Greetings and welcome. I think we'll go ahead and get started. I'll have to say, I wish this room was full because I think we're going to be talking about some things that are going to be really interesting to everybody here that are sort of above and beyond PACT Act and military exposure specifically in veterans, but we're really glad that you're here. Joe and I are pleased to have this opportunity to talk to you about PACT Act. If you sat in on Peter's session, then we're not going over the fundamentals again. What we're going to be talking about is, so what do we do about this in terms of actually taking care of the veteran that walks into the clinic? My name's Steve Hunt. I'm a primary care doc and occupational environmental medicine doc in Seattle and clinical professor of OEM at University of Washington. Joe will introduce himself. Joe is with home office and the center for exposures, complex exposures, threats. It's a new center that we have that's part of the home office, the health outcomes of military exposures. Is that right? Or is it part of the risk? You're about right, yeah. What's happening in the VA these days is that we are, we had a lot of good stuff going on and now we're kind of putting it together in a way that actually helps veterans, helps the veteran walking into the clinic. The content I'm going to do is just going to briefly, I didn't do my OCMED training until I was 50. I'd been working with veterans for decades at that point and I realized much of what I was seeing in terms of health concerns were related to things that individuals had been doing, jobs they'd been doing in the military, highest risk jobs you can imagine, many of them, in these environments of extreme risk as well, whether it be combat deployment or even garrison. So I went back and did training in occupational environmental medicine, so I'm sort of a newbie. I wish I could say when I was 50 was not so long ago, it's been a while, but I'm intrigued still at what this discipline has to offer, what this profession has to offer. And to me, what it had to offer was a lens through which to look at the experiences and exposures and health risks of individuals that had served in the military and just looking at the picture here, it just begins to touch on the sorts of things that people can experience in the military. And the reason when I talk about this, when we talk about exposures in the military, it makes your head spin how many there are, occupational, environmental, and so on. And I put this up there because, well, just look at this list, and let's take 30 seconds, each of you, to think about if you were mandated by Congress to screen every enrolled veteran in the VA, 8.6 million veterans, screen every one of them for potential health concerns related to exposures. So just take 30 seconds and think about that. We were given 90 days, I'll give you 30 seconds, but what sort of, what would you do? How would you go about this? The exciting thing for me about this was that it brought everything I learned in occupational environmental medicine to bear, population health, surveillance, screening, case finding, clinical care, it really kind of brought all the pieces together. So here's what we did, and this has been almost two years now since PACT Act was passed. And Peter did a great job, and I should say, you know, that Peter, and Eric, and Melissa, and Menengi, and we have incredible partners, Joe, in these offices in the VA, the War Related Illness and Injury Study Centers, as well as the Health Outcomes and Military Exposure. So we have this great setting in the VA to do some novel things, taking care of individuals with exposures, and that's what we're doing, and that's what we're going to be talking about today. So PACT Act, again, reviewing what Peter talked about, it's, you know, it took many actions. It was almost unanimously passed. So there's something about this that appeals to nearly everybody in this country of ours, which right now it's kind of rare to find something like that. But expanding eligibility, improving the presumptive process, you know, education, resources, research. So the PACT Act really gave us a boost in the arm to put the pieces together. Now Section 603, which is, so I'm the physician lead on this screening process in the VA, so that every enrolled veteran will receive an initial toxic exposure screening and follow-up every five years for any exposures during their military service. So how do we do this? Excuse me. So I have asthma. Part of that is because of an exposure in the Northwest because of the fires two or three years ago, which touches on the fact, again, that this issue of exposures and how we take care of individuals that have exposure as part of their risk profile is not just about veterans. It's about the whole population. So many of the things we're talking about today have applications in the greater populations as well. So we came up with this tool that would allow us to kind of connect with the veterans and offer them support that they need. All hands on deck. Things I love about the VA, you know, half the time you're kind of beating your head against the wall and pulling your hair out because it's really frustrating sometimes in a big organization to get things done. When the VA puts the pieces together, it gives you goosebumps. And this has been one of those things that I feel like, okay, here's what you can do when you have a system of individuals focused on a mission, working together, and really invested in what we're doing. So the idea of asking the question, we designed the whole thing around asking the veterans if they had concerns. We didn't pre-identify and say, oh, you should be concerned about this and this and this just because you were in these places. What we said was, are you concerned about anything you might have been exposed to that could have caused you problems? So I wasn't surprised. I figured it'd be somewhere around 30%, but Peter mentioned this as well. So we started screening veterans for these exposures and found that 43% of veterans reported concerns about exposures. And the main exposures that are bulleted there are burn pits, like Peter mentioned, Gulf War-related or Gulf War illness, Gulf War-related, multiple exposures of different sorts, Agent Orange exposure, ionizing radiation, and the contaminated ground water, Camp Lejeune. And then the reason we included those five is because for all five of those, we have presumptive conditions, which means we have a system to provide care without formal exposure assessment because we don't have exposure data in these cases. But we do have this approach that allows us to presume exposure if a veteran was in the same place as the chemical, and to presume a nexus, and this was mentioned in the earlier talks too, if the Institute of Medicine says there's any evidence, even a teeny bit, minimal but suggestive, NASEM now, that there could be an association between this exposure and an outcome, that's good enough for us. It's not causal, it's an association. So here's what it looks like. So we designed this tool, a veteran comes in, and essentially what we ask them is, do you believe that you experienced any toxic exposures such as, and then we list those