CARE OF THE VETERAN. Jennifer Hoffmann D.O. Wilmington VA Medical Center Wilmington, DE

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1 CARE OF THE VETERAN Jennifer Hoffmann D.O. Wilmington VA Medical Center Wilmington, DE

2 Questions I had before I worked for the Veterans Administration Why does my patient have to see a doctor at the VA in addition to me? Why is it so difficult to for my patient to have medications filled at the VA? Why have I never received records from the VA? Why do I often feel like I am missing something when I see a veteran as a patient? Where can I get more information?

3 Objectives Discuss care of the veteran as it relates to community practice Review basic eligibility for VA services Learn the elements of a military health history Discuss registry exams available for eligible veterans Discuss medical conditions unique to various eras of service

4 H.R Veterans Access, Choice, and Accountability Act of 2014 public law 8/7/14 have been unable to schedule an appointment at a VA medical facility within the Veterans Health Administration's (VHA's) wait-time goals for hospital care or medical services and such veterans opt for non-va care or services; reside more than 40 miles from a VA medical facility; reside in a state without a VA medical facility that provides hospital care, emergency medical services, and surgical care and such veterans reside more than 20 miles from such a facility; or reside within 40 miles of a VA medical facility but are required to travel by air, boat, or ferry to reach such facility or such veterans face an unusual or excessive geographical burden in accessing the facility. These nonva benefits are available for three years or until the appropriated funds are exhausted (10 Billion dollars) https://www.congress.gov/bill/113th-congress/house-bill/3230

5 VA Care Veterans may come to a VA medical center for all their primary care or for a portion of their medical care (copractice) Care may be provided by a clinic within a VA hospital or at a Community Based Outpatient Clinic (CBOC) Patients must be vested Patients need to be seen periodically to remain assigned to a primary care provider All patients who see specialists at a VA medical center need to have an active VA primary care provider All medical care pertaining to a service connected (SC) diagnosis is free Once a veteran attains 50% SC, al medical care and meds are free A veteran may be copay exempt if they fall under income limits Veterans who seek copay exemption for income must report their income information annually with a Mean Tests

6 VA Care Medications All medications issued by a VA medical center must be written by a VA provider There are national and local formularies Some medications can be obtained via a non-formulary consult Has to be entered by a VA provider Requires detailed information regarding prior medication trials and reasons the medications were not tolerated Some medications can only be prescribed by specialists Some medications can only be prescribed if the patient meets the national Criteria for Use Generic status of a medication may not be relevant Copays are $8 or $9 depending on the veteran s priority group status Medications for service connected care/diagnoses are free

7 VA Care Records Records can be released only with a signed release from the veteran Signed releases must be obtained each time information is requested Releases must be filed with the Release of Information Office NonVA release forms are not sufficient Providers have to have a signed release in order to discuss the veteran s health with or release any medical information to any third party

8 Eras of Service WWII 12/7/ /31/1946 Vietnam 8/5/1964 5/7/1965 Includes in country vets serving 2/28/1961 Post Vietnam Gulf War 8/2/1990 to present Persian Gulf 1991 Operations Desert Shield, Desert Storm, Desert Sabre War in Iraq Operation Iraqi Freedom (OIF) Operation New Dawn (OND) War in Afghanistan 2001-Present Operation Enduring Freedom (OEF)

9 Eligibility Active military service or Reserves or National Guard called to duty by federal order Met minimum duty requirement Not dishonorably discharged

10 Eligibility OR the following Are a Former Prisoner of War (POW) In receipt of the Purple Heart Medal. In receipt of the Medal of Honor. Have a compensable VA awarded service-connected disability of 10% or more. In receipt of a VA Pension. Were discharged from the military because of a disability (not preexisting), early out, or hardship. Served in a Theater of Operations for 5 years post discharge. Served in the Republic of Vietnam from January 9, 1962 to May 7, Served in the Persian Gulf from August 2, 1990 to November 11, Were stationed or resided at Camp Lejeune for 30 days or more between January 1, 1957 and December 31, Are found by VA to be Catastrophically Disabled. Previous years' household income is below VA's National Income or Geographical-Adjusted Thresholds.

