How do you provide specialist services for a population that is spread all over the country? 

The solution is actually quite simple. Veterans break into 2 main groups - those that have pretty routine primary care problems and only occasionally need a bit of advice or support with a very specific problem. The second group have a lot of service-related problems and need a high level of specialist support.  

We have set up a veterans clinic that provides face to face consultation for those whom need it. Just contact us and we can organise someone to to provide a consult, onsite or as a virtual consult.

 The much larger need is to provide advice to other providers. This is in two parts - a simple resource to look routine things up and more direct advice for specific problems.

A few examples will make it easier to understand 

Lets say we have a young veteran whom has no current service induced problems. They need a standard Gp and a way to get in touch (for them or their Gp) when they need some specialist advice. Their routine healthcare is through their Gp and they are enrolled with their Gp. When they get a family, they are enrolled with their local Gp. If something routine crops up the Gp can go to the information resource and look it up - no different to any other demographic in the country.

In the real world when the Gp needs more advice than that they talk to a colleague with the specialist knowledge (a specialist is someone who knows more about less). This can be a request for advice or a request to provide specific care. Its normally done by a refferal letter - which is why its a slow process. In NZ there is currently no specific place for these veterans specilaist refferals to go. What we want to do is provide that resource. Its email a freind for your Gp to sort Veterans problems that are uneconomic or just too complicated in General practice.

As ever it comes down to who pays the Bill for a service like this. Currently its the veteran for non service induced conditions and for conditions that are service induced but have not yet been accepted by VANZ or ACC. 

A general practice enrolls patients to get their subsidy funding from GONZ for ongoing care. A veterans virtual service would not have enrolled patients in the main - they would be what is termed casual patients (more like an accident and medical and we all know how expensive they are because there is no subsidy funding). If the condition is already accepted by VANZ or ACC a practice can claim funding from those entities for services rendered - its a fee for service model.

Whilst these problems are generally uneconomic for most General Practices, it is possible to build a model where this will break even in a veterans clinic because of 2 factors. The first is that specilaist knowledge which makes identifying the problems faster and then knowing where to send them for the specialist investigation or intervention. 

The second factor is an economy of scale. There may be 40,000 combat veterans in NZ, but that equates to maybe 20 per practice on average out of 1500 to 1800 enrolled patients. if you consider that 1 in 5 have longterm propblems then that is 4 out of 1500 - or about 1 in 400 people in the practice. Its not something the practice can afford to have specific mechanisms for managing. A veterans clinic can have those mechanisms in place which simplify the common presentations — which rduces the cost of service overall. 

Now let us consider the veteran whom has lots of service induced problems. They enroll with the General practice but a shared care plan is developed early in their management. Their consultations are predominantly with their Gp, however there is a regular followup with the veterans clinic which updates the veteran specific problems. 

With the advances in modern telehealth and the ubiqyuity of smart phones giving web access a virtual veterans clinic can be a reality now. 

A specialist virtual clinic would need to be able to cover off on the common service attributable problems "in house" and reduce the need for onwards refferal into the public system. This achieves two things - from the veterans point of view its the ability to access services in a timely manner whilst from the Governments point of view it reduces secondary care demand and reduces cost. 

The developemnt of a virtual veterans clinic allows the development of integrated multidisciplinary care for veterans with complex problems. There is however a larger payoff in this model of service delivery. By intervening earlier in a multidisciplinary manner there is evidence that the longterm cost of care is reduced and outcomes are improved. This engaging the common service elements on a common platform creates a huge opportunity. We avoid the delays and duplication of referring out to the various providers when we have them all on the same information system, which means internal referrals are a simple task on the system.   

The other part which is often not considered is expertise. We expect the surgeon to know how to do a hip. What most surgeons do not understand however is how to work out if something is service attributable and the specific issues in managing military veterans (or military in general). By investing in specific providers, we can build their level of expertise with respect to military specific conditions. This allows us to then provide a quality service to our military and veterans across a broad range of conditions.  

There are typically two components to military medical presentations - the physical and the mental. Its uncommon to find one without the other. The aim would be to use the opprtunity that any presentation provides to proactively manage both issues in order to reduce longterm morbidity and hence cost - its simple health economics.  

Where are we now? Well, the face to face clinic is conducting limited consultations now. The aim is to expand into the full range of consultations in the first quarter of 2025, all going well.  

Currently we have the ability to provide face to face consultations in Whanganui. 

We are currently in design for a national veterans virtual clinic. We know the technology works from our recent experiences with Telehealth and we are now looking at how we integrate that into a physical clinic with the potential complexity that multiple providers spread across the country would introduce.  

The veterans clinic, the standing orders project and the Provider portal all dovetail together to provide a suite of solutions.