five, or other. So if it was one of the exposures that don't have presumptives, they could endorse that as well. So we really start by asking the veterans, what are your concerns? And if they say yes, then you endorse which exposure they were concerned about, and up pops all of the presumptive conditions for that exposure. So immediately, we're able to connect veterans with benefits, and resources, and so on, that can be helpful to them, related to these presumptive conditions. And if the veteran says, well I don't know, should I be concerned? Then the education process, that's 90% education, is so the veterans understand what's available to them, so we understand how the system works, how we actually can get help for them, and so we would say, well gosh, notice that you were deployed to Iraq at this particular time, and so you may potentially have been exposed to burn pits. We don't know for sure, but we know that they were around, and we just presume anyone in that area may have been exposed, and so the exposure piece is cared for, taken care of. If you have any conditions that could be related, then you don't have to prove that it contributed to your problem. We have a system set up that presumes nexus, presumes an association, not causality. I'm not sure if Wendy's here or not, but I was talking to Wendy Thanasi, and she was bringing up the fact that often individuals will say, well how can we say that this veteran's hypertension is related to Agent Orange, or is caused by Agent Orange? And we'll say, we're not saying that, nobody knows that. What we do know is we're presuming this person, this veteran was in Vietnam, or he was in Thailand, or whatever, he was in an area the chemical was present, so we assume this veteran was exposed, and there is some evidence of a potential association between hypertension and dioxin. That's good enough for us. This is policy, it's not science, it's veteran-centric policies. So what we wanted out of the screen was an affirmation to the veteran that, yep, we know this is important to you, we want you to know this is important to us, too. We're going to take care of these things, if it's even possible, it hurts you. And we connect them with presumption, we provide them with information about these various exposures, and we put it on their problem list. And this gets to this idea of exposure-informed care. What we're trying to do is set up a system that we just kind of always keep in mind that on almost every veteran's risk profile would be consideration of potential exposures while they're in the military, or at Camp Lejeune, in garrison, Fort McClellan, maybe, and we put it on the problem list as potential exposure to a hazard. So Peter, it was also mentioned, this whole idea of presumptive conditions, which is one of the more, you know, I think kind of transformational things going on here, is we have a policy, we have policies and things set up where we don't have to prove someone was exposed to something, we presume it, if they were in the same place as the chemical. And they don't have to prove, we don't have to prove, that it caused the condition. If there's any evidence it might have, that's good enough for us. We assume it may have contributed. And so what I was saying to Wendy was, every day for decades, I've said to veterans, you may, you probably will get service-connected for your prostate cancer because there's some evidence it might be related to Agent Orange exposure, and you were in Vietnam. But you can't say, my prostate cancer was caused by your Agent Orange, and I will say this to veterans literally, almost every day. What you can say is, you were in Vietnam, Agent Orange was pretty much everywhere, we don't know who was exposed to how much, we presume you were exposed, and there's some evidence that it could have contributed to your prostate cancer. So you're service-connected, not because it caused it, but because there's some evidence that it could have contributed. Veterans understand that, and they really appreciate it. Instead of our saying, eh, don't worry, you weren't there that long, probably didn't hurt you, we're saying, we don't really have good exposure data, so here's our approach. So it's very popular with veterans. And yeah, so we just inform the veterans, presumptives for Agent Orange, here's a list of them, and again, when you screen a veteran, these pop up as part of the screen. You know, it was sprayed, hand sprayers, Jeeps, helicopters, C-130s, it was everywhere. And so again, we just, we don't know who was exposed to how much for how long, so we just say, we presume you were exposed, good enough for us. And this is just an indication of how things changed with the Burn Pit, I'm sorry, with PACT Act is, two or three years ago, these were the three presumptives for Burn Pit exposure, asthma, sinusitis, and rhinitis. After, you know, sort of going through all the literature and looking at all the malignancies and looking at all the other potential conditions that could possibly be related, the number of presumptives was expanded remarkably. So that's another thing that's happened now, is we're really pushing the notion of expanding presumptives, so when that's appropriate. Looking at pulmonary disease, you know, almost every pulmonary disease could be exacerbated or contributed to by particulate exposure, or exposure to Burn Pits. So now what's happening in the VA is every specialty care knows that it has certain conditions, like cardiology, ischemic heart disease, or now hypertension, in Vietnam veterans that may have been exposed, and so on. So everyone's starting to think, oh yeah, this is a 75-year-old veteran, could be Vietnam, if he's a Vietnam veteran, we need to be keeping in mind, might have been, if he was in Vietnam, we assume he was exposed to Agent Orange, and here's what we're seeing in our clinic, in our cardiology clinic, ischemic heart disease, hypertension, urology clinic, oh yeah, we're seeing bladder, you know, Camp Lejeune presumptive bladder cancer, and prostate cancer, and so on. So it's kind of diffusing through the organization, and now everyone's thinking about, oh yeah, exposures, oh yeah, this veteran that I'm seeing may have been impacted. So that is kind of the culture of exposure-informed care. Gulf War, this is one that we're just starting to screen for, and the idea of Gulf War illness, medically unexplained symptoms after the Gulf deployment, it's been very, very difficult, veterans have been frustrated, everyone's been frustrated. We do have presumptives that include other symptom-based syndromes, fibromyalgia, chronic fatigue, and functional GI disorder, and any other chronic, problematic, unexplained symptom. Migrating paresthesias, neurologists have seen them, it's not vascular, it's not metabolic, it's just this weird symptom, we can't explain it. We all see it in medical care all the time, right? This isn't new. We see it all the time. So we say, okay, let's keep an eye on it, and we'll make sure if anything changes, we'll do some more testing if we need to. But in this case, we also say, you know, you're twice as likely, twice as likely to have any of these conditions, or medically unexplained, any unexplained symptom if you were deployed to the