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Chiropractors in the Largest Health System: Anthony Lisi, DC on Integration in Veterans' Facilities PDF Print E-mail
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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Veeterans Affairs, VA, chiropractic, integration, health systems
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. 

In the last 3 plus years, the uptake of chiropractors inside the VHA has commenced. Lisi, a pioneering practitioner in the VA's Connecticut system, was recently named as national director for the Veterans’ Health Administration Chiropractic Service. Lisi is also an associate professor of clinical sciences at the University of Bridgeport College of Chiropractic
and an associate faculty member with the Palmer Center for Chiropractic Research. The Integrator contacted Lisi to learn about his position, and the status of the initiative.

Integrator:  The Veteran's Administration is a huge organization. Where is the entrance point for chiropractic?

chiropractic integration, hospitals, health systems, success
Anthony Lisi, DC, director, VA chiropractic health service
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.

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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