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OCR for page 29
4
Committee on the Evaluation of the Department of
Veterans Affairs Uniform Case Assessment Protocol
IOM was charged by VA with evaluating the adequacy of the UCAP, its
implementation, VA efforts at outreach to veterans, and education of providers.
IOM assembled a committee with expertise in neurology, neurobiology, internal
medicine, infectious disease, gastroenterology, psychology, psychiatry,
occupational and environmental medicine, obstetrics and gynecology, chronic
fatigue syndrome, trauma, and clinical assessment. The full committee met
three times, heard numerous presentations, and reviewed published material. In
addition, the committee conducted site visits of VA health facilities to obtain
firsthand information about the system and its implementation. The committee
also solicited written testimony from VA health care providers and veterans
service organizations on their views of the adequacy of the protocol and its
implementation.
SITE VISITS
The committee determined that it was necessary to visit a range of VA
health care facilities to understand how the providers at the local level are using
the Registry and UCAP protocols, and implementing the program for Persian
Gulf veterans. It must be emphasized that these visits were in no way intended
to be a comprehensive survey of how the system was working. Rather, it was the
intention of the committee to collect information that would provide a general
picture of how individual VA health care facilities have organized to implement
the protocols, and how the program was viewed by front-line providers in terms
of its strengths and weaknesses.
29
OCR for page 30
30
ADEQUACY OF THE VA PERSIAN GULFREGISTRY AND UCAP
The committee chose the sites to be visited primarily on the basis of
geographic region and the total number of examinations of Persian Gulf
veterans conducted. In addition, the committee decided that one of the facilities
should be a referral center. With these general criteria in mind, the committee
elected to visit (1) the VA Puget Sound Health Care System in Seattle,
Washington; (2) the James A. Haley VA Medical Center in Tampa, Florida; and
(3) the Houston Veterans Affairs Medical Center in Houston, Texas (a referral
center).
Before the visits the committee developed a question guide for members to
use during their visits. This guide was not meant to be an interview protocol
but, rather, to serve as a reminder of the topics that committee members wished
to cover during their visits to the facilities (see Appendix M for a list of the
questions). Meetings were scheduled with (1) designated Persian Gulf Registry
providers including physicians, nurse practitioners, and administrative staff; (2)
specialists commonly called upon to see Persian Gulf veterans, for example,
neurologists, psychiatrists, and dermatologists; (3) primary care providers
(physicians, nurse practitioners, and nurses) who were not part of the Persian
Gulf provider team but who would likely be involved in providing primary care
to Persian Gulf veterans; (4) outreach personnel who were the first point of
contact for the veterans and who conduct the local outreach activities; and (5)
Persian Gulf veterans who were patients at the facility.
The committee divided into three subgroups to conduct the visits. Each
subgroup consisted of at least two committee members plus one IOM staff
person. All visits were conducted during April 1997 and each visit took two
days. It was readily apparent that the Persian Gulf Registry and UCAP were
implemented differently at each facility.
One facility had formed a Persian Gulf Clinic in which all Persian Gulf
veterans receive the initial Registry and UCAP examinations as well as their
follow-up care from a single physician. This physician integrates all of the
medical and laboratory work conducted during both Phase I and Phase II
examinations. Only when the provider/patient relationship is well established is
primary care provided through a different clinic.
The second facility is organized so that Registry examinations are provided
on certain days of the week by one of two designated physicians. The
examinations are scheduled by a coordinator who arranges for the routine
laboratory and X-ray studies to be carried out before the appointment. If the
patient's first contact with the facility is through the Registry, the follow-up care
is typically provided by one of the Registry physicians. It is not unusual,
however, to assign patients to other primary care clinics for follow-up once the
health Registry and UCAP examinations are completed.
In the third facility, all Phase I Registry examinations are conducted by a
physician's assistant and are coordinated by the Registry physician. A social
worker follows all Registry patients in an attempt to ensure that scheduled
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COMMITTEE ON THE EVALUATION OF THE VA UCAP
31
specialty consultations are completed and reported. Follow-up care is provided
in the primary care clinics by other than the designated Persian Gulf providers.
Referral center patients are generally cared for on an inpatient basis, with
services coordinated by a designated physician. Follow-up care is provided at
the home VA facility.
WRITTEN TESTIMONY
Letters were mailed to 167 VA health care facilities and to 37 veterans
service organizations asking them to provide comments, based on their own
experiences, about the adequacy of the VA Persian Gulf Registry and UCAP.
Specifically, each was asked to submit written information that described its
experience with the VA clinical program as it related to (1) the adequacy of the
clinical protocol to address the wide range of medical assessment needs of
Persian Gulf veterans, (2) how well the protocol had been implemented and
administered by VA, and (3) the adequacy of education for providers and
veterans about the program.
VA Health Facilities
Responses were received from 89 VA health care facilities. About one-
third of those responding stated that the protocol was adequate, that it had been
implemented and administered well, and that education for providers and
veterans had been sufficient. The remainder of the responses provided more
specific information on both the strengths and the challenges of the program.
For a more complete summary of responses, see Appendix N.
High praise was given for the VA Environmental Agents Service
educational efforts aimed at providers, including the annual national Persian
Gulf Conference, video conferences, teleconferences, and newsletter updates,
although many believed that the potential audience was much greater than the
number of people who were currently participating.
Respondents reported difficulties regarding communication with and
scheduling of specialty consultations and referral center visits, problems in
completing the Registry Code Sheet, and reported the need for more information
that could be distributed to the Persian Gulf veterans.
Overall, the respondents indicated they believed that the program was
working fairly well in their own facilities, that minor adjustments were needed,
and that they were committed to meeting the needs of their Persian Gulf veteran
populations.
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COMMITTEE ON THE EVALUATION OF THE VA UCAP
31
specialty consultations are completed and reported. Follow-up care is provided
in the primary care clinics by other than the designated Persian Gulf providers.
Referral center patients are generally cared for on an inpatient basis, with
services coordinated by a designated physician. Follow-up care is provided at
the home VA facility.
WRITTEN TESTIMONY
Letters were mailed to 167 VA health care facilities and to 37 veterans
service organizations asking them to provide comments, based on their own
experiences, about the adequacy of the VA Persian Gulf Registry and UCAP.
Specifically, each was asked to submit written information that described its
experience with the VA clinical program as it related to (1) the adequacy of the
clinical protocol to address the wide range of medical assessment needs of
Persian Gulf veterans, (2) how well the protocol had been implemented and
administered by VA, and (3) the adequacy of education for providers and
veterans about the program.
VA Health Facilities
Responses were received from 89 VA health care facilities. About one-
third of those responding stated that the protocol was adequate, that it had been
implemented and administered well, and that education for providers and
veterans had been sufficient. The remainder of the responses provided more
specific information on both the strengths and the challenges of the program.
For a more complete summary of responses, see Appendix N.
High praise was given for the VA Environmental Agents Service
educational efforts aimed at providers, including the annual national Persian
Gulf Conference, video conferences, teleconferences, and newsletter updates,
although many believed that the potential audience was much greater than the
number of people who were currently participating.
Respondents reported difficulties regarding communication with and
scheduling of specialty consultations and referral center visits, problems in
completing the Registry Code Sheet, and reported the need for more information
that could be distributed to the Persian Gulf veterans.
Overall, the respondents indicated they believed that the program was
working fairly well in their own facilities, that minor adjustments were needed,
and that they were committed to meeting the needs of their Persian Gulf veteran
populations.
Representative terms from entire chapter:
gulf veterans
