Inside Oversight

Adam Roy:
Hello and welcome back to another episode of Inside Oversight, an official podcast of the Veterans Affairs Office of the Inspector General.

This is your host, Adam Roy.

Today I’m speaking with Erica Taylor, a health system specialist, within the Office of Healthcare Inspections here at the VA OIG. We’re going to be discussing the report Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida, which we published back in March 2023.

Welcome, Erica. How are you doing today?

Erica Taylor:
I’m great, thank you. I’m excited to here talking with you.

Adam Roy:
Excellent. So, let’s get started, if you could just briefly tell us the focus of this report.

Erica Taylor:
Sure, Adam. The OIG received allegations that a primary care provider and a pulmonologist failed to monitor a patient’s cancer after they completed radiation treatment, that this led to progression of the patient’s cancer. The complainant alleged that these failures ultimately led to the patient’s death. In evaluating the allegations, the OIG did not substantiate a failure to monitor the cancer by the primary care provider or pulmonologist but did find failures related to communication of test results to patients and the use of return to clinic orders. In addition, the OIG found a failure with coordination of care between the VA and community care providers. To understand many of the issues described in this report, I would like to provide some context about challenges the OIG has found with coordination of community care services more broadly.

Adam Roy:
That’s a good starting point. I appreciate that. Let’s start by telling our listeners what you mean by community care, and why coordinating this care is so challenging?

Erica Taylor:
Yes, of course. Very generally, the VA has a program called Community Care where the VA purchases care from medical providers outside the VA Healthcare System when the VA cannot provide the needed medical care. When this care is purchased, the VA administrative staff and the VA provider ordering the community care are required to continue involvement and coordination of the care for the patient. This can include things like requesting medical records, scanning them into the VA electronic medical record, and reviewing and acting on any recommendations from the community providers. The recommendations from community providers can include things like follow-up imaging and laboratory tests, prescriptions for medications, requesting additional visits with the patient, and consultation with medical specialists.

Adam Roy:
Perfect. The topic of community care is something of interest to the VA OIG. Prior to this report, can you talk overall the VA OG’s focus in regards to community care?

Erica Taylor:
Sure. Over the years, the OIG has published many reports detailing issues related to appointment scheduling with community providers and delays in VA getting clinical information back from community providers. There have been several prior reports that highlight failures in coordinating community care for services. For example, a report issued in February 2022 discussed failures in consult management and scheduling that led to delays in cardiology care for a patient at the Martinsburg VA. In this case, a patient waited 124 days to have follow up cardiology services in the community coordinated. During the intervening time, the patient was hospitalized for chest pain. In another report, issued July 8, 2021 the Community Care staff at the New Mexico VA Healthcare System were not correctly processing returned medical records from the community care providers, which resulted in the VA providers not having ready access to the information they needed to coordinate follow-up care for patients.

Adam Roy:
Ok, some history of challenges by the VA. In this situation, what happened at the West Palm Beach VA specifically?

Erica Taylor:
This report looked at coordination of a patient’s care and the monitoring of a patient’s cancer following treatment. One aspect I would like to focus on involved the coordination of care between the VA and a community care chiropractor.

Adam Roy:
So how does coordination of chiropractic care impact monitoring of a patient with cancer?

Erica Taylor:
I’m so glad you asked. In early 2018, the patient was diagnosed with a rare lung cancer. The tumor was treated with radiation, which shrunk the tumor, but it didn’t eliminate it. The patient required ongoing monitoring of the tumor after the treatment was completed.

During the monitoring, or surveillance phase of the patient’s care, the patient experienced pain in their back and buttock. The patient communicated to their primary care provider about their pain. To assess the cause of the pain, the primary care provider referred the patient for x-rays and to several specialists including a VA chiropractor. The VA chiropractor completed an initial evaluation of the patient’s pain, but then due to some scheduling limitations referred the patient to a community chiropractor for further evaluation and treatment. The community chiropractor assessed the patient and recommended an MRI of the low back in late summer of 2018. The community chiropractor’s notes were returned to the VA and scanned into the patient’s VA medical record in the fall. Because the VA chiropractor referred this patient to the community, the records from the community chiropractor were sent to the VA chiropractor, not the patients VA primary care provider. We know that the VA chiropractor received the records, but for unknown reasons, the recommended MRI was never ordered.

Adam Roy:
A follow-up question here. Would the MRI of the low back have detected lung cancer?

Erica Taylor:
That’s a great question. Unfortunately, the patient continued to have pain. And then in late July 2019, the day the patient was scheduled to have a routine imaging completed to monitor the lung tumor, they went to the emergency room due to their pain. The imaging of the lungs was completed that day and medical providers found the tumor had grown significantly. The patient was admitted to the hospital from the emergency room to control the pain and continue the evaluation of the lung tumor. An MRI was done during the patient’s hospitalization and multiple lesions and fractures were found in the lumbar spine. These fractures were characterized as likely related to the patient’s lung cancer,

Adam Roy:
To quickly summarize, the MRI the community chiropractor had recommended was not completed, and then when an MRI was completed, fractures that may be related to cancer were found in the patient?

Erica Taylor:
Yes. You’re correct.

Adam Roy:
Okay. That’s a good history of what occurred. So now walk us through what should have happened in this situation.

Erica Taylor:
We would have expected to find documentation that the community chiropractor’s recommendations for an MRI were reviewed to include any clinical reasoning for ordering or not ordering the recommended MRI. While we definitely cannot say that an earlier MRI would have changed the prognosis or outcome, there may have been a missed opportunity for an earlier diagnosis. For patients, even with a terminal disease, earlier diagnosis offers opportunities for other types of support. Some examples are appropriate pain control, education and referral to hospice care, and family and caregiver support. These are really meaningful interventions that all patients deserve.

Adam Roy:
That’s an absolutely valid point. Certainly meaningful. What recommendations in the report were made regarding this finding or the overall findings?

Erica Taylor:
Sure. The recommendations are pretty simple: we recommended that chiropractor providers review community care notes and take action as needed. The rules were in place, they just weren’t followed. These activities of “care coordination” are really so critical, and this case highlights what happens when community care is not a seamless and coordinated process for a veteran. VA relies on the participation of community care providers to meet the clinical needs of veterans, but we’re finding more and more gaps in this process. OIG will continue to look closely at VA community care and provide recommendations that will support improvements.

Adam Roy:
Absolutely. VA OIG certainly will do that. Thank you for your time today, Erica. Is there anything else you want to add before we wrap up?

Erica Taylor:
There’s not. Thank you for having me.

Adam Roy:
Erica, thank you so much for your time today.

I encourage those listening to visit the VA OIG’s website and read the full report there. Again, that report: Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida, and that was published in March 2023.

That’s it for this episode of Inside Oversight. I encourage you to listen to more episodes wherever you listen to podcasts. Also check out Veteran Oversight Now, our sister podcast where we cover oversight topics in greater detail. Thanks for tuning in.

This has been an official podcast of the VA Office of Inspector General. Inside Oversight is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Please subscribe and tune in monthly to hear how our work is helping to improve the lives of veterans. Visit the website to learn more about how the VA OIG conducts meaningful independent oversight.

Report potential crimes related to VA; waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800-273-8255, press 1, and speak with a qualified responder now.