11 Eligibility Priority Group 1 Veterans with VA-rated service-connected disabilities 50% or more disabling Veterans determined by VA to be unemployable due to service-connected conditions Priority Group 2 Veterans with VA-rated service-connected disabilities 30% or 40% disabling Priority Group 3 Veterans who are Former Prisoners of War (POWs) Veterans awarded a Purple Heart medal Veterans whose discharge was for a disability that was incurred or aggravated in the line of duty Veterans with VA-rated service-connected disabilities 10% or 20% disabling Veterans awarded special eligibility classification under Title 38, U.S.C., 1151, benefits for individuals disabled by treatment or vocational rehabilitation Veterans awarded the Medal Of Honor (MOH) Priority Group 4 Veterans who are receiving aid and attendance or housebound benefits from VA Veterans who have been determined by VA to be catastrophically disabled

12 Eligibility Priority Group 5 Nonservice-connected Veterans and noncompensable service-connected Veterans rated 0% disabled by VA with annual income and/or net worth below the VA national income threshold and geographically-adjusted income threshold for their resident location Veterans receiving VA pension benefits Veterans eligible for Medicaid programs Priority Group 6 Compensable 0% service-connected Veterans Veterans exposed to Ionizing Radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki Project 112/SHAD participants Veterans who served in the Republic of Vietnam between January 9,1962 and May 7,1975 Veterans of the Persian Gulf War that served between August 2, 1990 and November 11, 1998 *Veterans who served on active duty at Camp Lejeune for not fewer than 30 days beginning Jan. 1, 1957 and ending Dec. 31, 1987 Veterans who served in a theater of combat operations after November 11, 1998 as follows: Currently enrolled Veterans and new enrollees who were discharged from active duty on or after January 28, 2003, are eligible for the enhanced benefits for 5 years post discharge Note: At the end of this enhanced enrollment priority group placement time period Veterans will be assigned to the highest Priority Group their unique eligibility status at that time qualifies for. *Note: While eligible for Priority Group (PG) 6; until system changes are implemented you would be assigned to PG 7 or 8 depending on your income.

13 Eligibility Priority Group 7 Veterans with gross household income below the geographicallyadjusted income threshold (GMT) for their resident location and who agree to pay copays Priority Group 8 Veterans with gross household income above the VA national income threshold and the geographically-adjusted income threshold for their resident location and who agrees to pay copays

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16 All Veterans Depression and PTSD 22 veterans commit suicide every day PHQ-2 Suicidality assessment Alcohol and substance use AUDIT-C HCV and HIV screening Homelessness Military Sexual Trauma Combat exposure

17 Registry Exams Gulf War Registry Depleted Uranium registry Burn Pit Registry Agent Orange Registry Ionizing Radiation registry To enroll: contact the Environmental Health Coordinator at the nearest VA health care facility Federal Benefits for Veterans, Dependents, and Survivors 2013 Edition

18 Gulf War Service Gulf War Service For VA benefit purposes, Gulf War service is active military duty in any of the following areas in the Southwest Asia theater of military operations at any time during the first Gulf War starting August 2, 1990 through the Iraq War. This includes Veterans who served in Operation Iraqi Freedom ( ) and Operation New Dawn ( ). Iraq Kuwait Saudi Arabia The neutral zone between Iraq and Saudi Arabia Bahrain Qatar The United Arab Emirates (U.A.E.) Oman Gulf of Aden Gulf of Oman Waters of the Persian Gulf, the Arabian Sea, and the Red Sea The airspace above these locations

19 Gulf War Service Toxic embedded fragments (OEF/OIF/OND, Gulf War, Bosnia) Depleted uranium (DU) used on tank armor and projectiles to enhance penetration Exposure is from embedded fragments, inhalation, or wound contamination Riding in a tank or being around projectiles with DU is safe No known health conditions related to DU exposure, but there is a Depleted Uranium Follow-Up Baltimore VAMC Veterans can enroll in the depleted uranium registry

20 Depleted Uranium Registry Uranium left over after the radioactive isotope U-325 has been removed DU possesses 60% of the radioactivity of naturally occurring uranium The toxicity is related to heavy metal exposure Initial evaluation is a screening questionnaire and 24 hour urine For those with embedded fragments or contaminated wounds, more detailed follow up is offered Federal Benefits for Veterans, Dependents, and Survivors 2013 Edition

21 Southwest Asia Associated Conditions Chronic, unexplained symptoms existing for 6 months or more are related to Gulf War service without regard to cause Symptoms must have appeared during active duty or by 12/31/2016 Chronic Fatigue Syndrome: a condition of long-term and severe fatigue that is not relieved by rest and is not directly caused by other conditions. Fibromyalgia Functional gastrointestinal disorders Irritable bowel syndrome Functional dyspepsia Functional abdominal pain syndrome, Undiagnosed illnesses with symptoms that may include but are not limited to: abnormal weight loss, fatigue, cardiovascular disease, muscle and joint pain, headache, menstrual disorders, neurological and psychological problems, skin conditions, respiratory disorders, and sleep disturbances

