3.2. Amputee Clinic Teams
(1) Amputee Clinic Teams provide treatment to amputee veterans by:
(a) Examining VA beneficiaries requesting or requiring major prosthetic appliances.
(b) Determining that an appliance is no longer serviceable and needs to be replaced.
(c) Conducting closely-controlled clinical evaluations on new techniques and componentry under policies and procedures announced by the Chief Consultant, Prosthetic and Sensory Aids Service (P&SAS) Strategic Healthcare Group (SHG).
(d) Inspecting and evaluating new prostheses.
(e) Conducting follow-up examinations and treatments of beneficiaries who have received prescriptions through the clinic team.
(2) Amputee Clinic Teams are established in selected field facilities under the supervision of a physician who is knowledgeable about prosthetics and physical disabilities.
(1) The Chairperson, Amputee Clinic Team, must be a physician with a specialty in Physical Medicine and Rehabilitation, Orthopedic Surgery, or Vascular Surgery. The Chairperson, charged with the responsibility for the clinical treatment of all patients referred to the team, normally serves on an attending basis and is appointed by the Chief of Staff. NOTE: Exceptions to the appointment of a physician chairman requires the approval of the Chief Consultant, Rehabilitation Strategic Healthcare Group.
(2) The Chief, P&SAS, at a facility in which an Amputee Clinic Team is located, is responsible for the overall administrative management of the team. The prosthetic manager serves as coordinator, technical advisor, and the Chief, P&SAS's designee in inspecting and evaluating all appliances prescribed by the Clinic.
(3) The Amputee Clinic Team is responsible for orienting and training physicians, medical residents, and other clinical specialists who have an interest in prosthetics and/or will be working with amputee patients.
(1) The Amputee Clinic Team is comprised of an interdisciplinary group of professional providers with combined expertise to carry out all necessary and appropriate functions of the team as specified in subparagraph 2f. The team may remain flexible and be adjusted to meet local needs. In addition to the physician Chair and the Chief, P&SAS, members may include a podiatrist, physical therapist, occupational therapist, kinesiotherapist, the Preservation Amputation Care and Treatment (PACT) coordinator, a prosthetist (either VA or commercial), and other medical specialists as required. The physician directing the clinic must have appropriate medical training and a minimum of 2-years experience as a collaborative team member providing amputee services in a comprehensive amputee program. In lieu of 2-years experience, continuing education and mentorship may be used to gain this experience. Local prosthetic VA contract providers may be invited to attend the clinic. It is recommended that three to five providers be awarded contracts depending on the geographic area of coverage and volume of workload. If a commercial provider has fabricated a limb, the commercial provider may be invited to present the patient with the new prosthesis for evaluation and delivery to the clinic. NOTE: Every effort will be made to limit the size of the clinic team to a maximum of eight people.
(2) All assignments of VA personnel to Amputee Clinic Teams must be based on professional expertise, and are considered to be part of the regular assignment of clinical duties.
(1) Beneficiaries requiring artificial limbs are to be referred to the nearest Amputee Clinic Team when they are:
(a) Residing within the Prosthetic Primary Service Area (PSA) of the facility in which the clinic team is located.
(b) Residing within the PSA of another VA facility, which does not have an Amputee Clinic Team, or has been unable to resolve the patient's prosthetic problem.
(c) Determined to be a good candidate for a special (microprocessor knee units or other state of the art designs) or experimental type appliance which may only be prescribed by the team.
(2) Hospitalized or domiciled beneficiaries may be referred to Amputee Clinic Teams at other facilities, after appropriate arrangements have been made with the prosthetic representative of the facility in which the team is located. In such cases, a brief review of the beneficiary's problem, the local medical recommendation, and the objective expected to be accomplished must be provided to the amputee clinic where the beneficiary is to receive care and treatment.
e. Scheduling of Appointments and Preparation of Records
(1) The Prosthetic Representative of each Amputee Clinic Team arranges appointments for veterans to appear before the Clinic team. An appointment management entry must be established for each patient scheduled with the Amputee Clinic.
(2) Field facilities referring patients to the Clinic team must request appointments by use of electronic consults, or VA Form 10-2529-3, Request and/or Receipt for Prosthetic Appliances or Services.
f. Conduct of Amputee Clinic Team Meetings
(1) The patient must be treated with courtesy, respect, and empathy. The patient's personal preferences are to be solicited and considered before a final decision is made.
(2) Evaluation. Evaluations must be performed by professionals with the clinical expertise appropriate to the examination performed. The evaluation of each amputee patient needs to include, but not be limited to:
(a) Patient's current medical status;
(c) Date of amputation;
(d) Reason for amputation;
(e) Current weight;
(f) Current functional status and level of activity;
(g) Problems with the current prosthesis;
(h) History of prosthetic use;
(i) Reason for attending amputee clinic;
(j) Pertinent medical findings;
(k) Full physical examination of patient's residual and contralateral limb for strength, ROM, and sensation; and
(l) Gait with the current prosthesis.
(3) Each beneficiary must be carefully examined in a private room by the entire clinic team in order to assess the patient's needs. If a new or replacement prosthesis is indicated, the advantages of new technology are to be fully explained to the patient. However, if a patient has worn or used a particular type of appliance for several years without difficulty, and wishes to have an identical replacement, the patient's wishes are to be honored, unless there are definite medical contraindications.
(a) A new prosthetic prescription for the lower extremity prosthesis includes: type and shape of socket, type of suspension, knee component (TFA), foot and/or ankle components, endoskeletal versus exoskeletal.
(b) The new prosthetic prescription for an upper extremity prosthesis includes: type and shape of socket, body powered and/or myoelectric, suspension system, elbow component (THA), terminal device.
(4) In amputee evaluations, the medical findings and recommendations of the clinic team, with the specific component prescription for an artificial limb or major repair, must be included in the patient's Consolidated Health Record (CHR).
(5) If, prior to prescription of the prosthesis, additional treatment is indicated, the provision of the prosthetic limb will be deferred pending treatment outcome. If this is a first prosthesis, gait deviations or deviations in functional ADL's are significant. If significant changes are being made to the limb prescription, then prosthetic training by physical therapy, occupational therapy, and/or kinesiotherapy must be offered to the patient.
(6) Follow-up examinations must be scheduled, as needed, during the initial prosthetic fitting.
NOTE: It is recommended that after the definitive fitting, evaluations be scheduled annually, or more frequently if clinically indicated.
g. Action Following a Meeting of Amputee Clinic Team.
When the meeting of the Amputee Clinic Team is adjourned, the prosthetic representative is responsible for the following actions:
(1) Upon receipt of the prescription and contractor selection, the veteran must be provided specific instructions regarding travel, delivery, training, and follow-up. When pricing for the prescribed limb is not determined in the clinic, VA Form Letter (FL) 10-90 (ADP), Request for Firm to Submit Estimated Cost of Prosthetic Appliance, or a contractor's letterhead quote is necessary before procurement can be completed.
(2) In the event that a beneficiary fails to appear for a scheduled appointment without contacting the clinic coordinator, the referring facility must be advised that the appointment was not kept and that a future appointment must be scheduled as though it were an original request.
(3) In the case of beneficiaries referred from other field facilities and examined by the clinic team, a Standard Form (SF) 509, Medical Record ÔÇô Progress Note, must be prepared, in duplicate, and the original immediately forwarded to the facility from which the beneficiary was referred. The remaining copy must be retained for the clinic team file.
NOTE: Appliances or repairs prescribed by the clinic team must be obtained, inspected, evaluated and delivered in accordance with procedures outlined in this manual.