Veterinary care for all

"We are writing the textbook here," said Dr. Michael Blackwell, director of the Program for Pet Health Equity at the University of Tennessee-Knoxville. "We are writing the book on what it means to improve access to veterinary care." That book puts veterinarians, animal welfare advocates, and social workers at the forefront, working together, to find ways to provide veterinary care to underserved families.

Veterinary care access was the central topic during the first Access to Veterinary Care Symposium, hosted by the PPHE, June 28-29 in Knoxville, Tennessee.

Over 100 attendees from across the U.S. and Canada came together to discuss and debate how to care for the large number of animals owned by families that cannot afford veterinary care. The event focused on recommendations outlined in "Access to Veterinary Care: Barriers, Current Practices, and Public Policy," a report released by the PPHE in December 2018. Much of the discussion centered around the use of a subsidized veterinary care program called AlignCare that would provide incremental veterinary care, facilitate community-based funding, and engage social service agencies and social workers (see story).

"We have a mission to improve access to veterinary care," Dr. Blackwell said during the event. "It is a collective effort with a vision of a better society and a future where all pets have the access they need."

According to research from the report, an estimated 29 million cats and dogs belong to families that rely on food stamps; it is this group that is the target demographic of AlignCare. Food stamps cannot be used to pay for pet-related expenses such as dog or cat food.

The report also highlighted several areas where pet owners face hurdles in obtaining care for their pets, including a lack of transportation, no knowledge of where a veterinary facility is, and no equipment, such as crates or leashes, to move an animal. However, the main reason for not being able to obtain care, according to respondents, was financial constraints.

The symposium and the report are a part of a three-year effort started by the Access to Veterinary Care Coalition, which commissioned a national study of barriers to veterinary care, performed by the Center for Applied Research and Evaluation at the University of Tennessee College of Social Work and funded by Maddie's Fund. A subsequent $2.8 million grant from Maddie's Fund, announced last year, is supporting the implementation of AlignCare and further research into access barriers for pet owners. The symposium was also sponsored by PetSmart Charities and the American Society for the Prevention of Cruelty to Animals.

Breaking down barriers to care is one of the main goals of AlignCare and the PPHE.

Participants at the symposium came together to provide input to the PPHE on how AlignCare will function in communities and point out any problem areas. The program plans to release an AlignCare guideline book in the coming months based on the previous research it has done and feedback from attendees.

Incremental veterinary care tips

Incremental care was a major point of discussion at the symposium. Incremental veterinary care is described as patient-centered and experience-based medicine that focuses on problem-solving to achieve the best outcomes in the context of limited resources. Other phrases that have previously been used to describe this approach are empirical medicine and intuitive medicine.

Dr. Krista Magnifico, an attendee at the symposium and owner of Jarrettsville Veterinary Center in Jarrettsville, Maryland, said in an interview with JAVMA News, "Incremental care is a part of every case and every interaction that every veterinarian has with every client at my clinic."

Dr. Magnifico is also founder of Pawbly, a social network that answers pet-related questions for users. She has a YouTube channel and a blog to help educate, inform, and inspire other pet-loving people across all socioeconomic borders.

"My mission remains to provide transparency to allow greater access in the hopes that we can eradicate economic euthanasia," she said.

To explain how to implement incremental care within a practice, the symposium included the following questions to ask when evaluating a case with a client who has financial limitations:

• Do I have the skills, resources, and equipment to adequately and humanely treat and manage the case?
• Is there a good prognosis—is the condition treatable or manageable—or are there multiple problems?
• If the condition isn't treatable or manageable, is there a simple palliative option that can extend the animal's life while providing a good quality of life?
• Is the problem ongoing, or is it a chronic condition?
• Can the owners afford follow-up care or management?
• Can the owners afford overnight monitoring at an emergency clinic if it is necessary?
• Is the animal in critical condition?
• Would substantial amounts of money make a difference in a positive outcome?

Dr. Brian Forsgren, an Access to Care Coalition member and small animal practitioner in Cleveland, spoke during the symposium about the realities of providing incremental veterinary care and his own experiences since his career began in 1980.

His key piece of advice for other veterinarians is: "Just let them in the door. That's what access to care is all about."

Challenges Ahead

Despite the simplicities of some of the solutions, there are challenges ahead for access to care and AlignCare, including proper education and funding.

"We've heard from students, anecdotally, that they don't feel prepared to do this type of work, and it brings up a lot of anxiety around liability," said Dr. Blackwell during an interview with JAVMA News.

According to some attendees, the rise of specialists within the veterinary industry has decreased the number of general practitioners in academia and practicing in the field, which has led to young veterinarians not being exposed to basic care.

Many veterinary students only learn the gold standard, which doesn't necessarily prepare them to think creatively after graduation when they're practicing, according to some attendees.

For Dr. Forsgren, one of the components of implementing incremental care or a spectrum of care is to empower general practitioners, as those are the professionals in the industry who will be able to apply this kind of care most effectively. Dr. Forsgren suggests that veterinary students be exposed to more general practice work and this type of creative care planning so that students are not only learning the gold standard of care. Increasingly, veterinary colleges have started to offer students a chance to practice basic care with low-income owners, such as through the Wisconsin Companion Animal Resources, Education, and Social Services at the University of Wisconsin-Madison or the Cummings School of Veterinary Medicine at Tufts University's Tufts at Tech Community Veterinary Clinic.

Other challenges raised during the symposium include the following:

• Unwinding biases that include the notion that people who can't afford a pet shouldn't have one.
• Educating veterinarians and clients on the positives of incremental care.
• A reluctance for animal welfare advocates and veterinarians to collaborate and tension between for-profit and not-for-profit entities.
• Finding new sustainable funding sources.

Despite the challenges and complexities, Dr. Blackwell said, "When you make this about families, it opens up the possibilities."

A second Access to Care Symposium will likely be held in 2021.

AVMA Access to Care Initiative

The AVMA is working on access-to-care solutions as well, according to Dr. Kendall Houlihan, assistant director of animal welfare.

As part of the information-gathering phase of the AVMA Access to Care Initiative, the AVMA has convened a working group of stakeholders who are collecting information about how existing programs, practices, and tools are overcoming barriers to securing veterinary care, she said. A questionnaire has been distributed, focusing on programs and practices designed to increase access to veterinary care. Once the responses are gathered, that information will be distilled into practice models to assist veterinarians in working effectively and collaboratively within their communities to more actively evaluate opportunities to increase access to veterinary care by applying learnings that might best be adapted to their unique situations, according to Dr. Houlihan.

Along with the practice models, Association leaders are exploring the potential role of telehealth and an economic analysis to study the relationship between expenses for private practices versus shelter or not-for-profit clinics.

"AVMA staff also continues to monitor related legislation and attend meetings to communicate with key stakeholders and better understand the landscape of access to care," Dr. Houlihan said. "As this initiative evolves, its scope is designed to respond to needs across different sectors of veterinary medicine and to provide resources for individual veterinarians, traditional practices, and nonprofit organizations."

Related JAVMA content:

Report outlines barriers to accessing veterinary care, possible solutions (Feb. 15, 2019)

$2.8M grant to aid access to veterinary care (Sept. 15, 2018)

Coalition wants veterinary access for economically at-risk pets (Dec. 01, 2016)