Threats to Veterans’ Rights: The Impact of CARA & Violence Flags on Patients

"However, this directive was introduced years after CARA’s implementation, raising concerns about the interim period when veterans’ rights may not have been adequately protected."

For decades, veterans have faced significant challenges in accessing fair and equitable healthcare within the Veterans Health Administration (VHA). Programs designed to manage disruptive behavior and address the opioid crisis, such as the Comprehensive Addiction and Recovery Act (CARA) and the Prevention and Management of Disruptive Behavior (PMDB) program, have inadvertently posed threats to veterans’ rights. This article explores the complexities and unintended consequences of these programs, highlighting the need for a balanced approach that protects veterans’ rights while ensuring safety and quality care.

The Comprehensive Addiction and Recovery Act (CARA)

Enacted in 2016, CARA was a landmark legislation aimed at addressing the opioid crisis through prevention, treatment, recovery, and law enforcement1. While its intentions were noble, the implementation of CARA has raised concerns about its impact on veterans, particularly those managing chronic pain.

Screening and Restrictions: CARA includes provisions for managing opioid prescriptions and implementing drug management programs for at-risk beneficiaries2. This has led to stricter controls on opioid access, which can affect veterans who rely on these medications for pain management. Additionally, CARA allows for the screening of complaints related to access issues under these drug management programs2. While intended for quality assessment, this can be perceived as limiting veterans’ ability to voice concerns about their care.

The Prevention and Management of Disruptive Behavior (PMDB) Program

The PMDB program within the VHA aims to address and manage disruptive behavior among patients. As part of this program, Patient Record Flags (PRFs) are used to alert medical staff about patients whose behavior may pose a threat to safety or compromise the delivery of quality healthcare3.

Disproportionate Impact on Pain Patients: Reports indicate that many patients receiving behavioral flags were those in pain3. This suggests that the reduction in opioid prescriptions might be contributing to increased frustration and perceived disruptive behavior among patients struggling with pain management. The use of PRFs, while intended to ensure safety, can lead to stigmatization and inadequate care for these patients.

Transparency and Appeal: The Veterans Affairs Office of Inspector General (OIG) has identified issues with informing patients about PRFs and their right to appeal3. This lack of transparency can infringe on veterans’ rights to be informed and to challenge decisions affecting their care.

Veterans’ Rights Under 38 CFR 17.33

38 CFR 17.33 outlines the rights of patients within the VA medical care system, including the right to be treated with dignity, to receive appropriate privacy, and to have reasonable protection from harm4. These rights are fundamental and should be upheld in all circumstances. However, the implementation of programs like CARA and PMDB has sometimes conflicted with these rights.

By what authority does the VA have to limit 38 CFR 17.33 rights?

The Veterans Health Administration (VHA) has specific authority to limit certain rights under 38 CFR 17.33 in particular circumstances, primarily to ensure safety and the effective delivery of healthcare. Here are some key points:

1. General Rights: Under 38 CFR 17.33, veterans have the right to be treated with dignity, receive appropriate privacy, and have reasonable protection from harm1. They also have the right to the least restrictive conditions necessary to achieve treatment purposes1.
2. Restrictions: Rights can be restricted under certain conditions:
3. Documentation and Communication: Any restrictions must be documented and communicated to the patient, including providing a process for appeal3.
4. Appeals and Advocacy: Veterans have the right to appeal decisions and seek assistance from patient advocates to ensure their rights are respected and any restrictions are justified and necessary1.

Behavioral Restrictions: Under 38 CFR 17.107, the VA can restrict the time, place, and manner of care provided to a patient if their behavior jeopardizes the safety of others or interferes with the delivery of care5. While these restrictions are intended to ensure safety, they must be narrowly tailored, documented, and communicated to the patient, including providing a process for appeal5.

The Role of the VHA Patient Advocacy Program

The VHA Patient Advocacy Program, formalized in VHA DIRECTIVE 1003.04, aims to ensure that veterans’ complaints and concerns are addressed proactively and transparently6. However, this directive was introduced years after CARA’s implementation, raising concerns about the interim period when veterans’ rights may not have been adequately protected.

Concerns and Weaknesses Identified by OIG

The Veterans Affairs Office of Inspector General (OIG) has identified several concerns related to the management of disruptive behavior and the impact on veteran patients’ rights:

• Patient Record Flags (PRFs): There were issues with informing patients about PRFs and their right to appeal2. This lack of transparency can infringe on veterans’ rights to be informed and to challenge decisions affecting their care.
• Behavioral Restrictions: Facilities did not consistently inform patients about Orders of Behavioral Restriction, impacting their understanding and participation in their treatment plans2.
• Training and Data Collection: There were weaknesses in training for newly hired employees and in data collection and analysis of disruptive behavior incidents24.

Balancing CARA and Veterans’ Rights

While CARA aims to address the opioid crisis and improve care quality, it is crucial to balance these goals with the protection of veterans’ rights. The introduction of the VHA Patient Advocacy Program is a step towards ensuring that veterans’ complaints and concerns are addressed fairly and transparently.

Conclusion

The implementation of CARA and the PMDB program has highlighted the failure of the Veterans Healthcare Administration to reach the delicate balance between ensuring safety and protecting veterans’ rights. While these programs aim to address critical issues like the opioid crisis and disruptive behavior, they have also posed significant challenges for veterans, particularly those managing chronic pain. Ensuring transparency, providing adequate training, and upholding veterans’ rights are essential steps in addressing these challenges and ensuring that veterans receive the fair and equitable care they deserve

1: Comprehensive Addiction and Recovery Act (CARA) 2: Section 1860D-42 of the Social Security Act 3: Veterans Affairs Office of Inspector General Reports 4: 38 CFR 17.33 - Rights of Patients 5: 38 CFR 17.107 - Management of Disruptive Behavior 6: VHA DIRECTIVE 1003.04 - Patient Advocacy Program