Gulf. So now what we're doing is screening, oh gosh, I'm sorry, screening Gulf-deployed veterans, because if they have any of these conditions, they're eligible to put in a claim. We don't get tangled up in why, what's it about, what causes it, we don't know. But what we do know is that they're almost twice as likely, if they were Gulf-deployed, to have this sort of condition. Camp Lejeune, these slides, there's a lot of information on them. I hope you can use them. They're available to you as a resource as well. Camp Lejeune's interesting because the health benefits mean dependents can also receive health care for any of the conditions on the left side there, if they were on the base as well. The right side is the disability piece, which means if you're a veteran, you can also get compensation as well as your health care. So here's what we've seen. Actually it's 5.5 million, we've screened 5.5 million veterans in somewhat less than two years. And probably 40% of those have gotten some very, and 43% endorsed an exposure. You can see it on the right side in the pie chart there. You know, the most common one, burn pits, Asian orange also, ionizing radiation, Gulf War. The other category is the challenge. Because it's a totally different process, there's no presumptive. So that means you have to have some sort of exposure assessment, and that's the challenge. Because an exposure assessment in the absence of exposure data, we all know how difficult that is, so we're trying to figure out ways of trying to at least approximate exposure risk in individuals. In the things, the best proxy we have found for exposure is location and time. If you were in the same place as the chemical, when the chemical was there, that's the best proxy we have for exposure. You know, we've tried looking at other activities. If you look at Vietnam veterans and Asian orange spraying, ranch hands, they were doing the spraying. They're probably the ones that have the highest level. So the studies were, yeah, let's study the ranch hands. And then it was like the Lembravos out in the field were saying, they were spraying the stuff on us all the time. We probably got more of an exposure than they did. And all we could say was, probably right, let's include them. You know, forward artillery bases, let's include them. And now it's gotten to the point where you have to draw the line somewhere. But the line for exposure for Asian orange includes even being up to 12 miles off the coast because of desalinated seawater that people were taking showers in or maybe drinking, who knows. But it's a challenge what we're trying to do. But it's a balance of veteran-centric policies where rather than saying, probably didn't hurt you, you probably weren't there that long, instead we say, you were there, chemical was there, we presume you were exposed. And if there's any evidence it might have hurt you, that's where the bar is. Because that's, those are our policies, it's not science. Those are our policies, our values, and our mission. And we have that in the VA, we don't have that in the broader world where we lean towards population health and the health of the environment. So it's been fascinating and essentially what we're trying to ask the veterans is find out from them, what'd you experience? You know, how do you think it's affected you? How you doing? And how can we help you? That's kind of our approach to this whole thing. And so we look at screening as step one in exposure-informed care. Find out what the veteran's concerned about. Find out where they were. Find out if they have risk. Get it onto their problem list and begin this process of exposure-informed care. Most important thing I learned in my OCMED training was really about the precautionary principle. I had this old, old guy who was one of my mentors, he's probably younger than I am now, but he was fascinated by it because I wrote a paper on this because I was so interested in it. But basically it's what we do when we don't have data. Do we lean towards the harmed population and the environment or do we lean away from it with our assumptions? Because really about it, we have some information, I can see Michael sitting here thinking, well, there's a lot of other information we can get about exposure risk. It's true. But at the same time, often the best we can do is to say we don't have exposure data at the individual level. So we're going to err on the way of caution. Imagine if we'd done that in the tobacco industry or opioids or whatever. If you started seeing, ooh, this might be causing a problem, just say, whoa, stop. Let's make sure we're not causing harm here. And that's kind of the precautionary principle. And in most of these cases, we don't have exposure data. So the presumptive approach essentially is if you were around the same place at the same time, we presume you're exposed. And if there's any evidence that exposure could have even contributed to even association, minimal but suggestive data studies, that's good enough for us. What we're trying to do is to build a, 85% of the care is done in primary care at the bottom. Then we need these step two providers that are kind of the local experts, and we're kind of putting that together, the home office and the registry examiners, and we have these deployment health champions. We're trying to build step two expertise, and then we have the step three level, like Joe's center and home office and the vet home program and so on. So what's exposure informed care? It's really, it's copied from the notion of trauma informed care, and I'm sure most of you know about that as clinicians. If psychological trauma can affect people's lives in many, many ways. It's not just like, oh, did you screen them for PTSD? Did it cause PTSD? Well, it may have contributed to PTSD, and we know from the ACEs study and trauma studies that it affects people in so many other ways. Physical health, mental health, you know, spiritual injuries, relational health, job, and vocational factors as well. So exposure informed care is similar. We always keep exposures in mind, try to factor them into the risk profile in these different ways, and try to make sure we keep a close eye on things. Maybe have a higher index of suspicion for certain testing, or a lower threshold for testing, and it will lead to more true surveillance and case finding down the road, but we're not there yet. So incorporating this information into the record, it's an ongoing process. Everyone's thinking about it. Everyone's talking about it. Everyone knows it's important. So a big part of it is just trust that we're building in our veterans, and it affects everything. Clinical care, research, education, training, policy, communication with veterans in the outside world as well. Last point. So we all know what social determinants of health are, and, you know, the way it's defined by CDC is it's the social environment. Well, at some point within the next decade for sure or two, we will be thinking always in terms of the physical environment as well. Physical environmental determinants of health. And living in the Northwest, were you there during the fires, water quality, air quality, soil contaminants, other sorts of individual activities, but also just