadership has mandated that the needs of this unique population be addressed in a focused manner. In 2008, the Secretary of Veterans Affairs mandated that a full-time Women Veterans Program Manager be in place at every VA facility and that every woman veteran have access to a VA primary care provider who can meet all her primary care needs, including gender-specific care (Hayes, 2008). Additionally, since PTSD rates are higher in women than in men (Tolin & Foa, 2006), and since over 20% of women seen in VA outpatient care have reported military sexual trauma (Kimerling et al., 2007), the VHA has mandated that services specific to these needs are available to all veterans, with women veterans receiving gender-specific care. The VHA has made women’s health services research a priority solicitation area for over a decade and mandates the inclusion of women in all VA studies (Yano, 2008).
Quality and Safety: “The Best Care Anywhere”
The VHA established a performance measure system that allows individual facilities to measure clinical care on a national, facility, and individual provider level. Thus, it is possible to determine success on such measures as diabetic control, immunization, heart failure readmission rates, and ventilator-acquired pneumonia, among others. The performance measure program has given rise to a number of clinical initiatives and has fostered the implementation of Institute for Healthcare Improvement bundles, MRSA prevention, and other safety programs. Nationally, the VA established the National Center for Patient Safety (NCPS) to develop and nurture a culture of patient safety, including the presence of patient safety managers in all VA hospitals. Notable for its emphasis on prevention rather than blame, the NCPS has fostered the use of root cause analysis to investigate how well patient care systems function and to create “hard fixes” for identified problems. These efforts have become widely emulated models for systems redesign in the private sector.
The performance measure system provides an important opportunity for internal and external benchmarking. The subsequent analysis and dissemination of data in lay and professional publications has significantly altered the public image of VHA. It is now possible to state that the VHA cares for an older, sicker, and poorer population and achieves clinical outcomes that match or surpass similar organizations in the private sector, and at a lower cost. This has led many to claim that the VHA provides “the best care anywhere” (Longman, 2007).
The Patient-Centered Medical Home
A patient-centered “medical home” is now established for each patient. In this model, also known as Advanced Primary Care, the primary care team takes responsibility for providing all of the patient’s health care needs, either directly or by facilitating the involvement of the appropriate specialty service. The basic primary care team includes a provider (physician, nurse practitioner, or physician assistant), an RN care manager, a clinical associate (health technician or licensed practical nurse), and a clerical associate. The patient is expected to act as a full partner with shared decision making for all actions. Other clinicians such as pharmacists and nutritionists, as well as tertiary specialists, are involved as appropriate to the patient’s needs. Electronic communication and secure messaging enhance communication between the patient and team members.
Health Care Issues of the Newest Veterans
Traumatic brain injury (TBI) has emerged as the signature injury of the OEF/OIF conflicts. Screenings for TBI, depression, and substance use are carried out for all newly returned veterans on a regular basis. Ending homelessness among veterans has also become both a presidential and VHA priority, and social service programs are in place at every VHA facility to assist veterans with obtaining jobs and housing, on both a temporary and permanent basis.
Suicide among veterans is an issue that has assumed a prominent place in VA care. Rates of suicide among VA health care users are at least 66% higher than the age and gender–adjusted U.S. population (McCarthy et al., 2009). All VHA facilities employ suicide prevention coordinators. These clinicians provide direct service to those at risk for suicide as well as educate staff, assess clinical environments, develop prevention strategies, and coordinate with community agencies.
The Electronic Medical Record
The VA has long been recognized for the development and implementation of a world class electronic medical record (EMR). It has evolved into a completely paperless system that is not only a robust data repository for documenting care rendered; it is also a uniquely configured system that ensures continuity of care. The EMR can be accessed by an unlimited number of personnel simultaneously. Thus, information is available as soon as it is entered by the clinician. Since the record is not stored in a remote location, clinicians do not need to “wait their turn” to access the record, and it is always available at the point of care. The ubiquitous nature of the data renders verbal orders obsolete because providers can enter orders from any location. Thus, an attending surgeon can monitor a postoperative patient from his or her home, enter orders, check on laboratory data, and change an intervention plan without requiring the nurse to receive and transcribe a verbal order.
The Bar Code Medication Administration (BCMA) system has revolutionized the way in which nurses administer, evaluate, and document medication regimens. As medication orders are entered into the EMR, they migrate to the BCMA data base. The prescription is automatically sent to the pharmacy, where it is verified for accuracy, allergy status, and interaction with other medications. It is also transmitted to the inventory control system, which monitors institutional use, pricing, reordering, and other actions. After verification, it generates a medication administration record. At the time of medication administration, the nurse brings the medication cart to the bedside, scans the patient’s wristband with a handheld scanning device, and administers the medication to the patient.
The chief nursing informatics officer in the Office of Nursing Services directs a comprehensive program. This expert nursing role manages a vast nursing outcomes database; systems design, simulation training, terminology standardization. Nurse executives at the various medical centers are provided with various management reports, including executive-level dashboard reports, nursing hours per patient day, RN satisfaction, clinical indicators, and demographic databases. These initiatives have wide-ranging utility and are more than mere recordkeeping devices. They provide an opportunity to create knowledge, to refine nursing practice, and to deliver the basis for evidence-based care.
