Chiropractors in the Largest Health System: Anthony Lisi, DC on Integration in Veterans' Facilities
Written by John Weeks
Chiropractors in the Nation's Largest Health System: Anthony Lisi, DC on Integration into Veterans Health Facilities
Summary: When Yale University School of Medicine
recently chose to bring a chiropractor into their first Integrative Medicine
Symposium, Anthony Lisi, DC was the chosen presenter. As director of the
Veterans Health Administration's Chiropractic Service, Lisi sits in the
hot-seat for the most significant complementary and alternative healthcare
integration effort nationwide. To Lisi's account, practitioner-to-practitioner
relationships and patient reports are overcoming the deep reluctance which
greeted this Congressionally-mandated program. The Integrator caught up
with Lisi to learn more about this pioneering initiative.
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VA - the Nation's largest health system
Anthony Lisi, DC, sits at the pinnacle of an initiative as painstakingly
molded as the mountain the Richard Dreyfus character built in his backyard in Close
Encounters of the Third Kind. Build it and they will integrate.
Lisi's opportunity was created by leaders of the chiropractic profession, many
of whom are veterans of the US Armed Forces, who believed that chiropractic
services should be included in Veterans Health Administration(VA)
facilities. Roughly a decade ago, lobbying commenced in earnest. It hasn't been
easy. Like the placement of the National Center for Complementary and
Alternative Medicine inside the National Institutes of Health, the
placement of chiropractors in the VA was compelled by hard-fought Congressional
mandate.
Integrator: The Veteran's Administration is a huge
organization. Where is the entrance point for chiropractic?
Anthony Lisi, DC, director, VA chiropractic health service
Lisi: When chiropractic was originally implemented in 2004, it wasn't
clear through which of the VA's many service lines it would be implemented. Locally,
individual facilities have latitude to structure implementation based on their
needs and resources. Nationally, Chiropractic Care Services is now part of
Rehabilitation Services, a strategic group within the Office of Patient Care
Services.
Integrator: How's that relationship going?
Lisi: It's going very well. They are taking the steps needed to establish
chiropractic as a program. Rehabilitation Services encompasses a wide range of
services. With operations in Afghanistan
and Iraq, there are increasing numbers of veterans needing these services.
Musculoskeletal injuries are very common in those coming back. But the percent
of veterans we see from Afghanistan or Iraq is small compared to the
overall veteran population. There are about 263,000 Iraq
or Afghanistan
veterans enrolled in the VA, and about 7.9 million overall veterans enrolled.
Integrator: What kinds of health problems are you seeing in
Iraq
veterans?
Lisi: There are a number of major traumatic injuries, what the VA calls
"polytrauma." Blast injuries from IEDs - improvised explosive
devices. These injuries are typically co-managed by teams. Sometimes
chiropractors can contribute. There are also veterans who have problems that
are secondary to less severe injuries like motor vehicle accidents, or even
just overuse from the physical demands of deployment Recent studies have shown
back pain is high in this group. There are many opportunities where
chiropractic can be helpful.
Integrator: How much integration of chiropractic is there at this
point?
Lisi: The number is small but growing. There are roughly 38
chiropractors working in clinics at 32 VA facilities. This is out of 155
medical centers and over 800 smaller outpatient clinics. Most of the chiropractic
clinics are in medical centers.
"There are roughly 38
chiropractors working in clinics at 32 VA facilities. This is out of 155
medical centers and over 800 smaller outpatient clinics."
- Anthony Lisi, DC
Integrator: Are they brought in as full-time employees?
Lisi: Currently most chiropractors have full-time staff appointments. However
some facilities have brought on a chiropractor as a part-time employee, and in
other cases the facility will have a contractual relationship with a chiropractor.
These 3 models of providing services are consistent with the way VA facilities
bring in various disciplines, based on needs and resources.
Integrator: How about the management process. Do VA patients have
direct access.
Lisi: The VA system employs a primary care provider model. As with other specialty clinics, like rheumatology,
optometry, or physiatry for example, a patient
reaches the chiropractic clinic by consultation. This can be from primary care,
or from another specialty clinic. A veteran can request it, and providers make
referral decisions based on medical necessity. There is no indication of any
obstacles. All of the chiropractic clinics are busy.
Integrator: I recall there being great concern from VA staff
early on.
Lisi: We are in the process of systematically assessing implementation,
but for now I can only speak for myself and other anecdotal reports. The
facilities weren't sure what to expect. Most administrators and [conventional]
providers had little if any experience with chiropractors. There was healthy
skepticism. In most places, the facilities allowed the individual chiropractor
who came in to sink or swim on his/her own abilities. We're faring very well.