the physical environment you've lived in as sort of what we do with an exposure history. And with the last question in the last session was something about how are we going to get better at predicting exposure. We're going to be able to monitor more closely more types of exposures in the environment and perhaps even at the individual level. So that's where we're hoping this goes, that there will be these physical environmental determinants of health as well. And we're already doing that in the VA, taking into account these things in a veteran's lifetime history. So there are some resources. And Joe is going to tell us now about another manifestation of this approach to care and uh. Thanks Steve. So it really is an honor to be here talking today with Steve. Steve is actually, I'm really a newbie. Steve has been in the VA for decades, whereas I joined the VA in August of last year after 30 years in the Army. So a lot of experience in exposure informed care from an Army perspective. And I'm certainly building up a portfolio with my time in the VA since August. So if you didn't know, Steve is actually the one that invented the term exposure informed care. So I think Dr. Hastings has really embraced it. Others have embraced it. And I think we're still evolving in terms of what exactly it means. And I think it's a great thing. And eventually we'll get there. But what I'm going to talk about is kind of how we're going to bridge the gap between primary care and what we do at the tertiary care level. So this is a slide actually from Dr. Barrett. So a lot of the approach, again, I think what we do in the VA, it really is a combination of the social and the physical determinants of care. We really want to like take into account kind of the entire, you know, what's going on with the veteran, both psychologically, physically, culturally, and a lot of that is what we do at the risk and at the set C, which I'm going to talk about. And if you don't do that, this is what the vets will report. They're going to be, you know, report frustration, pessimism, mistrust, and really trust is really what we want to do with the veterans. And by the way, I have about 25 minutes. So I should be able to cover everything. And as mentioned earlier, Dr. Rums' talk, the VA really does a good job in terms of educating our providers in terms of exposure-informed care. The risk and the sets, the set C, the risks and other providers within home, we all contribute to these different educational opportunities that's offered by the VA. So if you're in the VA, I really encourage you to take advantage of them, sign up for them. In fact, every week there seems to be something going on around noon on a Tuesday. So I really encourage you to sign up for those educational opportunities. And occasionally there are conferences, too, and I think next year hopefully we'll have another session at the beginning as a pre-course here at the AOHC. And by the way, I think this is my first talk at AOHC as a non-colonel or as a non-OcMed consultant for the Army. So thank you very much for the opportunity. So let me tell you about the risk. Again, the risk is a tertiary care center or a consultation center. There are three centers across the country. The first one was started in New Jersey back in the early 2000s, followed by D.C. and then followed by California. We all have the same mission. We provide basically three main services, clinical, research, and education. And we all want to deal with complex exposures, and I'll tell you about how we do that. And I think when we talk about our centers of excellence, we kind of take it at a new level in terms of really dealing with complex exposures for our veterans. I think what happened was, my understanding of the history was there was a great need for veterans saying, we need somewhere to look at our exposures at a very specific level, and that's how the New Jersey risk was developed. And again, the other centers followed, following essentially the same model. And what happened even after that, after the model was developed, which I'll talk about specifically, each center actually has developed a center of excellence. And I'm not going to talk about the other centers specifically, except to say that New Jersey focuses on airborne hazards and open burn pit kind of exposures, and the California risk has a female women's centric center of excellence, and we have recently developed a center of excellence on complex emerging exposures, or complex exposure threats at the D.C. risk, within the D.C. risk. And what this means is that as a center of excellence, obviously we're going to focus on these specific areas, and New Jersey actually received their center of excellence designation a couple years ago, and the women's center in California received theirs just actually a couple weeks to months ago, and we are in the process in D.C. of really just, we're just waiting on the VHA undersecretary to give his final approval before we're designated a center of excellence. And as a center of excellence, you know, we're not actually designated like a, you know, we're not automatically funded, but I think what it does is really opens the door for the home, the health outcomes, you know, military exposures, who we fall under, to kind of start funding us to our staffing needs and our staffing levels, and to our other kind of needs as a center to kind of support our specific missions. So it's not like a linear thing where, you know, we're designated and like a, you know, funding opens up. It's really kind of more of a process that's really not as linear as you would think. But I think once we get that designation, then we may have, be able to hire, or we should be on the, you know, in that direction of, you know, hiring and really being fully functional as a center of excellence. So again, the CETC, the Complex Exposure Threat Center, we're a subcenter within the D.C. RISC, and we fall under HOME. And our mission, really what distinguishes us from really the other kind of types of exposure-informed care is our expert care, and I'll talk about the clinical process, within our research, within our center of excellence. And of course, our ultimate goal is to make the lives of our veterans better, and I'll show you how, I'll kind of describe how we do that. I already talked about our center of excellence and where we're at, and I'll talk about kind of our process, which really describes our, you know, what's our clinical expertise. And I'll touch really briefly about our research, because, you know, it's really, they have a lot of initiatives that we just don't have the time to get into those specifics. But the bottom line is, we really don't want to duplicate what's going on in other parts of HOME. For example, they have experts in toxicology, they have epidemiologists, they have, you know, other experts in education. But we do want to add to what they're doing, and we want to, again, you know, provide the clinical expertise to kind of couple with what they're doing, and also the research capabilities as kind of tools for the VA secretaries and for the VA to serve our veterans. So these are our five lines of efforts. As I mentioned before, all the risks have clinical evaluations, and I'll talk