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The Veterans Health Administration: At the Leading Edge of America’s Health Care

If you want to see the future, you can start with the VA, America’s largest integrated health system. Penn Nursing faculty and alums are helping forge the path.

What do gps, chariots, and duct tape have in common? They were military innovations that found their way into civilian life–along with the internal combustion engine and the Internet. We all owe a debt to armed forces’ visionaries whose technologies and systems we use every day. Same with the Veterans Administration: from bar coding medicines to developing a new pain scale to discovering that a daily aspirin cuts in half the rate of heart attacks in patients with unstable angina, the VA is an incubator for innovations that improve the quality of life not only for veterans, but also for civilian populations around the world. And Penn Nursing is at the leading edge of research in the most exciting VA innovations. “The VA, as a closed, contained health care system provides some of the best opportunity to see the full impact of what it provides to a specific population,” said Julie Sochalski PHD FAAN RN, Associate Dean for Academic Programs at Penn Nursing.

Illustration by Sarah MaycockIllustration by Sarah MaycockIn 2011, Mary Ersek PHD RN FPCN, Penn Nursing’s Killebrew-Censits Chair in Undergraduate Education and Professor of Palliative Care, accepted a dual position as Director of the Veteran Experience Center, a national quality improvement initiative housed at Philadelphia’s Corporal Michael J. Crescenz VA Medical Center (CMCVAMC). The Center’s mission is to improve the quality of end-of-life care across the VA’s integrated health care system. The work is satisfying, she said, because it enables her to apply the sophisticated analytic skills she acquired through her research so that clinicians can use data to improve care. “That immediate translation of research into clinical practice was, and remains, very enticing and rewarding,” she said.

“Certainly veterans do seek health care outside the VA, but a large number of them do seek it there,” said Dr. Sochalski. Large enough, according to the Veterans Health Administration, to make the VA the U.S.’s largest integrated health system and the top employer of nurse practitioners–sort of a microcosm of the state of the nation’s health care. Along the way, it has created data systems for tracking outcomes–and that data is turning into a gold mine.

“It’s a great time for evidence-based research and training,” said Coy Smith ND RN MSN NEA-BC FACHE CPHQ, Associate Director Patient Care Services/ Nurse Executive at CMCVAMC and Assistant Dean for Clinical Practice at Penn Nursing. He agrees that the patient demographic at the VA has much in common with its civilian counterpart. “A lot of this work is transferrable for sure.”

If you’re following breakthroughs in health care, here are four that should put the Veterans Health Administration-Penn Nursing partnership at the top of your watch list.

Illustration by Sarah MaycockIllustration by Sarah MaycockBreakthrough #1: Traumatic Brain Injury Research

Penn Nursing alum Helene Moriarty PHD RN FAAN and VA psychologist Laraine Winter PHD are Principal Investigators of an NIH-funded study that evaluated the impact of the Veterans In-home Program (VIP), an innovative intervention for veterans with traumatic brain injury (TBI) and their families. VIP delivers occupational therapy in the home setting and with the involvement of family members. Most studies look at patient impairments, but this one targeted social and physical aspects of the home environment for modification. VIP provides strategies for veterans and family members to manage TBI-related symptoms. For example, some veterans have emotion regulation issues, said Moriarty. “They may have a short fuse, irritability, anger that comes out easily. Spouses or family members say ‘we are walking on eggshells.’” During the home visits, the OT interventionists worked with the vets on relaxation techniques, stress reduction, and other ways to manage demands and reduce emotion triggers. VIP also incorporated strategies to help veterans manage problems with memory, organization, and planning that are common in TBI. VIP’s purpose is to align the physical and social demands of the environment with the capability of the injured veteran. For example: “The common problem of losing personal belongings like keys often leads to frustration and anger, and gets the family upset,” said Winter. To address this, the OTs helped family members set up “control centers” in the home, usually near the front door. When patients got in the habit of depositing their keys and wallets at the control center, they tended to lose them less often. Veterans receiving VIP showed improved community reintegration and greater ability to manage their TBIrelated problems, according to Moriarty. Family members in VIP experienced lower rates of depression and caregiver burden. “This is groundbreaking research because VIP is the first intervention demonstrating benefits for both veterans with TBI and family members.” Moriarty adds that families of veterans with TBI may be more stressed and vulnerable than their civilian counterparts because of multiple deployments in a short time, and they may be dealing with concurrent comorbidities in the veteran, such as PTSD, depression, and pain. “We would love for this to move into the civilian population,” said Winter, noting that she and Moriarty are seeking funds to expand VIP and test it with veterans and civilians, and their families. “If we can replicate the findings with a general population with TBI, it would be a strong argument for delivery of some services in the home with the engagement of family members and for a focus on aligning environmental demands with patients’ capabilities.”

