The Veterans Health Administration (VHA) is the largest integrated health system in the United States. Through its over 1,200 facilities, the VHA serves nine million veterans—a patient population that is older and has higher rates of illness than the civilian population.
Despite its large scale, the VHA is uniquely positioned to focus on health and wellbeing of the people in their system.
“What made working in the public sector different was the freedom from the reimbursement constraints that exist in the private sector,” said Dr. David Shulkin, former United States Secretary of Veterans Affairs. “Rather than focusing on billing, the Veterans Administration team focuses on caring for their patients’ wellbeing. It’s a freeing environment where one gets to reconnect with the reason we all entered healthcare in the first place.”
The VHA designs programs that exist upstream in the care continuum. With an eye toward prevention and wellness, programs integrate social determinants of health (SDOH)—including economic, social and physical factors that interconnect to affect Veterans’ health and wellbeing.
For example, Homeless Medical Homes take an ultra-person-centered approach. A Homeless Patient Aligned Care Team coordinates care and comprehensive services with the goal of getting the veteran well and stably housed. Also, the VHA includes SDOH in their electronic health records systems, which helps them develop personalized, coordinated care plans and intervention strategies. Programs like these produce better cost and quality outcomes.
The VHA has applied this approach to how they serve older Veterans as well. These programs offer valuable lessons as our field is increasingly moving toward an integrated approach to value-based population healthcare.
The Whole Health for Life program supports behavioral health, wellbeing and mental health. The program includes Veterans as active participants in their care and support plan, teaching them how to achieve the health goals that they set for themselves. It also includes peer-to-peer support and coaching, as well as training in self-care such as mindfulness, yoga, and tai chi. Coordinated healthcare teams focus on these preferences and needs.
The VHA understands that physical exercise can delay or prevent physical decline and sustain independence longer. Cardio respiratory fitness reduces the rates of all-cause mortality and is linked to lowered rates of coronary artery disease, hypertension, diabetes, stroke and cancer. Physical inactivity is also costly. In 2013, the estimated physical inactivity cost to the world’s health systems was $53.8 billion.
For 30 years the VHA has offered Gerofit, a proactive, preventative model that manages diseases and promotes exercise and health. The goal is to slow or reverse functional decline—enabling Veterans to maintain their independence.
After a year in the program, participants have shown improvement in gait speed, number of chair stands in 30 seconds, and distance walked in six minutes. Many participate in Gerofit into their 90’s and develop lasting social networks in the process.
Dr. Steve Castle the Associate Director of Clinical Programs at the Los Angeles VA is passionate about Gerofit. “The impact is transformative, and patients improve before your eyes,” he said. “That’s why I am a big believer of providing some structure and healthcare support to fitness programs for older adults, including those in their 90’s and those with significant comorbidities. You are never too old to get fit!”
Because of the success of Gerofit, Medicare Advantage benefits are slated to enable private sector providers to implement the program starting in 2019.
Preoperative exercise can reduce the length of hospital stays and post-surgery complications in vulnerable patients. Patients who engage in preoperative exercise have a lower rate of readmission, recover more quickly and use less postoperative home healthcare support.
“Prehab” is an intervention provided by the Los Angeles VHA designed to get older Veterans in better physical shape before surgery. It emphasizes leg strength, so participants can get out of bed safely post-operation. The Prehab team also spends time learning more about the veteran, including their healthcare preferences and priorities, to provide a person-centered approach to the care event.
A “clinical moonshot” during Dr. Shulkin’s tenure at the VA was focused on enabling aging in place through the end-of-life. “No veteran should ever have to leave their home for care, especially at the end of life,” said Shulkin.
Shulkin championed the Mission Act, which, among other things, enables the VHA to train and send caregivers to veterans’ homes. “Before this program, the VHA was paying billions to house people in institutions,” he notes. The cost for a Veteran to live in an institution is approximately $123,000 annually. The cost of providing home caregivers is $53,000 annually.
While no health system is perfect, these VHA programs and others treat the whole person with a coordinated, multidisciplinary team. Finding ways to keep the veterans healthy is good for independence and quality of life for individuals, and often ends up reducing healthcare costs.