The VA employs more than 76,000 nursing staff (45,000 RNs, 13,000 LPN/LVNs, and 11,000 nursing assistants), making it one of the largest nursing staffs of any health system in the world. Approximately 80% of these individuals are in direct care positions, which demonstrates efficient staff utilization and a flat hierarchical structure. The variety of practice roles and specialty areas is vast. National mobility allows nurses to transfer from facility to facility without losing seniority or benefits; licensure is only required in one state. Educational benefits allow nurses to increase their knowledge in formal academic programs as well as enrichment programs. Additionally, unlicensed personnel can participate in mobility programs that advance them into technical and professional positions. All VHA employees have access to on-line programming that can be completed at the employee’s convenience, including programmed instruction and on-demand video learning.
Most VHA facilities have formal affiliation agreements with academic nursing partners, as well as with other health professions schools. As such, VHA is a major educator of future nurses, providing sites for clinical practice from the undergraduate to postdoctoral level. The VHA Office of Nursing Services (ONS) seeks to bridge the gap between basic nursing education programs and the realities of professional nursing practice by piloting RN residency programs. Begun in 2009, eight sites have implemented year-long programs to assist new nursing graduates with refinement of clinical competencies and development of professional behaviors and leadership skills. It is anticipated that this program will result in improved practice and staff satisfaction, as well as decreased turnover (ONS Annual Report, 2009).
Nursing faculty find the VHA to be a hospitable and fruitful partner for research, with faculty conducting research at VHA facilities as well as mentoring VHA staff in the research process. VHA’s ONS has formed liaison task forces with the American Association of Colleges of Nursing to explore issues of mutual interest such as nursing residencies, the clinical nurse leader role, and scope and development of the Doctor of Nursing Practice role.
A growing number of VHA facilities have achieved Magnet® status, with many facilities actively pursuing this achievement. As of March 2010, five sites achieved this distinction. In addition, at least one VHA facility has achieved the Beacon Award from the American Association of Critical Care Nurses for excellence in nursing practice.
The Clinical Ladder
VA nurses participate in a clinical ladder that allows them to be recognized for expertise, experience, and excellence. The National Professional Standards Board has established criteria that allow nursing practice to be categorized from Nurse I, or entry level with no experience, through Nurse V, the chief nurse executive level. Progression is rewarded with salary increases. Each local facility has a peer review professional standards board composed of nurses at the various levels who review each nurse on a regular basis to determine progression through the clinical ladder and provide advice on ways in which the nurse can advance, such as serving on committees, publishing, assuming formal and informal leadership, and certification.
Growth of Advanced Practice Roles
The VA utilizes many nurses in advanced practice roles including nurse practitioners, nurse anesthetists, and clinical nurse specialists. Many completed some or all of their clinical education at VA facilities, and many received educational benefits that allowed them to participate in these academic programs. Recently, the VA has partnered with the American Association of Colleges of Nursing to develop and implement the Clinical Nurse Leader role. This innovative role prepares nurses to act as clinical leaders while remaining at the bedside or point of care. A unique feature of these programs is the partnership developed between the academic institution and the VA facility in which both partners collaborate on curriculum development and shape clinical experiences around specific practice roles that the VA facility finds important to achieve excellent clinical outcomes. The Office of Nursing Services has set a goal of implementing the CNL role in every VA facility by 2016. As of 2009, 32 VAMCs employed 87 CNLs in various settings (ONS Annual Report, 2009).
The VA Nursing Academy
A national shortage of RNs is a constant challenge to the delivery of care and a serious policy issue as health care organizations confront current and future staffing needs. The shortage of nursing faculty forces colleges and universities to turn away thousands of qualified students each year. To address this serious and growing policy issue, the VA has established the VA Nursing Academy (VANA). Established as a five-year pilot project, this program is centrally administered through the Office of Academic Affiliations in partnership with the Office of Nursing Services. Based upon partnerships between a VA facility and an academic institution, this competitive program has awarded $59 million in funding to 15 partnerships. The goals of the initiative are to expand the number of nursing faculty, enhance the professional and scholarly development of nurses, and increase student enrollment by approximately 1000 students. Students receive most of their clinical instruction at the VA and are mentored by VA professional nurses. As they near graduation, it is anticipated that these students will gravitate to VA employment. Similarly, since each VA has invested significant energy in these students and has had the opportunity to guide them in experiences that are unique to the needs of the veteran patient, the VA will be more likely to employ these students after graduation. Thus, the return on investment by the taxpayer is enormous.
The VHA is one of the largest health care systems in the world, providing a full range of health care and social services. This federally funded system also acts as a training ground for the majority of the nation’s health care professionals. The VA’s excellent clinical outcomes can be documented by a robust performance measure program.
The opinions expressed herein are those of the author and do not represent the official position of the Department of Veterans Affairs.
For a list of related websites, please refer to your Evolve Resources at http://evolve.elsevier.com/Mason/policypolitics/