about that process in a bit. Again, the research is kind of unique to each risk in the three regions. And by the way, you know, we all cover three regions, so the consults are supposed to come within the region to that risk that covers that area. But, you know, we do encourage you that if there are certain cohorts that fall under the set C, that if other, you know, if one of the other risk centers get a consult that really fall under this, they will send us those consults, and I'll talk about that in a second. And finally, education. You know, every center kind of focuses on kind of education really related to their percent of excellence, and I'll talk about that in a bit. What's a little unique in terms of what we do at the set C is the health threat detection and exposure cohort management, which I'll talk about next. So what the health threat detection is, it's a line of efforts, but what we want to do is we want to kind of look over the horizon. What is the next exposure threat that's going to affect our active duty military and later on as they become veterans? So obviously we're looking at different things, novel weapons systems, et cetera, as you can see in that picture there. And what we're trying to do is we're trying to team up with a center out in the University of Maryland College Park called ARLIS, and they have a SCIF where we can actually go there and look at, you know, information that's sensitive and, again, kind of look at things not just from a medical perspective, but really from an operational perspective and say, okay, what's going on out there which may be the next Havana syndrome, the next, you know, anomalous health incidents? And let's start kind of studying that and see what we can do to anticipate what's going to happen in the future. We've also gone to meetings with the DOD where we look at, you know, what's going on with Havana syndrome, and we sit down with them and kind of explore kind of what is DOD doing, what is NECO doing at Walter Reed, and kind of explore, you know, what we can do for our veterans at the RISC and at the CETC. In terms of cohort management, really cohorts is what defines the CETC. As I said before, all the RISCs are interested in complex exposures, but right now the CETC is really focused on two main cohorts. Number one, the Explosive Ordnance Disposal Personnel. As you can imagine, these are personnel across the services that have exposures not just in combat, not just when they're deployed, but from the time they start their training, as they train up to be, and kind of what they do every day, not just in, again, not just in deployments, but also in a garrison setting. And certainly in the deployments, we have EOD veterans that report, like, blast injuries that are just amazing when you go through their exposure history, and you're sometimes amazed that they aren't, you know, worse off with more medical issues. The other cohort, as I mentioned earlier, is AHI, or the Anomalous Health Incidents, or Havana Syndrome. Obviously, you know, it's not just veterans or military that are exposed. There are diplomats that aren't military, but certainly what we want to take care of is whether they're military, whether they're veterans that may have gone to service with the embassies, we want to see them also, or if they might have experienced these type of incidents while they were on active duty. So again, if one or the other risk gets a consult for either an EOD professional, with a veteran, or an AHI, we want them to send that to the DC risk and become a Set C patient. And for now, those are our main cohorts of interest, just not to say that we may develop, not develop other cohorts, and certainly the secretary of the VA, or the undersecretary of the VHA may turn to the Set C and say, hey, this is the next issue that we want you to look at, whether, you know, evaluate them clinically, or, you know, apply your research protocols to them. Again, we're the tool for the VA to do that. In addition to that, there are some historical cohorts that we are in the process of taking over. They are the Chemical Warfare Agents, as well as Carmela Lee, and fortunately, when I was on active duty, I was actually involved with both these cohorts when I was at the National Guard Bureau, and while at the Office of the Surgeon General. So the idea is that, you know, what is the long-term management of these cohorts? Obviously, we're going to still work hand-in-hand with the DOD, but we're going to, at least eventually in the future, once we get the full staffing to do this, also support that long-term management of those cohorts, in conjunction with epidemiology and other parts of the VA, as well. This is our clinical process, and the clinical process for the Set C is the same as the risk. Essentially, what determines them as being a Set C patient versus risk is whether or not they're part of those cohorts, whether they're EOD or a part of the EHI. So far, we've only seen one EHI patient, and we're in the process of developing a protocol clinically for the EHI patients, but what the patients do is, you know, we go through our process of screening consults that come to our risk. If we decide that they are a comprehensive or a comp patient, then we bring them to the risk for a whole week, and during that week, they get clinical evaluations, such as neuropsychiatric testing. From the medical side, we do a full history, and if necessary, a physical exam. We do a full exposure history, so we can spend up to, you know, one to three hours going through their exposure history, which, again, primary care doesn't have the time to do that, but we will spend the time thoroughly going through every single exposure that they are concerned about, and document that, and trying to determine whether or not there's a link between that and some of their medical issues. But they see social workers. They see a social worker. They get health coaching. Again, a weak process going through this, which I don't think you're going to see anywhere else within the VA or in the DOD. Generally speaking, the veterans are ecstatic by the process. They appreciate the time being spent with going through their history. I think the key is also, we're very honest with them. We understand the limitations of what's in ILR, what's in their clinical history. A lot of the clinical history, exposure history, it has to be, it's subjective. It's not, you know, we don't have exposure monitoring in most cases, so history is really the key. And really upfront with them, it's like, you know, yeah, you know, we think that this might be related or not, and certainly we understand the presumptions, and we give them some advice about what they might fall under as a presumption as well. So anyway, that's a process. And the ones that don't go into the comprehensive process, that's weak. We actually do an e-consult where we, again, address the issues. We send it back to the provider with the idea that the provider will go back and talk to the veteran about that. Even though we do what we do, it still goes back to primary care, and it's still up to the primary care physician to take our recommendations, talk with the veteran. Obviously we advise the veteran upfront, but in terms of the clinical