An Interdisciplinary Clinic for Former Prisoners of War
Background: The former prisoner of war (FPOW) population is mandated to “receive the highest quality care and benefit services” from the US Department of Veterans Affairs (VA). Each VA medical facility is required to have a special Care and Benefits Team to meet this policy goal.
Methods: In South Texas, 40% of FPOWs had no VA primary care or clinic assignment. In consideration of the commitment of the VA to care for FPOWs, the unique POW-related medical and psychological issues, the geriatric age of many FPOWs, and the surprising number of FPOWs currently not receiving VA care, the South Texas Veterans Health Care System in San Antonio incorporated the concept of geriatric evaluation and management into its cognitive behavioral therapy team to create a specialized interdisciplinary FPOW Clinic. The main purpose of this project was to advise FPOWs of VA benefits and services as well as to facilitate the identification of overlooked conditions with a presumption of service connection, for example, exposure to Agent Orange.
Results: As most FPOWs are aged > 65 years, the FPOW Clinic was designed as an interdisciplinary team similar to that proven successful in geriatric medicine. Overlooked FPOW presumptive conditions were identified for 34% of FPOWs.
Conclusions: FPOW veterans are rapidly dwindling in numbers and may live in rural areas. Consistent with the VA’s desire to adopt novel technological approaches, we propose to modify our FPOW Clinic by adopting telehealth.
Design
The design of the FPOW Clinic team is based on an interdisciplinary model that has proven successful in geriatric medicine.7 The team comprises a physician, a social worker, and a registered nurse.8 All members have expertise in geriatric medicine and specific training in FPOW-related issues by completing a VA employee education training session on FPOW case management. Completion of this training ensured that team members were:
- Familiar with the experiences of FPOWs as well as about the medical, psychosocial, and mental health conditions that affect FPOWs;
- Knowledgeable about FPOW presumptive conditions;
- Familiar with the VBA process for rating FPOW disability claims; and
- Capable of FPOW case coordination, workflow, and communications between the FPOW Clinic team and the VBA to avail FPOWs and their families of all eligible benefits.
In-person FPOW clinic visits and chart reviews helped identify overlooked FPOW benefits. To facilitate case management, a representative of the VBA attended the initial evaluation of each FPOW in the clinic to confirm any overlooked presumptive benefits and to familiarize FPOWs with the claims process. FPOWs were also given the choice to officially enroll in the FPOW clinic for primary care or to remain with their current health care provider. Special efforts were made to enroll those FPOWs who had no STVHCS assigned primary care clinic.
The clinic was scheduled for 4 hours every week. Initial patient visits were 2 hours each and consisted of separate evaluations by each of the 3 FPOW Clinic team members who then met as a team with the addition of the VBA representative. The purpose of this meeting was to discuss overlooked benefits, address any other specific issues noted, and to devise an appropriate interdisciplinary plan. Findings of overlooked benefits and other relevant outcomes then were conveyed to the FPOW. For FPOWs who opted to continue in the clinic for their primary care, subsequent appointments were 1 hour.
Implementation
STVHCS FPOW advocates identified and sent letters to FPOWs announcing the opening of the clinic and its goals. Phone calls were made to each FPOW to address questions and to ascertain their interest. The FPOW advocates then worked directly with schedulers to make clinic appointments. Forty-one FPOWs responded to this initial invitation and attended the new clinic. Subsequently, this number increased through FPOW consults placed by STVHCS primary care providers.
The service-connected disability rating of clinic patients ranged from none (6% of attendees) to 100% (28% of attendees). For 34% of patients, clinic attendance resulted in identification application for overlooked presumptives. VBA evaluation resulted in increased service-connected disability ratings for nearly one-third of clinic patients. All clinic patients without a service-connected disability prior to FPOW clinic evaluation received an increased service-connected disability rating. Overall, 60% of the FPOWs who attended the clinic opted to receive their primary care at the FPOW clinic.
The FPOW Clinic successfully identified overlooked presumptives and facilitated the determination of appropriate service-connected disabilities. Interestingly, the FPOW Clinic encountered an unanticipated challenge to identifying overlooked FPOW benefits—veterans’ medical conditions that are listed by the VHA as being service-connected in the Computerized Patient Record System did not always reflect those listed officially in VBA records. This led to occasional identification of apparently overlooked FPOW presumptives that were already recognized by the VBA but not reflected in VHA records. This issue was addressed by ensuring that VBA representatives attended postclinic meetings with clinic staff and avoided the need to pursue supposedly unrecognized benefits that were recognized.
