Access to Pain Care From Compensation Clinics: A Relational Coordination Perspective

Chronic pain is common in veterans, and early engagement in pain treatment is recommended to forestall consequences of untreated pain, including depression, disability, and substance use disorders. The Veterans Health Administration (VHA) employs a stepped care model of pain treatment, with the majority of pain care based in primary care (step 1), and an array of specialty/multimodal treatment options made available at each step in the model for patients with more complex problems, or those who do not respond to more conservative interventions.¹

Recognizing the need for comprehensive pain care, the US Congress passed the Comprehensive Addiction and Recovery Act, 21 USC §1521 (2016), which included provisions for VHA facilities to offer multimodal pain treatment and to report the availability of pain care options at each step in the stepped care model.^2, With the passage of the Veterans Access, Choice, and Accountability Act of 2014, 38 USC §101 (2014) and now the MISSION Act of 2018, 38 USC §703 (2018) veterans whose VHA facilities are too distant, who require care unavailable at that facility, or who have to wait too long to receive care are eligible for treatment at either VHA or non-VHA facilities.³ These laws allocate the same pool of funds to both VHA and community care and thus create an incentive to engage veterans in care within the VHA network so the funds are not spent out of network.⁴

An opportunity to connect veterans with VHA care arises at specialized VHA Compensation and Pension (C&P) clinics during examinations that determine whether a veteran’s health conditions were caused or exacerbated by their military service. Veterans file claims with the US Department of Veterans Affairs (VA) Veterans Benefits Administration (VBA), which sends the patient to either a VHA facility or private practitioners for these examinations. Although the number of examinations conducted each year is not available, there were 274,528 veterans newly awarded compensation in fiscal year 2018, and a substantial number of the total of 4,743,108 veterans with C&P awards had reevaluation examinations for at least 1 of their conditions during that year.⁵ Based largely on the compensation examination results, military service records, and medical records, veterans are granted a service-connected rating for conditions deemed related to military service. A service-connection rating between 0% and 100% is assigned by the VBA, with higher ratings indicating more impairment and, consequently, more financial compensation. Service-connection ratings also are used to decide which veterans are in the highest priority groups for receipt of VHA health care services and are exempt from copayments.

Although traditionally thought of as a forensic evaluation with no clinical purpose, the C&P examination process affords many opportunities to explain VHA care to veterans in distress who file claims.⁶ A randomized clinical trials (RCT) involving veterans with mental health claims and a second RCT including veterans with musculoskeletal claims each found that veterans use more VHA services if offered outreach at the time of the C&P examination.^7,8 In addition to clinical benefits, outreach around the time of C&P examinations also might mitigate the well documented adversarial aspects of the service-connection claims process.^6,9,10 Currently, such outreach is not part of routine VHA procedures. Ironically, it is the VBA and not VHA that contacts veterans who are awarded service-connection with information about their eligibility for VHA care based on their award.

Connecting veterans to pain treatment can involve clarifying eligibility for VHA care for veterans in whom eligibility is unknown, involving primary care providers (PCPs) who are the fulcrum of VHA pain care referrals, and motivating veterans to seek specific pain treatment modalities. Connecting veterans to treatment at the time of their compensation examinations also likely involves bidirectional cooperation between the specialized C&P clinics where veterans are examined and the clinics that provide treatment.

Relational coordination is a theoretical framework that can describe the horizontal relationships between different teams within the same medical facility. Relational coordination theorizes that communication between workgroups is related synergistically to the quality of relationships between workgroups. Relational coordination is better between workgroups that share goals and often have high levels of relational coordination, which is thought to be especially important when activities are ambiguous, require cooperation, and are conducted under time pressure.¹¹ High relational coordination also has been associated with high staff job satisfaction, high satisfaction with delivered services, and adherence to treatment guidelines.^12-14 An observational cohort study suggested that relational coordination can be improved by targeted interventions that bring workgroups together and facilitate intercommunication.¹⁵

To better understand referral and engagement for pain treatment at compensation examinations, VA staff from primary care, mental health, pain management, and C&P teams at the 8 VHA medical centers in New England were invited to complete a validated relational coordination survey.^11,16 A subset of invited staff participated in a semistructured interview about pain treatment referral practices within their medical centers.