Exposure-Informed Care

Abstract

Background:

Providing care for individuals with environmental and occupational exposure health concerns is challenging. There is rarely exposure data to allow for verification of dose and duration of exposure, and even when there is, it is difficult to conclusively determine if or to what degree a health condition is associated with an exposure. This uncertainty can lead to disagreement between patients and providers, lowering trust and satisfaction. To address these issues the Veterans Affairs (VA) has developed, and is implementing, Exposure-Informed Care (EIC). EIC is a model of care that recognizes previous possible or known exposures to environmental factors may impact health and cause concern and seeks to create an environment that at every level is validating, transparent, and proactively addresses environmental exposures.

Objectives:

This paper provides a framework for how the VA has implemented the core features of EIC that can be adapted by other health care systems.

Results:

The VA has implemented EIC through: (1) screening for potential exposures and integration of exposure-related information into clinical care, risk communications, and trust building; (2) trained clinicians to provide evaluations and consultation; (3) surveillance and research; (4) investment and commitment to workforce development by providing education and implementation support and evaluating the impact of these efforts; (5) leadership commitment to standardize institutional policies and create cultural change.

Discussion:

While this paper focuses on a single health care system, EIC principles can and should be adapted to clinical settings outside of the VA. This is important for Veterans seen in community care as well as civilian populations who are likely to have been exposed to environmental hazards.

Exposure to environmental factors such as air pollution and chemicals is estimated to cause nearly 25% of deaths, many of which are preventable.¹ Work-related environmental exposures are commonplace and often associated with various medical conditions. Some of those conditions occur acutely (eg, rashes), while others may only become apparent after prolonged exposure or after years have passed. The World Health Organization and International Labour Organization estimated that 1.9 million deaths in 2016 could be attributed to occupational risk factors with over 450,000 of these from particulate matter, gases, and fumes.²

Active-duty service members, in particular, experience environmental exposures during their military service that can lead to long-term adverse health outcomes, or at a minimum, be a source of worry and concern (Table 1).^4,5 Many exposures occur during everyday military operations (eg, jet fuel, firefighting foam). Some may occur in garrison, such as contaminated water at Camp Lejeune, and noncombat deployments, such as Enewetak Atoll and Palomares, Spain, radiation sites. Other exposures occur in combat theaters such as Agent Orange during the Vietnam War and open-air burn pits and other airborne hazards in southwest Asia (see⁶ for information on these and other military exposures). Historically, environmental exposures, including those experienced in the military,⁷ have inequitably effected individuals attributable to systemic factors.⁸

TABLE 1.

Military Occupations and Environmental Exposures

Military Occupations. The military culture is defined by a sense of “mission first” with a focus on getting the job done and less regard to personal comfort, needs, or even safety. One should not assume that military life is always dangerous. If one visited a military base and observed service members at work, it would look like many civilian jobs where many staff work in offices on computers. However, military bases also have unique circumstances that can lead to exposures not typically encountered in civilian areas, such as firing ranges, older buildings, large motor pools, and contact with industrial products. Risks for these environmental exposures are compounded in combat zones.

Garrison Exposures. Garrison is the installation where troops are stationed. It is often not only where the service member works, but also where they and their family live. As a result, environmental exposures can adversely impact not only the Veteran, but also their family members. Hazardous materials can include asbestos, heavy metals, chlorinated solvents, hydrocarbons, munitions, and jet fuels. Recently, concerns have arisen regarding per- and polyfluoroalkyl substances (PFAS), such as the contaminated water at Camp Lejeune from 1953 to 1987.3

Deployment Exposures. Deployment is the movement of service members for military action, including for combat where environmental monitoring may not be possible. The variety of exposures during deployment may be the same as those experienced within a garrison but can vary based on location and nature of deployment. Exposures to weather extremes are frequent and can lead to heat exhaustion, frostbite, and others. Insect bites can lead to infectious diseases such as dengue, malaria, and yellow fever. Other hazards can include materials left by enemy or locals such as fuels, munitions, chemicals, solvents, chemical warfare agents, and depleted uranium. Deployment may also include exposure to physical hazards, including blast, vibration, noise, and others. Mobilization is like a deployment and refers to when an individual or unit is sent somewhere within the continental US or its territories. This is typically for disaster response, such as hurricanes, wildfires, and floods. Exposures can include infectious diseases, fuel/chemical leaks, smoke/pollution, among others.

