Training at PVAMC is “a crash course in internal medicine,” says one doctor. Residents see firsthand how social-economic factors such as education and income impact physical health.

Asch trained at PVAMC as a resident and has been involved with it throughout his more than 20 years on Penn’s faculty. In 2001, he founded CHERP, the Center for Health Equity Research and Promotion. Areas of research include chronic illnesses such as diabetes and hypertension, mental illness, joint replacement, and pain management. A partnership with the University of Pittsburgh, CHERP is now the Department of Veterans Affairs’ national program on health disparities. It has grown to become a highly respected, multi-faceted organization with a nearly $10 million annual budget; its 34 core investigators focus on understanding and eliminating disparities caused by social and cultural forces. “Health care is not the only thing required for health,” Asch says, pointing out the important roles social support and education play.

By providing essential services to the Philadelphia region’s large veteran population, PVAMC helps alleviate some of the pressure on the city’s health system, Asch says, noting that it’s “the closest thing Philadelphia has to a public hospital.” When patients need services not provided at the VA, such as maternity or radiology, they will be treated at a Penn Medicine facility. In addition to having 140 acute-care beds and a 220-bed nursing home, PVAMC provides extensive outpatient care as well as housing information, education support, and other services; part of what Asch calls its “social mission.” Last year, nearly 68,000 veterans were treated on an outpatient basis at PVAMC or one of its four community-based clinics. The center received $9 million in federal stimulus funds through the American Recovery and Reinvestment Act of 2009, which it will use primarily to upgrade and increase the capacity of its emergency room.

PVAMC has developed an expertise in treating and providing services to patients who are homeless or have spent time living on the street. In April, the VA Central Office announced that it was establishing a National Center on Homelessness among Veterans at PVAMC. It will be a joint initiative with a VA medical center in Tampa, Florida; Penn and the University of South Florida will provide support. While the VA has provided extensive outreach and case management for homeless veterans across the country since 1987, this will be its first initiative to conduct research and develop policy on the issue.

The Philadelphia region has one of the highest concentrations of veterans in the country, with close to 330,000 in the city and six surrounding counties. Of those, more than 94,000 are enrolled at PVAMC, a nearly 30 percent penetration rate that is especially impressive because not all veterans are eligible for coverage. (Enrollment criteria include financial and medical need, military record, and whether or not a disability is service-related.) A number of government and civic leaders have proposed expanding eligibility to help address our nation’s current health care and economic issues. They say this is particularly important now, given the high percentage of military personnel from low-income backgrounds, compared with the draft era.

In 2004, Congress granted all Iraq and Afghanistan war veterans five years of free health care following active duty. The Philadelphia VA now has almost 2,200 vets from those conflicts enrolled, a 47 percent increase from 2006. It expects the numbers to increase even more this year, with the planned return of many Pennsylvania and New Jersey National Guard units.

To serve these returning veterans, PVAMC expanded its Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) program so that it could provide more comprehensive case-management and social-work assessments. It has also received funding to increase the staff and equipment of its interdisciplinary polytrauma team, which addresses the severe, multiple injuries that many OEF/OIF veterans sustained from explosions and blasts. These include traumatic brain injury, amputation, visual impairment, and post-traumatic stress disorder.

The influx of OEF/OIF veterans means that PVAMC is now treating more women and younger veterans than ever before. Its Women’s Health Clinic offers mammograms, Pap tests, infertility referrals, and other services. Across the country, the VA system began providing medical and psychosocial services for women in 1988, when women represented just 4.4 percent of all veterans. Last year, women made up 11 percent of OEF/OIF veterans nationally, and it is estimated that by 2010, more than 14 percent of all veterans will be women. Nearly 67 percent of the women who use VA health services across the country are under 30, compared to less than 59 percent of men.

One of the goals of offering Iraq and Afghanistan veterans free health care is to help them avoid some of the health problems now faced by aging Vietnam vets by starting them on a lifetime of preventive care. The VA is considered one of the most accomplished primary-care providers in the country. Its electronic health-records system is often cited as a model for facilitating comprehensive continuity of care across locations and over time. Physicians know when to remind patients about screening tests and can easily access data from previous tests, an advantage not lost on trainees. “It’s more navigable and almost seamless,” says Dr. Judd Flesch C’01 M’06, a third-year resident, describing the benefits of using one system to order, conduct, report, and evaluate medical tests. As residents make their rounds, they frequently stop at a computer to check a patient’s medical history.

The electronic health-records system dates back more than 20 years, arising from the need to serve a large, mobile patient population, and it gives Penn researchers access to essential longitudinal data that they say they could not get elsewhere.

“You can’t do outcomes research without a strong retrospective data base,” says Dr. Glen Gaulton, executive vice dean and chief scientific officer for the School of Medicine, who notes that the relationship with PVAMC benefits Penn research in numerous ways. It provides Penn with “access to a distinctive patient population” that supports its work in areas such as mental health and geriatrics. Penn physicians are directly involved in the Philadelphia VA’s special programs on Parkinson’s disease, mental illness, and other conditions. This has given Penn a “head start” in preparing to treat our nation’s aging population, says Gaulton, and it is now “ahead of the curve because we had to address it.”

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FEATURE:
Crossing the Street By Randy Mintz-Presant
Photography by Candace diCarlo

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