CARE OF THE VETERAN
Jennifer Hoffmann D.O. Wilmington VA Medical Center Wilmington, DE
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?
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
H.R.3230 - Veterans Access, Choice, and
Accountability Act of 2014 public law 8/7/14
https://www.congress.gov/bill/113th-congress/house-bill/3230
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
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
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
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
Eras of Service
http://www.va.gov/vetsinworkplace/docs/em_datesNames.asp WWII
12/7/1941 – 12/31/1946
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) 2003-2011 Operation New Dawn (OND) 2010-2011
War in Afghanistan 2001-Present
Eligibility
http://www.va.gov/HEALTHBENEFITS/apply/veterans.asp
Active military service or Reserves or National
Guard called to duty by federal order
Met minimum duty requirement
Not dishonorably discharged
Eligibility
http://www.va.gov/HEALTHBENEFITS/apply/veterans.asp
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, 1975. Served in the Persian Gulf from August 2, 1990 to November 11, 1998.
Were stationed or resided at Camp Lejeune for 30 days or more between January 1,
1957 and December 31, 1987.
Are found by VA to be Catastrophically Disabled.
Previous years' household income is below VA's National Income or Geographical-Adjusted
Eligibility
http://www.va.gov/HEALTHBENEFITS/resources/priority_groups.asp
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
Eligibility
http://www.va.gov/HEALTHBENEFITS/resources/priority_groups.asp 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.
Eligibility
http://www.va.gov/HEALTHBENEFITS/resources/priority_groups.asp
Priority Group 7
Veterans with gross household income below the
geographically-adjusted 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
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
Registry Exams
Federal Benefits for Veterans, Dependents, and Survivors 2013 Edition
Gulf War Registry
Depleted Uranium registry
Burn Pit Registry
Agent Orange Registry
Ionizing Radiation registry
To enroll: contact the Environmental Health Coordinator at the
Gulf War Service
http://www.publichealth.va.gov/exposures/gulfwar/military-service.asp
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 (2003-2010) and Operation New Dawn (2010-2011).
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
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 Program @ Baltimore VAMC
Depleted Uranium Registry
Federal Benefits for Veterans, Dependents, and Survivors 2013 Edition
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,
Southwest Asia Associated Conditions
http://www.publichealth.va.gov/exposures/gulfwar/medically-unexplained-illness.asp#sthash.v5kklIJl.dpuf
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
Infectious Disease of SW Asia
http://www.publichealth.va.gov/exposures/gulfwar/infectious_diseases.asp#sthash.PPXAPLrB.dpuf
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
Gulf War Registry
Federal Benefits for Vetrerans, Dependents, and Survivors 2013 Edition
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
Burn Pit Registry
http://www.publichealth.va.gov/exposures/burnpits/
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, 2001. 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
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
Agent Orange
http://www.publichealth.va.gov/exposures/agentorange/locations/index.asp
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
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)
Camp LeJeune
http://www.publichealth.va.gov/exposures/camp-lejeune/index.asp
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
Camp LeJeune—associated conditions
Esophageal cancer
Breast cancer
Kidney cancer
Multiple myeloma
Renal toxicity
Female infertility
Scleroderma
Non-Hodgkin's lymphoma
Lung cancer
Bladder cancer
Leukemia
Myelodysplastic syndromes
Hepatic steatosis
Miscarriage
Neurobehavioral effects
http://www.publichealth.va.gov/exposures/camp-lejeune/index.aspExposure assessment
http://www.publichealth.va.gov/exposures/providers/exposure-assessment.asp
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.