Veterans and service members may not recognize the impact of these environmental exposures on health or may not make the connection between the exposure and current health problems.⁹ Because most clinicians do not have extensive training in occupational or environmental health, they may not ask questions about these exposures, may fail to consider how symptoms may be related to their exposures, or may be unsure how to respond to a patient’s concerns about military exposures.^10,11

To address these issues the US Department of Veterans Affairs (VA) has developed, and is implementing, Exposure-Informed Care (EIC).¹² EIC is a model of care that recognizes previous possible or known exposures to environmental factors may impact health and cause concern, and seeks to create an environment that at every level of the health care system is validating, transparent, and proactively addresses environmental exposures. This paper describes the elements and implementation of EIC in VA and provides a framework that can be adapted by other health care systems.

CORE FEATURES OF EXPOSURE-INFORMED CARE

Providing care for individuals with health concerns related to environmental and occupational exposures is difficult.¹³ There is rarely exposure data, and it is typically not possible to prove causality between an exposure and a medical condition.¹⁴ In most exposures, no data exists at the individual level, so there is no reliable way to quantify or even roughly estimate dose or duration of exposure.¹³ Further, even when such data exists, there is often limited, if any, evidence to suggest that the medical condition is associated, much less caused by the exposure. Most diseases have multiple contributors, including genetics, lifestyle choices, and social determinants, making it difficult to clearly establish causality between the disease and the exposure. The uncertainty inherent with environmental exposures can cause disagreement between patients and providers, and even within the medical community. Patients can feel their health concerns are dismissed, or worse that the government is covering up the impact of known toxic exposures, leading to distrust, dissatisfaction, and feelings of institutional betrayal.¹⁵

EIC is a model of care that addresses these challenges. While the term exposure-informed care is novel, the concept of “informed care” has been gaining ground over recent decades. In an “informed care” approach, all aspects of health care, from the organizational to individual level, are developed in consideration of the patients’ experience of the concern to be validating, accommodating, and welcoming. Perhaps the best known, and most relevant, example is that of trauma-informed care.^16,17 There is evidence that trauma-informed care models positively improve outcomes.^17,18

As is true with psychological trauma, environmental exposures are common, impact health, color patients’ experience of health care, and are of concern to patients, their families, and caregivers. EIC recognizes the impacts of environmental exposures and seeks to provide proactive care that acknowledges and validates the patient’s experience. A Delphi study identified the core components of EIC as: use concordant communication, build trust, assess and document, provide support and resources, take professional responsibility, integrate into care (Fig. 1).^19,20

FIGURE 1.

Reproduction of VA’s infographic of the core components of exposure-informed care.

Embracing an EIC model of care can improve patients’ health outcomes, strengthen trust in the health care system, and support clinicians. EIC can potentially lead to early identification of exposure-related conditions, prompt preventative intervention or treatment, thus improving health outcomes. EIC can enhance trust between the patient and their clinician and the clinical health care system, empowering patients to better manage their own care. EIC supports clinicians to have the knowledge to confidently deliver appropriate and timely care for exposure-related concerns, use risk communication, and appropriately refer for additional benefits and services, which can improve clinician satisfaction and reduce burnout.

OPERATIONALIZING EIC INTO CLINICAL PRACTICE

Toxic Exposure Screening

In VA, Toxic Exposure Screening (TES), developed through the VA Office of Primary Care, is the gateway to EIC, often beginning the conversation between the Veteran and the clinical team.²¹ All enrolled Veterans receive the Toxic Exposure Screening at least once every 5 years, and ∼45% of Veterans report at least one potential environmental exposure during their screening.²² The Toxic Exposure Screening asks the Veteran if they believe they experienced an exposure to airborne hazards and open burn pits, Gulf War-related exposures, Agent Orange, radiation, Camp Lejeune contaminated water, or “other” exposures, while serving in the Armed Forces. The first 5 listed exposures are among some of the most frequently reported military exposures and the VA has established that certain medical conditions are presumed to be associated with each of these exposures.²³ That is, if the Veteran was at a location with the known exposure (eg, open burn pits) and develops a condition associated with the exposure (eg, asthma), it is presumed the exposure, at least as likely as not, contributed to the health condition, and the Veteran is therefore eligible for compensation and benefits.²⁴ The most common “Other“ reported exposures are asbestos and fuels. Veterans are encouraged to apply for compensation and benefits for all health conditions they believe are related to their military service. For nonpresumptive conditions, decisions are made on a case-by-case basis.²³

There are no diagnostic tests or physical exams that are routinely completed as a part of the Toxic Exposure Screening. Responses are based purely on Veteran report, which validates that they are the recognized authority of their own exposure history, thereby enhancing trust and respect. During the Toxic Exposure Screening, the reported exposures are documented in the health record, and education and information on available resources are provided. Toxic Exposure Screening Navigators are clinicians at each VA medical center who support the Toxic Exposure Screening and exposure-informed care.

