b'created an obstacle to care for many veterans eligible for and interested inFigure 2: Federal and Nonfederal Sources of the Reported Extramural Research receivingthelong-actinginjectableSpending for VA-Approved Research in Fiscal Year 2019 formofnaltrexone, Vivitrol,tohelp(Spending in millions of dollars) them in recovery. AstheVACriteriaForUsefor Vivitrolplacednorestrictions onwheretreatmentcouldbe administered, a St. Louis VA mental healthclinicalpharmacist,Lauren Ash,PharmD,quicklyidentified two veterans who could benefit from receivingtreatmentatthemore convenient CBOCs. One was referred totheSt.CharlesCBOCandthe other to the North County CBOC for follow-upinjections.Ashaskedthe Alkermesteamtoprovideproduct anddirectionsforuse,in-service training and continuing education for the clinics primary care nursing team prior to the patients next injections.aWith referrals picking up, it becameGovernment includes state and local government. clear that providing proactive training The federal and nonfederal sources of funding included a range of atprimarycareCBOCswouldbetterorganizations and funding levels. enableseamlesscontinuityofcarewithoutneedlesslyAs it has throughout its quest to reach more veterans in Federal sources. The National Institutes of Health (NIH) provided disrupting workflow. Linda Rogers, RN, a primary caretheir homes and communities, the Vturned to technology. A$293.5 million (57.6 percent of federal and nonfederal extramural clinic resource nurse, and her group of primary care nurseContinuous glucose monitors (CGMs) are small, wearable funding), while the Department of Defense (DOD) provided $56.5 education coordinators set to work developing hands-ondevicesthatcheckbloodglucoselevelsconstantly million (11.1 percent), and other U.S. federal agencies, including the injection training and overall education on alcohol usethroughoutthedayandnightandalertthepatientand Centers for Disease Control and Prevention (CDC) and the U.S. disorder identification, stigma, diagnosis, treatment andcarervicer orowoed ing .tr millioor 6.2 percent). ws. The VA Public Health Segive, pf vidrry$31 7ends n (dangerous locounseling.has steadily increased its use of CGMs for Type 1 diabetics Nonfederal sources. Private companies, including pharmaceutical In late December 2019, Alkermes and the St. Louis V t and Type 2 diabetics who use insuli l trial recent years.Aand bio echnology companies conducting clinica n ins, provided $49.4 million (9.7 percent of all fed ral and nonfederal e for use ofteam coordinated injection training for approximately 100In November, the V erelaxed the criteriaxtramural CGM Afunding). Academic institutions, private donors, and state and local nurses throughout the St. Louis VA outpatient clinics anddevicesduringthepublichealthemergency.Theuse governments provided $44.3 million (8.7 percent), and voluntary CBOCs. At the same time, the clinical pharmacy teamoftherapeuticcontinuousglucosemonitorsmayallow agencies or foundations, including the American Heart Association providedin-serviceeducationonalcoholusedisorderpatients to proactively treat their diabetes and prevent the and the American Cancer Society, provided $34.3 million (6.7 diagnosis and treatment to primary care providers.need for hospital-based diabetic care, the memorandum percent). explained. Practitioners will also have greater flexibility to allow more of their diabetic patients to better monitor Monitoring Diabetes From Home GAO-20-570VA Research Page 10their glucose and adjust insulin doses from home by using TheCOVID-19pandemicdramaticallyacceleratedthea therapeutic continuous glucose monitor.delivery of healthcare to patients homes, for the VA and theTheAbbottFreeStyleLibre2system,anintegrated other providers worldwide. The VA was well positioned toCGM with high accuracy standards that make fingerstick respond via telehealth, thanks to the partnerships launchedconfirmationtypicallyunnecessary,comeswiththe in 2019 and the groundwork laid in previous years. Still,LibreViewcloud-baseddiabetesmanagementsoftware videochatsfromhomedonotalwaysprovidealltheand a smartphone app (LibreLink) that simplifies sharing information needed to manage care. of data with healthcare providers. Clinicians can use the Thatsparticularlytruefordiabetes.Withoutregularfree and secure LibreView software to guide treatment appointments to check A1c levels, clinicians faced newdecisions, regardless of the patients location. challengesinmanagingglucoselevelsforveterans,Whether at the local or national level, the expertise of particularlythoseoninsulin.Atthesametime,theindustry partners has enabled the VA to move further increased risk of serious illness that SARS-CoV-2 posesfaster in its mission to reach veterans where they are and for diabetics made bringing them in to clinics or hospitalsincrease access to services and medications that improve for check-ins too fraught.their lives and health.THE VALUE OF THE PARTNERSHIP: Industry and the Federal Customer Working Together 5'