Paradigm shift for VA amputation care

Abstract

INTRODUCTION As the Department of Defense (DOD) identified a need to modify the type and delivery of services to the combat-injured with major traumatic limb loss, so too has the Department of Veterans Affairs (VA). While the majority of veterans with amputations receiving care in VA medical facilities have sustained their amputations because of medical conditions such as diabetes and peripheral vascular disease, a significant number of individuals also sustain amputations because of trauma on the battlefield. Each major military operation has resulted in a new cohort of veterans with combat-incurred traumatic amputation: almost 21,000 in the Union Army during the Civil War, more than 4,000 during World War I, about 15,000 during World War II, over 1,000 in the Korean war, an estimated 6,000 during the Vietnam war, and 15 during the Persian Gulf war [1]. To date, Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) conflicts have resulted in nearly 1,000 amputations. The VA has always been committed to the principles of rehabilitation, and one of the major goals driving care is to restore the capability of veterans with disabilities to the greatest extent possible and improve their quality of life and that of their families. To this end, the VA has invested significant resources into creating a new paradigm of care to meet the needs of the newly combat-injured veterans from OIF/OEF while also improving care to all veterans with amputations due to medical causes. CHALLENGES IN CARE FOR COMBAT-INJURED The VA has faced several challenges in providing care to this new group of veterans. A major challenge is that battlefield injuries are often complex, resulting in amputations and residual limbs that prove challenging for later prosthetic fitting because of length, scarring, heterotopic ossification, and additional associated injuries, such as burns or complex fractures. In addition, these veterans access VA healthcare at varying stages in their recovery and rehabilitation, challenging the system to provide care across the entire continuum. Also, these veterans are widely distributed across the country and the VA healthcare system so that any particular VA medical facility may have the opportunity to provide care for only a few individuals. Finally, this is a young, highly trained group of individuals committed to an active lifestyle who are early in their developmental life cycle. They are computer literate and take an active role in learning about and directing their healthcare. They are often working, going to school, or raising families and thus require efficient and convenient service. VA'S VISION FOR NEW AMPUTATION SYSTEM OF CARE First and foremost, care must be person-centered. The person receiving care must drive the process and set the goals. Care is delivered by an integrated, interdisciplinary team, including medical professionals, therapists, prosthetists, mental health professionals, and other specialists as needed. The focus of care is on meeting the goals of the veteran, maximizing function, community integration, and participation. Care must be evidence-based, comprehensive, and holistic, addressing medical needs and comorbidities, as well as the individual's psychosocial needs, developmental stage in life, and goals (functional, vocational, and leisure). A prosthesis is viewed as a medical device requiring careful evaluation, resulting in a prescription based on joint decision making, best medical evidence, and practice. Finally, care must be provided, as needed, throughout the person's life. The team must provide regular checkups to continually reassess function, satisfaction, and lifestyle and interest changes, and to manage medical problems such as pain, skin problems, cardiovascular changes, or weight loss/gain. Routine checkups can also introduce new developments in componentry that may contribute to an improvement of function or increase in satisfaction. …