Exposure-Informed Primary Care

Most toxic exposure screening and subsequent follow-up and care for health concerns potentially related to military environmental exposures occur in primary care, although both also occur in specialty care settings. VA delivers primary care through the Patient Aligned Care Team (PACT), which generally consists of a provider (ie, MD, DO, advanced practice registered nurse, physician assistant), registered nurse care manager, clinical associate (ie, licensed practical nurse, health technician), and administrative associate.²⁵

For most Veterans, primary care serves as the main point of contact for medical care and overall health maintenance. A key component of primary care is longitudinal care for prevention and early detection of health concerns.²⁶ Primary care providers consider all the factors that influence Veteran’s health and comprise the Veteran’s overall risk profile. In addition to standard social history, providers are encouraged to conduct a military history, including a description of military occupations, deployments, and mobilizations, in addition to significant military environmental and combat exposures.^27,28 This provides the clinical team an understanding of other factors that may be influencing the Veterans health, including ones the Veteran may not be aware of (eg, jet fuel exposure). Symptoms of disease are evaluated using standard evidence-based clinical practice guidelines, regardless of the Veteran’s exposure status, including appropriate referral and consultation for specialty care. Given the multifactorial nature of health concerns, primary care teams exercise prudent clinical judgment when considering what additional assessments and diagnostics are appropriate in the evaluation of the Veteran’s health.

Health conditions, including those that may be related to military environmental exposures, are addressed using team-based, integrated, Veteran-centered, Whole Health-oriented care.²⁹ In general, treatment for health conditions does not change because the condition may be associated with a military environmental exposure; however, the conversation with the Veteran does. Providers use standard evidence-based approaches to address chronic conditions, while using risk communication to provide the Veteran information about what is known and not known about the exposure and its relationship to health concerns. The VA uses a Whole Health approach where treatment goals are based on the Veterans’ expressed priorities and goals.²⁹ As primary care providers make assessment and treatment decisions, they can consult with experts in military environmental exposures who are available to provide more complex military environmental exposure assessments and address less common exposures and their potential health impacts, supporting both the frontline primary care clinicians and the Veteran.

Environmental Health Team

The environmental health team consists of Environmental Health Clinicians, who are clinical experts in military environmental exposures, and Environmental Health Coordinators, who provide administrative, technical, and analytical support.³⁰ Environmental Health Teams are integrated into VA medical centers to provide consultation and management of VA’s military exposure programs and are available to support primary care teams.

An essential and fundamental role for the Environmental Health Clinicians is to educate the Veteran’s health care provider about military environmental exposures and how to communicate with the Veteran about these concerns. They are also a source of information for staff and Veterans regarding administrative requirements of military environmental exposure assessments, as well as referrals to the War Related Illness and Injury Study Center (WRIISC),³¹ VA’s tertiary care center for Veterans with exposure-related health care concerns that are especially difficult to diagnose, manage, or treat.

Environmental health clinicians also provide specialized military environmental exposure evaluations, including examinations for VA’s environmental health registry program,^32,33 that are more extensive than an evaluation a Veteran might receive in a primary care setting. The clinical benefits of military exposure evaluations are to identify the type and potential health risks of possible military exposures, including the chronic and acute effects on various systems. These evaluations also provide clinicians an opportunity to share with the Veteran’s primary care provider personalized recommendations, including in-depth evaluations and preventative strategies. Veterans are educated on health risks related to possible or specific exposures and discuss potential long-term effects and strategies to monitor and protect their health. Information from military exposure evaluations, particularly those completed as part of a registry program, is used to conduct health surveillance for high-risk groups.

SURVEILLANCE, RESEARCH, AND POPULATION HEALTH OUTCOMES

The VA, US Department of Defense, as well as other Federal agencies, have been conducting population surveillance studies for decades to determine whether there is evidence that specific military environmental exposures are associated with certain health outcomes.^32,33 This surveillance improves experiences of care by enabling clinicians to address health concerns and share risk information. It improves clinical prognosis by guiding clinicians on when to assess for disease and treat possible health outcomes early. Collecting objective information can guide public health efforts to ameliorate inequities³⁴ and facilitate preventive efforts to address health concerns before they occur. The evidence base from surveillance studies also informs VA and legislative decisions on presumptive conditions.³⁵

One way the VA seeks to conduct surveillance is through registries. Medical registries are databases of information from individuals with a “clearly defined set of health and demographic data collected for a specific public health purpose.”^36,37 Currently, VA has 6 exposure registries for active-duty service members and Veterans, primarily based on specific deployments³⁸ and for which service members and Veterans generally volunteer to be included and typically receive a registry medical examination. The redesigned Airborne Hazards and Open Burn Pit Registry^39,40 now incorporates data from existing Department of Defense and VA databases and includes all individuals who meet eligibility criteria, improving the validity of the results and allowing this registry to more effectively contribute to surveillance.