Breakthrough #2: Evidence-Based Quality Initiatives

“Change, no matter how you look at it, is hard,” said Amy Sawyer PHD RN, Penn Nursing’s Associate Professor of Sleep & Health Behavior who is currently leading 15 evidence-based quality improvement projects at the Philadelphia VA addressing varied practices at the medical center. Examples include pressure injury prevention in surgical patients, pre-operative warming for prevention of intraoperative hypothermia, and secondary traumatic stress in health care providers. “It’s hard,” she said, “to accept and it’s hard to convey to others that change needs to happen.” One recent occupational health project involved switching from PPD to the T-SPOT.TB for testing incoming employees for tuberculosis. Unlike the standard PPD, the T-SPOT.TB does not require a follow up visit after 48 to 72 hours. During a PPD shortage a couple of year ago, VA clinicians put the T-SPOT.TB procedure in place and followed it for a year. “It was cost effective,” said Sawyer. “You aren’t bringing people back for a second appointment.” She notes that, while the T-SPOT.TB test requires a potentially off-putting blood draw, the test puts less burden on patients and employees, requires less time and money, “and if there’s a positive result, treatment can begin immediately.” The program, which has since rolled out across the entire VA system, saw a 29 percent increase in employee compliance, a 40 percent drop in costs, and a 50 percent reduction in time to clear new hires.

“We used to think of quality improvement and research as separate,” said Mary Ersek. “But over the years we’ve gotten more sophisticated. We use research methods. We sort of mimic statistically a randomized control trial.”

The primary tool that Dr. Ersek and her team use in their VA work is a National Quality Forum-endorsed patient/family reported outcome measure called the Bereaved Family Survey (BFS). The BFS was developed through a VA-funded research project and is now used throughout the VA. The BFS asks respondents to evaluate specific aspects and the overall quality of care at the end-of-life. It’s mailed to the next of kin of every veteran who dies as at a VA facility or in one of several VA Home-Based Primary Care programs. Facility level scores are calculated on a quarterly basis and sent to each facility in a report. The Veteran Experience Center also works directly with care teams to help them interpret their scores and develop strategies to improve care and outcomes. “We conduct phone conferences with the teams twice a year in conjunction with the Implementation Center, which offers clinical resources and support,” said Ersek. “For example, we might identify chronically low scores on the overall item as well as those related to communication for a specific facility. In response, the Implementation Center may work with the team to initiate training and practice in conducting family conferences. We continue to monitor their BFS scores during and following the training and see if it had an impact on outcomes.”

The Bereaved Family Survey, is “a unique way to keep a pulse on the quality of care at the VA for veterans and families,” said Ann Kutney-Lee PHD RN FAAN, Adjunct Associate Professor of Nursing. Dr. Kutney-Lee studies the effects of nursing care organizations on patient outcomes. “We ask about communication with providers, whether or not their preferences were met for treatment,” she said. “We ask about emotional and spiritual support. Did they get the amount of support they wanted? Did they see a chaplain if they wanted one?”

Some of the nation’s top medical centers— including Duke, Stanford, Mount Sinai of New York, and Kaiser—use versions of the BFS. Soon, the Centers for Medicare and Medicaid Services will require every Medicare-certified hospice in the country to report findings from a similar survey.

Breakthrough No. 3: End of Life and Palliative Care Improvements

Demographics are shifting for the veteran population. “In recent years they were mostly World War II and Korean War vets,” said Dr. Kutney-Lee. “They are now at the end of their life span and we’re seeing a new wave who served in Vietnam.” The change in demographics has implications for end-of-life care. Veterans from the Vietnam era, she said, are more likely to have been exposed to dangerous combat situations that they were unable to escape. “Many veterans were fighting in jungles and mountains, there were hidden explosives planted, all with a near constant threat of being ambushed…the nature of the direct combat situations was very different.” And the way in which society welcomed home the veterans was different. World War II vets were treated as heroes. They enjoyed national support. They were seen as having fought for a cause. But Vietnam was different. “They were not welcomed when they got home,” said Dr. Kutney-Lee. “Things were thrown at them when they got off the planes and they are less willing to talk about their experiences.” This, she said, can bubble up emotionally at the end of life. Unlike World War II vets, those who served in Vietnam may never have had a chance to process their experiences.