care, it still falls on the primary care to implement that. And I'll go over some of the limitations of that in a bit about, you know, the good and bad about the risk, what the risk in the CETC does. In terms of the clinical research, there's actually three cores. I'm not going to go into the specifics of those different types of efforts within the CETC, but I want to mention there's a really exciting effort to look at exposures, you know, from an allostatic load model, you know, kind of the ideas that, you know, think about TBI and those personnel that have sub-concussive TBI. And what about the ones that have, like, multiple, hundreds of them? Is there at some point a threshold reached where, which may trigger something more that may contribute to their other medical problems? So again, we want to approach this from kind of a basic science level and look at that, and we're partnering with the University of Maryland College Park to look at that physiologic model and put the veterans through that scientific process to investigate that. But again, there are some other research protocols that our research team is doing, and they're really doing some pretty amazing stuff from a scientific and research side of perspective. And I did not mention education yet, and so I somehow the slide slipped out, but obviously a big key to what we do is educating the veteran about their medical issues, how they relate to exposures, as well as educating the providers that treat them at the primary care level about, you know, what we have to, what we saw from our comprehensive process, our review of the consult. But in addition, we also want to provide education to trainees, you know, whether they're fellows, residents, medical students, we're in the process of developing opportunities for those trainees to come to the risk or the set C. We currently have neuropsychiatric fellows within the risk and the set C, and that's something that we, I think we have them rotate every couple of years through our program. And what this slide, and sorry, this slide wasn't really related to that, but what this slide is talking about is kind of our capabilities as a set C. So we can potentially, we haven't had to do it yet, respond quickly or rapidly to the secretary of the VA, the undersecretary of the VHA saying, hey, you know, CETC, we want you to look at this group, this cohort of exposure, of exposed veterans, we want you to apply your clinical program or your research protocols to this cohort and give us some answers to whatever that question is. But of course, you know, we are, our standard process is not going to be that rapid response but our normal process through the CETC. Our quick accomplishments, Brady talked about our Center of Excellence application, hopefully that will come through soon. You know, one of our big initiatives is the V-MODE. If you haven't heard what the V-MODE is, I'm not going to go through the acronym, but it's really our effort, and Dr. Barrett is back there, he really kind of led the effort and he had a poster out there earlier this week, but it's our effort to try to develop a comprehensive questionnaire that really goes through somebody's exposure history, not just their military history but their pre-military as well as their post-military history to, again, look at the full and comprehensive exposure history of our veterans. We're in a kind of a, we've done a version one, we're kind of in the process of a version two, and it's extremely exciting and it's extremely complex, but I think from what I've seen so far, once we come up with a final product, it'll be the best thing out there in terms of the subjective exposure questionnaire. And finally, we recruited more staff, I think Dr. Fisher was here, I think I saw him earlier, I was recruited within the past year after coming straight out of the Army, and we have to hire more staff to support all our different lines of effort into the future. It really is a great team, I really appreciate the support from Dr. Barrett, Dr. Reinhardt, who's our clinical director, he's really awesome, and I think everybody at the risk team is really, and the CETSE team are very happy with what we do, and if you're interested in kind of working in this kind of medicine in the future, please talk to me because I know there are opportunities and other risks that may be available either now or soon. So I do want to talk about, you know, how to do a good consult to the risk, obviously, you know, think about what Steve talked about earlier, you know, it's going through this toxic exposure screening, I think the challenge is there's just not enough time within most of the primary care to do a really thorough workup, so that's why I think there's secondary providers that Steve talked about that are also there, and certainly, you know, again, if it's a very complex case, we want you to send it to the risk, but we also want to make sure that it's a good consult as well. So you know, the other thing is just make sure you do a complete workup. I think one of the frustrations we've seen is that, you know, they still have a pending neurology consult, they have a pending derm consult, I think it really helps to kind of answer those questions, because they're still pending, you know, these consults and other specialists that we don't, you know, that we really need as part of our assessment, it kind of either may ask you to, well, maybe send the consult to us after these are done, and then it would like help us to really do more of a complete consult. In addition, there are certain tests that don't need to go through us in order to get assessed, for example, depleted uranium. As Dr. McDermott said earlier, you know, you can do a mail-in test to the Baltimore VA, it does not have to go through us. Also Asian orange presumptions, you know, if there are presumptions in place, I think it really is helpful to understand the presumptions, and while we can help, we're happy to kind of go through that with a veteran. I think if you already understand and know those presumptions, then that's one way you can help the veteran right away, you know. So again, we're happy to assist with that, but I think if you can help them to connect with the VBA and say, hey, these presumptions are part of the benefits I deserve, then it should happen at the primary care level and not necessarily have to come to us. Another thing you need to know is a campylogean is a completely separate clinical process, you know, so if a campylogean consult comes up, we're going to refer them to the campylogean process. I'm actually a campylogean provider, and we review the charts when it goes into, it's actually a separate application, so just be aware that, you know, they really don't need to come to the risk because of that process is in place. We're happy to redirect that, but it's kind of a, we're really kind of a bump in the road into them getting to that process, so really understand and inject them into that process. And you can probably go through your environmental, you know, care coordinator at your VA as well. And one final thing is garrison exposures are typically not addressed by the Set C of the risks, so while we don't acknowledge that, you know, somebody at Fort Ward may