A unique instrument to track military exposure information for clinical and epidemiologic surveillance purposes is the Individual Longitudinal Exposure Record (ILER).⁴¹ ILER integrates exposure information from multiple Department of Defense and VA sources. A summary of the information in ILER for each individual Veteran is available through the VA medical record. This information on potential military exposures may be helpful in determining eligibility for enrollment, assessing disability claims, and guiding clinical evaluation.

VA’s Health Outcomes Military Exposures (HOME) Epidemiology Program conducts large-scale research studies to understand the health impacts of military exposures. This programmatic research was expanded with the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022, or PACT Act,^42,43 which included ten research initiatives, in addition to provisions for expanding and improving VA’s health care and benefits. Competitive funding is also available to individual VA researchers, through the VA’s Office of Research and Development, encouraging scientific innovations in military exposure research.⁴⁴ Finally, an interconnected network of Centers of Excellence in military environmental exposures brings together research, clinical care innovations, and clinician and Veteran education to facilitate the translation of clinical observations into research and research into clinical care.^31,45–47

LEARNING HEALTH SYSTEM APPROACH

The VA uses a learning health system approach to continuously improve EIC. This includes educating clinicians about the latest surveillance and research on military environmental exposures and evidence-based practices for exposure-related health conditions, supporting providers to implement these in the medical system, and evaluating the effectiveness of this and other education and implementation efforts (Table 2).

TABLE 2.

Training and Resources for Military Environmental Exposures

Resource type	Description	How to access
Certification program (E-learning modules)	A partnership between the VA and American College of Preventive Medicine (ACPM), health care professionals can earn Level 1 (introductory) and Level 2 (advanced) certifications in military environmental exposures.	https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/education/provider-training/ACPM.asp</underline>
Information sheets	Information sheets provide useful information about many deployment health concerns in a short, concise, and printable format.	https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/education/informationsheets.asp
Live webinars	VA offers webinars and other live offerings to provide clinicians with tiered learning opportunities to develop best practices and ultimately manage Veterans complex postdeployment and exposure-related health care concerns.	https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/education/provider-training/index.asp
On-demand trainings	VA provides clinicians with the ability to complete its current best practice curricula via accredited recordings.	Search the VA TMS: https://www.tms.va.gov/SecureAuth35/ (for VA employees only) or TRAIN https://www.train.org/vha (non-VA employees) for “WRIISC-HOME” to find available on-demand training.
Podcasts	VA's Veterans’ Health Matters podcast series focuses on issues that are important to the health care community, Veterans, and their caregivers.	https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/education/vhmpodcast.asp
Mobile App	VA Exposure Ed App delivers information on military-related exposures to health care providers.	https://mobile.va.gov/app/exposure-ed
Provider resource site	A landing page that supports the implementation of EIC for health care professionals. This site outlines flexible training modules, toolkits, and how to sign up for additional training and educational resources.	https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/EIC/Providers.asp
SharePoint (internal use only)	War Related Illness & Injury Study Center-Health Outcomes Military Exposures (WRIISC-HOME) SharePoint is available to VA employees and consolidates all information and resources on military environmental exposures and exposure-informed care for health care professionals.	For VA employees only: https://dvagov.sharepoint.com/sites/vawriisc

As the field evolves, health care clinicians need fundamental knowledge of approaches to care for individuals with military environmental exposure concerns, access to ongoing, updated learning, and support to apply this knowledge to effectively deliver EIC. This is particularly important because most clinicians never receive training in military environmental exposures. VA has mandated core training for all VA providers, nurses, psychologists, social workers, and other clinicians. The goal of this training is to ensure all Veterans at every encounter, are cared for by clinicians who have a basic knowledge of how to assess and communicate about military exposures. Environmental Health Clinicians receive additional comprehensive training in military environmental exposures, which is available to all VA and non-VA health care staff. In addition, VA and non-VA health care staff have access to multiple monthly live trainings, which disseminate the latest data from surveillance and research on military environmental exposures and access to tools, such as the Exposure Ed App, which facilitate the application of this knowledge to clinical care. An internal VA SharePoint, brings together all resources, tools, research publications, and education on military exposures into one consolidated management system. This ensures VA staff have access to what they need to address military exposure concerns.

