Academic journal article Generations

Primary Care for Older Veterans

Academic journal article Generations

Primary Care for Older Veterans

Article excerpt

Increasing diversity among the patient population and calls for enhanced patient and family involvement are resulting in a paradigm shift to a new delivery system.

The Veteran's Administration (VA) medical care for veterans of all ages evolved in the closing years of the twentieth century from a hospital-based system to one focused on ambulatory services and satellite clinics. This physical restructuring of care was accompanied by an organizational restructuring that led to development of the present primary care system in the VA. Increasing diversity among the veteran patient population and calls for enhanced patient and family involvement with care are resulting in a paradigm shift to a new delivery system. Each of these trends has impacted the primary care of older veterans in its own way.

The origin of the Veterans Administration, the federal agency that in 1989 became the Department of Veterans Affairs, was the Veterans Bureau, an entity that arose from World War I as an amalgam of federally operated supervised housing units and insurance plans that contracted for medical, surgical, and dental services from the U.S. Public Health Service (PHS) (Director, United States Veterans Bureau, 1922). In 1923, the Veterans Bureau began divesting itself of its PHS linkages with the opening of its own health clinics and hospitals that gradually grew into the VA (Director, United States Veterans Bureau, 1923). By the late 1940s, the agency supported a national system of hospitals (some of them focused exclusively on psychiatric needs and others on tuberculosis) with associated longterm living units, called domiciliaries. This structure was dramatically expanded after World War II to address the health needs of the 16 million veterans returning from that war (Committee on Veterans Affairs, 1967).

Under this system, care was veteraninitiated in reaction to a symptomatic complaint that was customarily worked up and addressed in the inpatient setting. Outpatient care was largely limited to specialty clinics that were small appendages to more robust inpatient consultation services. Lengths of stay were prolonged, costs of care (to the extent they were tracked), were extreme, and quality was not a consideration. Eventual discharge was back into the veteran's home or, if there wasn't one, into a VA domiciliary. Those whose self-care abilities were not deemed adequate even for that level of independence would be transferred into a VA nursing home where nursing staff attended to daily custodial needs such as bathing, dressing, and toileting (Committee on Veterans Affairs, 1967), and there was little to no emphasis on further restoration of function.

In the late 1970s, geriatric assessment, a concept that had been pioneered in Great Britain by Marjory Warren, was introduced at a limited number of nursing homes, both within and outside the VA (Warren, 1946). The concept held that a nursing home should not be a terminal placement and that elders should be eventually discharged home (or at least to a less restrictive level of care) through a coordinated multidisciplinary set of assessments. In this way, the complex of intertwining chronic diseases and conditions that rendered a frail elder so dependent could be teased apart, and a plan for rehabilitation could be developed and executed.

This approach was termed the geriatric evaluation unit. Following the publication of a promising controlled trial at the Sepulveda VA in North Hills, Calif., near Los Angeles (Rubenstein et al., 1984), inpatient units in medical, psychiatric, neurology, and rehabilitation services joined those in VA nursing homes as a national program of geriatric evaluation and management, or GEM (Fozard, Tillman, and Mather, 1985). The proliferation of GEM was fueled by, and in turn supported, the growth of advanced fellowship training programs in geriatric medicine-also largely a VA effort. These developments also influenced the appearance of a dozen or more VA geriatric research, education and clinical centers (GRECC), whose efforts blended clinical innovation and basic research into the aging process and the diseases affecting elders, and education efforts to bring the lessons learned to the existing and emerging VA healthcare workforce (Goodwin and Morley, 1994). …

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