INTRODUCTION
Fragmentation of medical services is a significant barrier in modern patient care with contributing factors including patient and system level details. The Veterans Affairs (VA) department is the largest integrated health care organization in the US. Given the complex challenges of such a system, the VA has developed resources to lessen the impact of care fragmentation, potentially widening services and diminishing traditional barriers to care. We present a patient case as an example of how VA programs are impacting current veteran oncologic care.
CASE PRESENTATION
An 86-year-old veteran with shortness of breath and fatigue was found to have macrocytic anemia. Located nearly 200 miles from the closest VA with hematology services he was referred through the National TeleOncology (NTO) service to see hematology using clinical video telehealth (CVT) technology stationed at a VA approximately 100 miles from his home. Consultation led to lab work revealing no viral, nutritional, or rheumatologic explanation. A bone marrow biopsy was completed without clear diagnosis though molecular alterations demonstrated ASXL1, TET2 and CBL mutations. Hematopathology services were sought, and the patient’s case was presented at the NTO virtual hematologic tumor board where expert VA hematopathology, radiology and medical hematology opinions were available. A diagnosis of myelodysplastic syndrome was rendered with care recommendations including the novel agent luspatercept. Given patient age and comorbidities, transportation remained a barrier. The patient was set up to receive services through home based primary care (HBPC) with weekly lab draws and medication administration. Ultimately, the patient was able to receive the first dose of luspatercept through the NTO affiliated VA with subsequent administrations to be given by HBPC. Additional visits planned using at home VA video Connect (VVC) service and CVT visits with NTO hematology at his local community based outpatient center (CBOC) located 30 miles from his home.
DISCUSSION
Located over 3 hours from the closest in-person VA hematologist, this patient was able to receive complex care thanks to a marriage of in-person and virtual services involving specialty nurses, pharmacists, and physicians from across VA. Services such as the NTO hub-spoke model, virtual tumor boards and HBPC, reveal a care framework unique to the VA.