VA evaluates education and implementation efforts to guide continuous improvement of EIC. Veterans are surveyed about their health care experiences for exposure concerns, including their perceptions of feeling respected and valued by their provider, and trust in VA to care for military environmental exposure concerns. In addition to discrete qualitative and quantitative evaluations of specific tools and initiatives, biannual national clinician needs assessments assess educational needs to address military exposures and perceptions of organizational support.^11,48 The data is used to tailor the type, delivery method, and quantity of education.

ORGANIZATIONAL COMMITMENT

Leadership commitment is essential to truly deliver EIC and requires changes to practices, policies, and the organizational culture. Leadership support facilitates change management, commits resources, assures workforce development and training, enhances awareness, and enables collaborations to create EIC communities. Ultimately, this leads to a paradigm shift in which EIC becomes part of routine clinical practice, providers who are not specialists receive needed foundational training, illnesses are identified earlier, prognoses are improved, surveillance leads to exposures and associated medical illnesses being identified, and ultimately, employee performance is improved and burnout reduced. This is precisely how VA has been able to implement EIC across the organization. Leaderships’ first step was to require training of all clinicians on basic information on military environmental exposures and how to communicate risk appropriately. Additional features included:

• Reaching out to Veterans who were not currently using VA health care to apprise them of the benefits of enrollment.

• Conducting a screening for potential toxic exposures.

• Collecting relevant data and then communicating that information internally for action.

• Connecting Veterans with resources and benefits.

• Establishing a public-facing website of the federal government funded toxic exposure research that Veterans and providers can use to better understand health risks and outcomes.

• Tracking and trending enrollments to better project future health care needs.

• Assuring close communications and joint projects between VA and Department of Defense to facilitate identification of military exposures and associated medical sequelae.

• Frequent engagements with external stakeholders, including Veterans Service Organizations, to obtain feedback on the interests and concerns of Veterans.

These efforts require vision, strategic planning, enterprise-wide engagement, change management, and dedicated staff and resources. Successful buy-in from every level of the organization is essential for implementation and is achieved primarily by communicating the need to focus on core values that define VA’s mission, namely “to care for those who have served in our nation’s military and for their families, caregivers, and survivors.” It also involves working closely with federal partners, including Department of Defense as the authoritative source for military exposure data, Environmental Protection Agency and Center for Disease Control and Prevention for large study public health research, National Academy of Medicine for consensus reports, and Department of Energy for radiologic exposure information. VA also shares their expertise such as providing Department of Defense health data to connect to exposure data, and providing World Trade Center Program guidance on research and policy on health outcomes from exposures.

OTHER EXAMPLES OF FEDERAL OCCUPATIONAL EXPOSURE PROGRAMS

The World Trade Center (WTC) Health Program has some of the same elements of EIC that have been implemented in the VA.⁴⁹ It is a federal program that provides monitoring and treatment for certified World Trade Center-related health conditions for eligible individuals. The program also conducts scientific research to better identify, diagnose, and treat physical and mental health conditions related to 9/11 exposures. Five Centers of Excellence have been established that offer unique expertise in this area.

Other relevant programs include the Radiation Exposure Compensation Act (RECA), which was a program for diseases associated with nuclear testing during the Cold War.⁵⁰ RECA, which ended on June 7, 2024, provided one-time benefit payments to persons who may have developed cancer or other specified diseases after being exposed to radiation from atomic weapons testing or uranium mining, milling, or transporting. The National Radiation Exposure Screening and Education Program (“RESEP”), provided grants to rural health clinics located in Nevada, Colorado, Utah, Arizona, and New Mexico. RESEP clinics provided medical screening for compensable diseases under RECA, referral services, diagnostic tests, educational materials about preventive health measures, and assistance with claims.

CONCLUSIONS

As the largest system of health care and benefits for Veterans, the VA is the ideal institution to operationalize the principles of EIC. However, occupational exposures are commonplace in non-Veteran populations as well. While this paper has focused on a single health care system, EIC principles can and should be adapted to clinical settings outside of the VA. This is important for the estimated 45% of Veterans seen in community care and potentially applicable to civilian populations who are exposed to environmental hazards.³

Implementing EIC requires: (1) screening for exposures and integration of exposure data into clinical care, risk communications, and trust building; (2) trained clinicians to work with clinical teams to provide evaluations and consultation; (3) surveillance and research; (4) investment and commitment to workforce development by providing ongoing education at all levels of personnel; (5) standardized institutional policies that include staff, clinician, and consumer input. This paper builds on the extensive work of researchers, epidemiologists, clinicians, educators, and leaders, all of whom are committed to the mission of fulfilling President Lincoln’s promise to care for those who have served in our nation’s military, and for their families, caregivers, and survivors.