Improving communication and access for prosthetic limbs

VA provides care for more than 45,000 Veterans with major limb loss, including those with amputations secondary to combat. Veterans with major limb loss who use VA for prosthetic limb care require a high degree of care coordination to ensure their needs are met.

To address these challenges, a team of VA staff in VISN 20—including physicians, prosthetists, purchasing, contracting and administrative staff—worked together to understand the process and potential areas for improvement. In 2017, they launched FLOW3.

This novel workflow optimized the prosthetic limb care process, improving timeliness in care, employee satisfaction and Veteran experience.

The original design team was led by Dr. Jeff Heckman, now medical director at the Southeastern Regional Amputation Center at the James A. Haley Veterans Hospital and Clinics in Tampa.

Innovating in prosthetic care

FLOW3 centralizes all components of the prosthesis ordering process for Veterans and VA prosthetic limb care teams, allowing VA clinicians to view prescription details, comments and purchase activity all in one location. FLOW3 also notifies providers as orders move through the process, allowing for timely and improved follow-up care.

“We’re able to give Veterans information about where their limbs are in the process,” said Heckman. “It provides transparency into the system that previously was an area of frustration.”

With support from Diffusion of Excellence as a 2017 VHA Shark Tank Competition winner, the FLOW3 team—including Jeff Bott and Wayne Biggs—expanded the practice to VISN 12 and started their journey to implement on a national scale. By 2021, FLOW3 was implemented in 157 facilities and benefiting over 17,600 Veterans.

Evolving FLOW3 to FLOW4

FLOW3 initially focused on artificial limb prostheses for Veterans with amputation. In September 2023, the team launched FLOW4, an updated version

Building on the success of FLOW3, FLOW4 also seeks to expand workflow capabilities beyond prosthetic care to include orthotic and therapeutic footwear intervention. FLOW4 is the culmination of years of Veteran and clinician feedback.

FLOW4, the latest iteration of the FLOW system, aims to provide Veterans the ability to track their device orders like they track online purchases with real-time notifications and delivery updates.

“It’s real-time. It’s instantaneous. As soon as the limb is delivered, we find out about it through our system and then we get the Veteran back in for follow-up care,” explained Heckman, noting the major improvements that the FLOW4 system provides.

With support from the VHA’s Orthotic, Prosthetic & Pedorthic Clinical Services Program Office, the team is currently piloting FLOW4 at 16 VA sites.

“FLOW3 was a groundbreaking advancement in prosthetic limb care, developed and based on the experiences of our Veterans. It provides increased transparency, accessibility and support with the goal of improving their experience,” said Dr. Ajit Pai, executive director of VHA’s Office of Rehabilitation and Prosthetic Services. “The evolution to FLOW4 marks a pivotal transition, ensuring continuous improvement in the field of prosthetic limb care, moving in step with VA’s modernization efforts and improving Veteran experience with real-time tracking and instant notifications.”

Learn more

Read more about the work of FLOW3 in a recent study published by Heckman, in collaboration with VHA Quality Enhancement Research Initiative and VA Rehabilitation and Prosthetics Services. The study, published in the Journal of Implementation Science, compares the impact of two FLOW3 facilitation strategies on adoption, implementation and sustainment. 

To learn more about FLOW4, explore their page on Diffusion Marketplace. If you are a Veteran looking to learn more about VA prosthetic services, contact your VA primary care provider. Veterans can also directly schedule with the amputation clinic team at their local VA facility.

Learn more about innovation at VA: Visit our website, Diffusion Marketplace, subscribe to our weekly newsletter and explore VA Pathfinder to learn more about our opportunities.

(The top photo was taken using a GoPro mounted to the left side of the plane tail. The Veteran was jumping over Lake Dora, Florida, with the Phantom Air Brigade, a Florida non-profit dedicated to providing military trained airborne-qualified personnel (whether active duty, retired or Veteran paratroopers) to continue jumping in the manner they were used to while serving. They’ve completed over 20K descents.)