not, you know, could be exposed to, you know, trichloroethylene or at any other site, the fact of the matter the risks are really designed and set up for war-related, you know, illnesses and injuries. So if they're not in a, you know, deployed veteran, typically we will not see them. The exception I will say is that if you have an EOD veteran that did not deploy, which I would say is pretty rare, because most of them get deployed a lot, but if you do happen to see an EOD veteran that was not deployed, we want to see them because we really need that comparison population, and it's possible that as we get other cohorts of interest that we want to see the Set C, there may be some exceptions where, you know, deployment may not be the issue. So just be aware that deployment is currently a requirement to be accepted as a risk consult. And as I mentioned before, you know, if we get a complex airborne hazard case that's kind of beyond our capabilities, we're going to send it out to New Jersey for them to do, to assess, you know, with their expertise and their center of excellence. Just as if they, if anybody, if the other risks get an EOD patient, the EOD veteran, or an AHI veteran, they're going to send it to us. But the risk and the Set C consults are really one and the same. So if you want to get somebody to the Set C, send it to the risk that's in your region, and that consult will come to the risk consultation process to us in Washington, D.C. So kind of in conclusion, I think we're still in the process throughout the VA of collectively doing this veteran exposed, exposure informed care. I do think that some of the challenges between the risk and primary care is that when we do get a risk consult or a Set C consult, we tend to give tons of recommendations to the point that it's sometimes overwhelming to the primary care. So we've been trying, we've been tried, or we're working on really prioritizing those so that the primary care provider can really focus on maybe the top five, but we also want to be comprehensive in what we recommend to both the veteran and to the primary care. So it really is a balance, and certainly if you've given a consult to the risk and you've had that challenge, please talk to us, let us know how we might be able to streamline that better and better help you as a primary care provider. Again, there are secondary providers within VA vet home, I know that Steve has been involved with kind of bridging that gap between the primary care and the risk. I think some of the challenges with the risk is our process is so intensive that we can only see one patient a week, so our throughput is really kind of low. It's possible that as we get more staffing at the Set C in D.C. that we can at least double that throughput, but the fact of the matter is our process is very intense, it's very time consuming, and so I'm not sure that throughput is going to get that much better at this point in time. But I think that's kind of what it's meant to do, and it's meant to be comprehensive. And also we want to focus on research as well, so that's kind of the challenges of the risk in the Set C. And I'm kind of open about how we can bridge those gaps better, because I don't have any solutions about primary care doing everything or us, you know, obviously being able to do I have a high output either, so there's probably some solutions in between primary care and the risk consults that need to be developed in the future. And I'm open to what they are, and I'm sure Steve maybe has some ideas as well, or others. Please let us know, and I think we as the enterprise can probably make that better and support our veterans even better than what we're doing now. I think, so here's some resources, and I think we have 10 minutes to answer any questions, so Steve, you want to come up here? And there's a microphone up front, you have to turn it on, so please turn it on. There you are. We're going to try to get a PDF of our slides in case you want those handouts, so I'll work on that. I thought I had done that previously, but I don't think it's, it actually happened for some reason. So please come up for any questions, and go to the mic, because this is being recorded. So thank you. Before our first question, one point I wanted to make was, leading the charge of this idea of exposure-informed care, in my opinion, will be occupational and environmental medicine linked with point-of-contact primary care. Family docs, docs in the community, I think it's another thing in our profession we can do that's going to really support individuals that have health-related, or exposure-related health concerns. So I think this is going to be really important for OEM as well. Thank you. Good afternoon, everybody. Thanks, Dr. Ortiz. I am Erlinda Singaraja. I am an NP at the VA in Phoenix, appreciate your service. And to all servicemen and women, I am an environmental registry clinician, as well as an OEM clinician, combined role, up until the PACT Act, which expanded. My question to you is, because I've met a lot of our veterans who've done such a great job informing us, OEM providers, about the veteran care, exposure care to our veterans. However, what I find what a gap is, is that we have not reached out to our non-primary care providers, nor our specialists. So what's the plan moving forward? Because I've seen a lot of our veterans who have seen specialists who are not informed of a presumptive list of conditions from agent or an exposure, and that is a missed opportunity for them to be able to receive the benefits that's duly for them. I'll start off really quickly first, Steve, and I'll give you the opportunity if you don't mind. I think it's a good point. I think within each VA medical center, it may be even a different solution. I know within our VA medical center, I know Dr. Barrett talks with the other providers, like for example, we actually have a care clinic that does exposure informed care, kind of hip to hip with a pulmonologist there. So I think that's one good model, but it's also a model of one within the VA, so it's not necessarily a model that exists elsewhere. But I do think that there's opportunities either from the risks or within each VA medical center, or even across regions where we can talk to providers that aren't OCMED, but are dermatologists, probably need to focus on pulmonologists, maybe other specialists like hematology, oncology, but certainly we need to educate them as well in addition to the primary care providers. I think how to do that, there is a education center in the New Jersey risk that may help with that. But again, I'm new to the VA, I don't know what they've done to kind of bridge that gap, but it's a good point and a good, so Steve. What was your name again? Perla? Yeah. We're doing an enormous amount of education of both primary care providers and specialty providers through the test screening. Are you a navigator or no? I am, as well as TES. Yes. Okay, good. Navigator, we have a special cadre now of individuals that support the toxic exposure screening in our centers are called toxic TES navigators, and it's awesome. So there's a pulmonary echo, there's a hematology echo, there's a cardio echo educational series going on. You can contact me and we can hook you up with that. And what percentage of our toxic exposure screening do you suppose is happening in primary care? Just guess. 