22 Infectious Disease of SW Asia VA presumes the following infectious diseases are related to military service in the Southwest Asia theater of Operations during the first Gulf War starting August 2, 1990, through the conflict in Iraq and on or after September 19, 2001, in Afghanistan. Disease must have occurred within 1y of separation and have ongoing disability Malaria Brucellosis Campylobacter Jejuni Coxiella Burnetii (Q Fever) Mycobacterium Tuberculosis Nontyphoid Salmonella Shigella Visceral Leishmaniasis West Nile Virus

23 Gulf War Registry Purpose: to identify possible health effects resulting from service in Southwest Asia Endemic infectious diseases Occupational exposures Environmental exposures Heavy metals Inhaled particulates Inhaled hydrocarbons Inhaled gases nitrogen oxides, carbon monoxide Federal Benefits for Vetrerans, Dependents, and Survivors 2013 Edition

24 Burn Pit Registry Eligible servicemembers were deployed to Southwest Asia theater of operations at any time on or after August 2, 1990 or Afghanistan or Djibouti on or after September 11, These regions include the following countries, bodies of water, and the airspace above these locations: Iraq, Afghanistan, Kuwait, Saudi Arabia, Bahrain, Djibouti, Gulf of Aden, Gulf of Oman, Oman, Qatar, United Arab Emirates, Waters of the Persian Gulf, Arabian Sea, and Red Sea Burned materials: Chemicals Paint Medical and human waste Metal Aluminum cans Munitions Unexploded ordnance Petroleum products Plastics Styrofoam Rubber Wood Discarded food

25 Readjustment Counseling Provided at Vet Centers Free-standing clinics Support is offered to veterans and their family members Veteran s Crisis Hotline Apps for support Texting support

26 Agent Orange Herbicide sprayed in Vietnam between January 9, 1962 and May 7, 1975 Used to deforest areas to expose the enemy AO exposure occurred to veterans on the ground, working with C-123 airplanes during and after the Vietnam war, from testing and use at other military bases The manufacturing process created dioxin

27 Agent Orange Presumptive Diagnoses AL Amyloidosis Chronic B-cell Leukemias Chloracne (or similar acneform disease) Had to occur within 1 year of exposure Diabetes Mellitus Type 2 Hodgkin s Disease Ischemic Heart Disease Multiple Myeloma Non-Hodgkin s Lymphoma Parkinson s Disease Peripheral Neuropathy, Early-Onset Had to occur within 1 year of exposure Porphyria Cutanea Tarda Had to occur within 1 year of exposure Prostate Cancer Respiratory Cancers (includes lung cancer) Cancers of the lung, larynx, trachea, and bronchus Soft Tissue Sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi s sarcoma, or mesothelioma)

28 Camp LeJeune Drinking water at USMC Camp LeJeune, North Carolina was contaminated with VOCs Contaminants included: Dry cleaning solvents Solvents used to clean metal (vehicles, weapons) Gasoline from leaky tank Veterans and family members who served on active duty or resided at Camp Lejeune for 30 days or more between Jan. 1, 1957 and Dec. 31, 1987 may be eligible for medical care

29 Camp LeJeune associated conditions Esophageal cancer Lung cancer Breast cancer Bladder cancer Kidney cancer Leukemia Multiple myeloma Myelodysplastic syndromes Renal toxicity Hepatic steatosis Female infertility Miscarriage Scleroderma Neurobehavioral effects Non-Hodgkin's lymphoma

30 Exposure assessment Ask the Veteran about exposure concerns What were you exposed to? Chemical (pollution, solvents, etc.), biological (infectious disease), or physical (radiation, heat, vibration, etc.) What precautions were taken? Avoidance, PPE, treatment, etc. How were you exposed? Inhaled, on skin, swallowed, etc. How concerned are you about the exposure? Where were you when you were exposed? When were you exposed? Who else may have been affected?

31 Resources Federal Benefits for Veterans, Dependents and Survivors Handbook (issued annually) VHA Public Health Initiatives Institute of Medicine reports Access via the public health website Your closest VA Medical Center Your patient s VA Provider!

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