In almost every case, supervisors and administrators, are reporting a lot of
success.
Integrator: I recall seeing that the American Chiropractic
Association (ACA) hasn't been too pleased with the velocity of the inclusion.
"We started in 2004 with 25, we are currently at 32 and 3
more are in development as we speak. In a little more than three years since implementation
we have seen part-time people going to full- time and new clinics developed.
We've seen that the services are manageable. We have many anecdotal reports
from administrators that it's going well."
- Lisi
Lisi: The ACA has been quite clear that they want chiropractors in 100%
of the facilities and they are supporting legislation to that effect. Current
legislation requires the VA to provide on-station chiropractic services at a
minimum of 21 sites. We started in 2004 with 25, we are currently at 32 and 3
more are in development as we speak. In a little more than three years since implementation
we have seen part-time people going to full-time and new clinics developed.
We've seen that the services are manageable. We have many anecdotal reports
from administrators that it's going well.
Integrator: What are the issues for the chiropractors? There is
not a large group to draw upon who have this kind of experience.
Lisi: The main issue is: how do we maximize our contribution to the VA?
There is no template for implementing chiropractic services into the largest
integrated healthcare system in the US. There is much work to be done
to learn how we can improve quality, improve outcomes, and improve
satisfaction. True, most DCs have not worked as part of a hospital system. However
when the system recognizes that the given chiropractor takes a patient-centered
and evidence-based approach, the process works. It is necessary to examine in detail viagra wiki. Additionally, we are looking at
developing a postgraduate educational program for chiropractors in the VA
system to develop that very experience. There is more team medicine here than
most are accustomed to, more co-morbidities. We think there is value in this
training.
Integrator: Is there a national credentialing standard?
Lisi: There are national qualification standards for chiropractors as with
other professions, but credentialing and hiring is done locally by each
facility. We have found that the type of chiropractor who is best suited
to the VA system is one who has prior experience working with medical doctors,
who has some academic experience and some research experience.
Integrator: Many of these positions are linked to chiropractic
schools aren't they? The Association of Chiropractic Colleges was a major
proponent from day one as I recall, working side-by-side with the ACA. I would
think that this academic backing would make it somewhat easier.
"Right now 12 VA facilities
have academic affiliations
with a total
of 9 chiropractic
schools. We have rotations
of students, similar to our
college
teaching clinics. Over
300 chiropractic students have
undergone some
training."
- Lisi
Lisi: Right now 12 VA facilities have academic affiliations with a total
of 9 chiropractic schools. In these facilities we have rotations of students,
under the supervision of staff chiropractors, similar to what we do in our college
teaching clinics. Thus far over 300 chiropractic students have undergone some
training at a VA facility. Additionally, other trainees such as medical
students or medical residents may rotate through a VA chiropractic clinic. Integrator: What sorts of research are you engaging?
Lisi:The VA Office of Research and Development has issued a Request for
Applications for chiropractic research projects. Currently my colleague Paul
Dougherty from the Canandaigua, NY VA has received the first intramural grant
for an RCT on low back pain. I have a grant in revision for an assessment of
implementation of the chiropractic program. We have a few other
externally-funded projects in various stages. And my colleague Andy Dunn from
the Buffalo, NY
VA has already published a few papers on consultation requests and student
training. Developing more research is critical. This will help us understand
the best way that the chiropractic program can contribute to the VA’s Mission of serving our
Nation’s veterans.
Integrator: Well it's a fascinating role you have and things seem
to be working about as well as they could. Good luck with your next steps!
________________________________
Comment: I recall a meeting in 2004 in which a colleague, Reed Phillips
[DC, PhD] addressed medical directors and administrators of two community
clinic who was reluctant to consider adding chiropractic services. Phillips,
the original chair
"It
took a while for the
horns to go away from
visions on both sides, but
they went
away as we
got to know each other."
- Reed Phillips, DC, PhD,
former chair, VA chiropractic
advisory committee
Just two weeks ago, on a separate project with Phillips, we learned that yet
another set of hospital system medical leaders refused to consider any
relationship with a chiropractor. I wish these could hear Lisi's story, and
Phillips' account. Prejudice will subside with these relationships, as the VA
experience shows. Yet too many medical directors continue with their
self-fulfilling prophecy, denying access to chiropractors then saying: See,
those chiropractors aren't team players.
It's long
past time for us to move beyond the era of segregation in US medicine.
Credit the members of Congress who supported the VA initiative, and the
chiropractic leaders who conceived it, for forcing our guilds to surmount our
isolation-born bigotries.
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