By Casey Rogers, DC
President John F. Kennedy once said, “Change is the law of life. And those who look only to the past or present are certain to miss the future.” The future of health care, business, and our society will be uniquely shaped by the current year. As well, health care, business, and our society will be uniquely different in the year 2030 than it is today. The predominate influence behind these changes has undoubtedly been the presence of SARS-CoV-2, better known to many as COVID-19.
Over the past several months healthcare professionals, public health workers, and citizens have been working (mostly) together to implement new policies and changes to healthcare delivery that will create a safe environment for patient populations and healthcare employees alike. Some of these policies have included the closure of “non-essential” departments or elective surgeries. As well, many chiropractic professionals have been impacted by mass closures or restricted hours1. These limitations have prevented many with musculoskeletal pain, a condition affecting millions2, from receiving treatment services. The suspension, delay, or discontinuation of these services can, unfortunately, produce undesirable consequences including increased pain, depression, and disability1. Further, patients may instead seek services in emergency and/or urgent care settings increasing healthcare costs, prescription drug use, and exposure of themselves, or others, to the COVID-19 virus. Auspiciously, The U.S. Department of Veterans Affairs has implemented policies to help mitigate these unfavorable consequences and provide safe, effective, and essential chiropractic services throughout this global pandemic.
Remaining “Essential” Through Innovative Pathways
The chiropractic department within the Bruce W. Carter VA Medical Center in Miami, Fla., was operating at peak capacity with patients pre COVID-19. At any given time four treatment rooms could be in operation delivering chiropractic services. However, in March 2020, as a result of COVID-19, the department temporarily suspended face-to-face services and offered telehealth services delivered through telephone or virtual platforms for the veteran population so that care would not be halted. After deliberation and adherence to local mandates and Centers for Disease Control and Prevention (CDC) guidelines, the department resumed face-to-face services in early June 2020. A hybrid model of care has been implemented since, with face-to-face services being offered on a limited basis and continuation of telehealth/telemedicine.
Prior to March 2020, the chiropractic department did not offer telemedicine and these unique services. The extended time between these suspended face-to-face encounters was the thrust necessary to force innovation and changes to delivery of care. Telephone calls, virtual appointments, the VA’s video on demand (VOD) platform, and text messaging services were all employed to retain patient/provider communication and develop effective care strategies during the pandemic. After March 17, certain “everyday” digital media was authorized for use as a HIPAA-compliant platform by the Department of Health and Human Services, consequently increasing access for many veterans in need.3
With this technology utilized, other VA healthcare providers could continuously send consultative requests for veterans. Thus, evaluations of complaints and continued diagnoses were made, education was provided, and referrals for additional medical care and diagnostic imaging were placed when appropriate and available. It is important to note that some services were suspended during this time and exposure risk needed to be evaluated for the individual veteran.
Other benefits of implementing telehealth services includes assigning home exercise programs and self-care strategies to each veteran. VOD could verify safe technique and utilization of devices and at-home therapeutics. Durable medical equipment and therapeutic aids such as transcutaneous electrical nerve stimulation (TENS) units, thermotherapy devices, Therabands, or foam rollers, could be delivered to the veteran via mail to provide safe at-home therapeutic tools. This continued virtual care assisted in potential alleviation of the veterans seeking services in emergency departments or urgent cares, and allowed those other healthcare professionals in turn to remain focused on combating COVID-19.
When face-to-face services were reinstated, they were on a limited basis. Many new protocols were implemented by the VA for the safety of both the patient and healthcare provider. Entrance and exit of the facility were regulated for only those veterans with appointments and for staff. Facial masks were mandated, and everyone was screened with temperature checks and comprehensive questions relating to potential COVID-19 exposure. Providers utilized personal protective equipment (PPE) such as gloves, facial masks, and protective eyewear. The masks recommended were basic surgical masks as chiropractic procedures and deep breathing do not constitute as aerosol-generating procedures4, though it was also recommended patients adhere to not removing their face coverings. Gowns were also available when deemed necessary for precautionary purposes. Additionally, visits were structured to support social distancing with no overlap of patients during allotted visit intervals. This allowed sufficient time for the provider to sanitize tables, rooms, and equipment during the absence of reduced staff that previously engaged in assisting with these protocol measures.
Transitioning from Clerk to Resident and Applying Hybrid Care Model
For the 2020-2021 class of VA residents, I was fortunate enough to match with the Miami VA hospital through the rigorous residency application process. Having previously been a student clerk at this location, I had familiarities with much of the staff and even several patients. Though some of the new changes took me by surprise, I feel I was able to transition quickly to the newly implemented policies and procedures. For example, when a new consult for chiropractic is inputted, we now contact the veteran directly and determine an appropriate sequence of care. This sequence is based on many factors including patient comorbidities, risk for severe COVID-19 symptoms, the severity of functional impact from their current pain levels or chief complaint, and degree to which their condition is changing over time. The veteran may be at high risk if they are older than 65 years of age, or have a significant history of chronic lung disease, heart conditions, diabetes, liver disease, or immunosuppressing conditions.5 When possible, virtual consulting and evaluating is utilized. Care is provided through a hybrid face-to-face and telemedicine model with the type of services being directed though mutual decision making. However, if the veteran feels their pain is significant enough that delay in care may worsen their condition or require other healthcare utilization, hybrid face-to-face and telehealth services can be implemented. Other factors such as clinic availability and the person’s ability to manage their condition at home will also play a role in determination of an appropriate sequence of care.
Beyond one-on-one encounters, the VA offers a variety of benefits for the veterans to utilize at-home services through a digital platform to maximized social distancing. The VA can offer virtual yoga, meditation, mindfulness, and relaxation courses through pre-recorded or live-group programs. Veteran involvement in these programs can keep them active and provide safe techniques to control their pain experience while keeping them secure from COVID-19 exposure while awaiting services in the chiropractic department. When deemed appropriate, and operating under proper protocols, the veteran can then report to the clinic for face-to-face treatment of their musculoskeletal condition(s).
Preparing for the “New Normal”
Ultimately, it is uncertain when practice will return to “normal,” if ever. Many of the changes implemented may be long lasting and affect services for some time to come. Regardless of these changes and events, patients still suffer with pain, acute or chronic, and will seek care for their ailments. During circumstances such as global viral pandemics, pain is not controlled by social distancing, PPE’s, and sanitizing. Instead, essential services such as chiropractic can help regulate and control these conditions. The VA Healthcare System has implemented such policies to continue to provide these essential chiropractic services to the veteran population seeking care for these situations. As we enter the unknown future of health care it is important to understand that pain care is, in fact, essential and ever changing. It is imperative that chiropractic providers meet these changes and challenges with innovative and effective techniques to provide quality and evidence-based care that will best suit the individual to reach their healthiest goal. As noted by the historian and philosopher Thomas Carlyle, “He who has health, has hope; and he who has hope, has everything.”
Dr. Rogers is a chiropractic resident at the Bruce W. Carter VA Medical Center in Miami, Fla. To read previous posts written by VA's chiropractic residents, click here.
- Eccleston C, Blyth FM, Dear BF, et al. Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161(5):889-893.
- Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. Published 2018 Sep 14. doi:10.15585/mmwr.mm6736a2
- Notification of Enforcement Discretion for Telehealth. HHS.gov. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
- Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. doi:10.1371/journal.pone.0035797
- People Who Are at Higher Risk for Severe Illness. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html