Kutney-Lee and her fellow researchers are trying to understand what is different about these vets at the end of life and how to prepare health care providers inside and outside of the VA. They are seeing higher rates of chronic illnesses that correlate with chemicals such as 2,4,5- T, an ingredient in the herbicide Agent Orange, to which soldiers were exposed in Vietnam–along with higher rates of anxiety and post-traumatic stress. In an effort to be proactive, the VA’s Hospice and Palliative Care Program Office and its analytic arm, the Veteran Experience Center, are using the BFS and other data to create educational programs. These programs are aimed at helping providers meet this group’s unique end-of-life needs. “You see increased anxiety, stress, emotional distress, feelings of guilt,” said Dr. Kutney-Lee. “We want the vets’ and their families’ experience to be as peaceful as possible at the end of life.”

She is involved in another project with Penn Nursing professors Ersek and Margo Brooks Carthon PHD RN FAAN to study racial and ethnic disparities in quality end-of-life care for vets. A couple of years ago they found that, according to the BFS, next-of-kin of African-American vets were 50 percent less likely to report that their loved ones received excellent care at the end of life. The researchers want to know why. Is it the facility itself? Is it how nursing care is organized? One clue: members of racial and ethnic minorities tend to be more sensitive to changes in nurse staffing levels. The researchers hypothesize that in facilities where staffing is better, nurses are better positioned to meet the complex care needs of patients, and this may also apply at the end of life. “They have the resources they need and the time to spend with their patients,” said Kutney-Lee. “It could be that nursing care isn’t as well organized in facilities with high populations of racial and ethnic minorities, or that minorities might be more susceptible in that kind of environment.”

Illustration by Sarah MaycockIllustration by Sarah MaycockBreakthrough No. 4: Pain Management, Mental Health, and PTSD Programs

VA research looks at the relationship of pain and behavioral health–and a lot of the researchers’ conversations dwell in how to integrate behavioral health into primary care.

One promising area: acupuncture. It may come as a surprise to some, but the VA and the Department of Defense are among the largest users of acupuncture in the nation. “Battlefield acupuncture,” developed by Air Force physician Richard Niemtzow MD, entails inserting small needles in a patient’s earlobes. Unlike standard acupuncture, the practitioner need not be licensed. “It can be taught easily,” said Assistant Dean Coy Smith.

“It’s being taught and utilized at the VA.” The Philadelphia VA, he added, uses both kinds of acupuncture. Battlefield acupuncture, which can be administered anywhere (not just on the battlefield), leaves the needles in the patient’s earlobes, so there is a carryover analgesic effect after the treatment is complete. While news media have covered the disproportionate suicide rate among veterans, the VA’s success in curbing that trend may be underreported. “You can’t prevent all suicides,” said Smith. “But you can prevent a lot of them.” The VA’s active suicide prevention program includes a screening tool for clinicians and providers to help determine suicide risk, along with a number of experts across the VA who specialize in suicide research and prevention. In fact, a perusal of the literature on suicide risk and prevention reveals that the VA is behind much of the work. “In the general population of veterans the suicide rate is high,” said Smith, “but it’s notably lower for any vet who gets their care at a VA.”

Pain management entails a complex matrix of mind and body. “What comes first, the chicken or the egg?” said alum Nicholas Giordano PHD RN. A post-doctoral fellow at the Defense & Veterans Center for Integrative Pain Management, he is examining the links between pain and mental health among combat-injured personnel. His Penn Nursing PHD dissertation posed a key question: In an era of unprecedented survival after complex and life threatening injuries, what are the short- and long-term symptom trajectories of PTSD and pain? One finding: veterans who present early on with symptoms of PTSD might experience more intense pain. “We are following traumatically injured individuals from time of injury until two years later,” Dr. Giordano said. “This is more than a snapshot. We see how symptoms develop over time and how they are related to one another.”

Penn Nursing’s work with the VA is even changing the standard pain scale, thanks to Rosemary Polomano PHD RN FAAN, Penn Nursing’s Associate Dean for Practice and Professor of Pain Practice. She specializes in managing acute pain after combat-related injuries. After learning that clinicians in 28 facilities who used the standard numeric pain rating scale (0-10) indicated that this scale was inadequate in helping patients and health care providers communicate about pain intensity levels, Polomano collaborated with leaders from the Defense and Veterans Center for Integrative Pain Management and others to develop the Defense and Veterans Pain Rating Scale (DVPRS). According to Polomano, DVPRS is now the official military pain scale with the goal of being in use in all DOD healthcare facilities. The scale integrates word anchors (“No pain,” “Hardly notice pain,” “Sometimes distracts me,” “Hard to ignore,” “Awful, hard to do anything,” to “As bad as It could be, nothing else matters”) with color-coding and facial expressions to help patients rate their pain. Other health systems are free to use the DVPRS, said Polomano. “It is in the public domain.”