100%. Close. 90%. But we are pushing what we're calling the big seven, which are specialty, particularly pulmonary hematology, cardiology, urology, the extended care geriatrics as well, and mental health, because that's another place. So we're trying, you get a hold of me, there are some nice educational programs, and also through the test screening group, we do educational work with, if you have groups that want us to do a talk for them, we'll be happy to present to their grand rounds or whatever. We have a special presentation. If you're a pulmonologist, this is what you should keep in mind. If you're a hematologist, oncologist, this is what you should keep in mind, and so on. Yeah. Yeah. My question builds off is how do you reach out to the community outside of the VA? Oh, I'm sorry. Oh, outside of the VA. Oh, okay. Because I think it does depend on the VA, but not outside of the VA. Most important thing you can do by far is to get the word out that anybody here that's not a VA provider, you're seeing veterans every day, if you're seeing adults. Find out if the folks you're seeing are veterans. If they are, one of the first things you can think of, by the way, did you know that they're now screening all enrolled veterans? If you're not enrolled, get enrolled, get screened. If you'd like to be screened, call your local VA, ask for the TES, Toxic Exposure Screening Navigator, and they'll get you screened. Because I went to ACP, and all these pulmonologists and hematologists were coming up to me and saying, hey, we heard the VA's doing this, and so we had information sheets. Here's what you do. Call your local VA. Say your veteran wants to get screened. Get them screened, and we'll help you out. Really great stuff. Is this working? Yeah, they turned it on. It's great stuff that you're doing. Yeah. It should be a switch there. It's turned on now? Yeah. Very good. So, I'm going to start using exposure-informed care term. I love that term. And what I'm wondering is about the civilian employees that are working alongside the military personnel and getting the same exposures. So, I'm wondering if you could talk a little bit about that, because I think it's a really good question. Yeah. So, the VA can take care of them, but there should certainly be a parallel process. So, anybody that's taking care of contractors, for example, that are deployed to these same places, I think they should look at our model. Hey, Steve. Oh, I'm sorry. Yeah, I think they should look at our model, because I think they should be doing something similar. VA, if they're not veterans, we cannot help them, but we can help them by saying, hey, maybe your providers can do this. Yeah, that'd be good. So, same question. about training non-military providers to be aware and give them tools? I think a lot of cases that becomes a workers' compensation issue too, so it, and then when you get into contractors, it becomes even more complex as well. So. If they're a veteran, we can take care of them. Yeah. And then it becomes, yeah, yeah, exactly. Yeah. Essentially, it's an occupational exposure after you left the military, and you may not get benefits for service connection for the exposure, but you certainly can get healthcare. Yeah, that's a key, that presumption is only if there's a connection within, you know. But it may be complicated because they could be deploying as a contractor around the same time. So then, yeah. But again, I think the presumption would probably favor the deployed as an active duty or as a soldier or veteran, so. And again, first thing, if you're not in the VA system, every adult person you see, you should ask if they've served. And if they've served, keep these things in mind. One of the resources on the slide was, there's a chapter in Harrison's now called Healthcare for Military Veterans. And it kind of talks about how veterans' healthcare is different from healthcare in general for a number of reasons, and this is one of them. So. I think Eric wanted to, yeah, Dr. Shippen. Everyone eligible for the PACT Act is eligible for VA healthcare. They can enroll. And as far as educating the whole U.S. healthcare system about veterans, I think the veteran can make a choice. It's, tell them to go, you know, be eligible for the PACT Act is pretty much automatic enrollment. If you have a terror claim, you can enroll and be in healthcare. So, I say choose VA because we are becoming the experts in this, too. And we just certainly can educate the whole U.S. healthcare system on this stuff. I mean, we can try. We can make efforts, but that's a Herbulean task. Sixty percent of veterans get co-managed care. They get some of their care in the community, some of their care from the VA. We love that. We love to partner and care with, we want veterans to get whatever care they want, wherever they want it. We also want them to know what's available to them through the VA. Hi. I'm Eric Wood. I direct the residency training program in Salt Lake City, University of Utah. And remotely in the past, our residents were able to get trained in the comp and pen system and some of the toxic exposures, but we haven't been able to do that for a number of years. And I'm wondering what opportunities are available for the next generation to train? And, you know, these are remarkable opportunities for learning about exposure-related diseases. I have residents and fellows with me all the time. And I think, and I used to have them do C&P, but now we have an environmental contaminants clinic where we do registry exams and we also do test screening and that sort of thing. I agree. And we have all of our internal medicine residents also spend time in the clinic. It doesn't take that much time. Even three, four clinic sessions, at least they're thinking about these things. So if there's any way you can do it, it is still being done in many places, and this step two care is a place where there should be, in the future, there will be local experts and it may be the registry clinicians, it may be OEM docs, it may be test navigators, but they would be a good teaching source for residents for sure. We need, all residents should be learning about this stuff. Any other questions or comments? We really appreciate your being here at the end of a long day. I do think and hope that there is relevance to what we're talking about today for you in your practice, wherever your practice may be. And Eric was saying we can't educate the whole country, but the truth is taking care of veterans is a national responsibility. It's not just VA. We want to be the best and do our very best, and we also want to be the best partners and educators of folks that aren't in the VA system. Yeah. All right. We'll wait around for a couple minutes a bit, you know, but obviously it's time for the next session. So if you want to ask more questions, come on up, please. Yeah. And thanks for attending, and thanks for the work you do.

PACT Act

Veterans Affairs system

Exposure-informed care

Military veterans

Presumptive conditions

Agent Orange

Burn Pits

Gulf War illnesses

Camp Lejeune contamination

Community outreach