Polomano also teaches Pain Science and Practice, a class open to students from Penn Nursing as well as Penn’s dental and medical schools. According to the syllabus, the “interprofessional course focuses on the biopsychosocial aspects of pain and pain management from the perspectives of individualized pain care, scientific discoveries, evidence-based practice and cross-disciplinary learning.” This year, in partnership with the Uniformed Services University Graduate School of Nursing in Bethesda, MD, 30 active duty military personnel from their nurse anesthesia program attended the class.

Penn Nursing alumna, Dr. Caroline Angel, now of the Reintegrative Health Initiative, reports that the evidence indicates that the stigma around seeking treatment for mental health is one of the biggest challenges faced by veterans who are struggling with PTSD in their reintegration. “Lack of accessible services can also present a barrier,” she said. These challenges also apply beyond those facing PTSD to include a broad range of mental health and reintegration issues. Clearly, there’s more work to be done.

Penn Nursing and the VA: Perfect Together

Nurses work at the heart of the changes in veterans’ care—and, therefore, in helping to determine the future of American health care. “Much of the VA’s innovative models of care delivery are due to the leadership and contributions of VA nurses,” said Distinguished Health Policy Fellow at the Penn’s Leonard Davis Institute of Health Economics, David Shulkin MD, a former Secretary of Veterans Affairs. “It’s often their affiliation with leading academic centers like Penn that help to ensure the VA remains at the forefront of these innovations.” Shulkin, a Penn professor before he headed the VA, said his tenure with the government was highly influenced by his university experience. “Penn Nursing’s leadership in primary care-based nursing and community-based nursing was influential in my thinking on expanding new models of care for veterans,” he said.

For example, Shulkin’s VHA Directive 1350, issued in 2017, used the power of “federal supremacy” to grant full practice authority to more than 5,000 advance practice nurses working in all 50 states. Their ability to practice to the full extent of their training and licensure without physician supervision at VA facilities, even in states with laws that would otherwise prohibit them from doing so, was a big step in promoting high-level nursing care. This one step, enabling full scope of practice, arguably constitutes the single most important recent advance at the VA.

“What the VA says is ‘we are a system,’” explained Julie Sochalski. “Trying to maintain polices that are discontinuous across states didn’t make sense, so they adapted full practice authority for any advanced practice nurse practicing at the VA.” For those nurses the policy is a game changer. “Say there is a restrictive practice act in Alabama. You can fully practice if you are at a VA facility in Alabama because there is federal authority. If you stepped out of the VA and went next door to a clinic, your practice would be restricted.” The goal, she said, was to “expand the number of [advance practice nurses] and reduce the time it takes to get in to see someone.”

“I’ve often felt that the VA is the best place for advanced practice nurses,” said Patricia D’Antonio PHD RN FAAN, Carol E. Ware Professor in Mental Health Nursing and Chair of Penn Nursing’s Department of Family and Community Health. She recalled that one of the best jobs she ever had was working with VA nurses to identify patients with compelling emotional or psychological needs and finding ways to meet those needs. One patient, an outgoing, lovable former boxer, would sometimes lash out and punch someone if he got upset. The VA nurses developed a plan to appoint him an unofficial nursing assistant. “He followed a nurse around, carried water, etc. He had a job to do.” With a new sense of purpose, he could control his anger. No more punching. One day he went missing. “I found him in the break room with the nurses,” said Dr. D’Antonio. “He felt such a part of the staff that he was with them.”

Palliative Care Professor Mary Ersek was similarly drawn to the VA’s work. “Do people forget the mission? Yes,” she said. “But you are reminded of it, and it is about people being impacted by experiences forced upon them. Being involved in the military, that’s a big honor. The mission is not about prestige. We get to use rigorous research methods, but I like that we stop and say it’s not just an academic exercise, it’s about how will using these advanced analytic methods improve care for veterans.”

This sense of purpose creates a unique esprit de corps among providers and researchers. Back when Dr. Giordano was a Penn Nursing undergraduate, the first thing he noticed about the VA was the camaraderie. “There’s definitely this idea of being on a mission,” he said. “At the Department of Defense it’s maintaining a medically ready fighting force, and at the VA it’s caring for that force long after the fighting.” Recalling his clinical rotation at the Crescenz VA Medical Center, he said, “These men in rooms together were talking to one another. My patients at the medical center never talked to each other, but at the VA, whether they served in the same conflict or decades apart, they were sharing their experiences.”

That sense of purpose goes a long way. “I haven’t practiced clinically at the VA since 1992,” said D’Antonio, “but I still describe myself as a VA nurse. It’s part of my identity.”

Louis Greenstein is a writer living in Philadelphia.