- Contact the Committee

Thank you for the opportunity to speak today about “Rural Veterans’ Access to Primary Care” in Maine. There have been many changes in recent years in the delivery of healthcare services in the Department of Veterans Affairs in general and Maine in particular.

At Togus, as well as throughout the entire health care field, there is now a sustained emphasis on outpatient services—an emphasis that has significantly reduced hospitalization stays and more clearly focuses on outpatient clinics and their available services. Although we have changed the manner in which we provide our care, we continue to provide the same broad range of services and high quality care that we have always provided to an ever increasing number of Maine veterans.

As our healthcare delivery system continues to evolve, it is critical that we continue to monitor our services through internal and external audits to ensure the quality of our services. Our various monitoring processes indicate we have maintained, and in many cases improved, the quality of medical services.

VA ACCESS TO PRIMARY CARE FOR RURAL MAINE VETERANS

During my 15 year tenure as Director of the Togus VA Medical Center, there has been a remarkable and sustained shift in the delivery of healthcare services in Maine. In particular, VA has been progressive in its attempt to provide rural healthcare access. Today, there are five full-time Community-Based Outpatient Clinics (CBOC) in Maine, several of which have been expanded more than once to meet increased demand. These full-service CBOCs are located in Bangor, Calais, Rumford, Caribou, and Saco.

As an essential part of primary care, all existing CBOCs also provide preventive health services and health promotion and disease prevention programs. Additionally, a part-time primary care access point is located in Fort Kent, which is a satellite of the Caribou CBOC. There are also two VA mental health clinics located in Bangor and Portland. In addition, there are 18 vet centers in VISN 1, five of which are located in Maine.

To better serve Maine veterans, four of these CBOCs were recently expanded or relocated, and the remaining CBOC in Calais will soon be in its new location. The anticipated moving date is October, 2005.

The larger spaces we have obtained has allowed us to increase staffing levels and offer additional services for the benefit of Maine veterans. Four of our five CBOCs now offer on-site phlebotomy services and all CBOCs have VA contracts locally to provide X-rays and stat lab services.

We’ve also been able to increase access to Mental Health care throughout the state. The Bangor CBOC has an adjacent Mental Health Clinic which is fully staffed and full-time. Mental health support for the Saco CBOC is provided by the newly expanded and relocated Mental Health Clinic in Portland. Tele-mental health is in place in Caribou and is planned for Calais when the CBOC is relocated later this year. Finally, the Rumford CBOC now has an on-site Mental Health clinician one day a week with plans to expand services when additional resources become available.

One of the most significant changes in VA healthcare in Maine has been the extraordinary increase in the number of enrolled veterans selecting VA as their preferred choice for healthcare services and support. In 1999, total enrollment for VA healthcare was 19,000 veterans. A short five years later in 2004, enrollment had increased to over 36,000, nearly double the numbers of five years ago.

Equally interesting is that in 1999, only a third of enrolled veterans sought their primary care at the CBOCs. In 2004, half of our enrolled veterans did so—and the percentage continues to increase. These statistics clearly indicate that veterans prefer to receive their VA healthcare closer to home, whenever that is possible.

The Togus VA Healthcare System has been coordinating closely with the Maine National Guard and various Reserve units to conduct outreach for OIF/OEF returning service members. The outreach efforts include healthcare and non-medical benefits briefings as well as information on readjustment counseling by the Vet Centers. Currently, approximately 550 OIF/OEF veterans have enrolled for VA healthcare and about 80% of those enrolled are actively seeking some type of medical and/or mental health care. At this point, the vast majority of OIF/OEF veterans have only required outpatient healthcare.

VA PLANS TO MEET THE CHALLENGE

In the May, 2004 CARES Decision six additional sites of care throughout Maine were authorized pending availability of resources and validation with the most current data available. To better meet the needs of underserved veteran populations, the majority of these newly authorized sites will be located in more rural areas of Maine which would significantly further the attainment of a primary goal of providing veterans quality healthcare closer to their homes. Togus will continue to closely monitor implementation of these additional sites of care as resources become available.

Based on the burgeoning veteran population seeking care at the current CBOCs, Togus will also continue to monitor the growth at the existing sites of care and provide additional resources and providers as necessitated by demand.

To help meet the emotional and medical support needs of the widely dispersed veterans in the huge area of far northern Maine, Togus has positioned two social workers in Aroostook County. While one social worker has more specific training in mental health issues and the other in medical issues, they both work at the Caribou CBOC and in the field addressing both kinds of problems and providing care to veterans in whatever setting is most beneficial. Both consistently receive positive and enthusiastic comments from the many veterans who are cared for by them.

Togus will also continue to be a leader in health care by identifying and employing new technologies such as the latest improvements in home healthcare monitoring.

To date, we have 69 patients receiving varying stages of adjunctive care through tele-health devices. A recent article from “US News and World Report” entitled House Calls discusses telemedicine and the VA’s use of this innovative medical tool. Currently, there are 102 total videophones located throughout the VISN and 28 of those are at Togus. Simple electronic devices, called Health Buddies, are placed in the patient’s home and connect through existing telephone lines to allow patients to send and receive information from their health care team. There are currently 108 of these devices located throughout the VISN and 24 of those are at Togus. Our Home-based primary care unit has been using video phone devices for more than a year to provide follow-up and on-going care to patients in individual and residential home settings. Physician assistants and nurses use these devices to review medications, look at wounds, complete psychosocial assessments, conduct follow-up reviews for medication changes, and to determine if there have been any changes in health status when medications have been changed.

Our spinal cord injury unit has been providing care through use of interactive tele-video devices for some time. These devices include cameras and video conferencing capabilities, and have the ability to measure blood pressure, blood sugar, pulse oximetry and weight. Patients can talk face-to-face with providers, show the status of wounds by moving the camera over the affected area, provide daily information on blood sugar readings, and provide other important information, so that areas of concern can be addressed without the patient having to travel to Togus.

Our Women’s clinic recently began to use an in-home messaging device to provide medication reminders, instructions on various home care needs, and general health improvement questions to provide support to this veteran group. These devices have a set series of questions designed specifically for the diagnosis being treated set in the machine with the patient going through the prompts and answering “yes” or “no” to questions.

The information is sent to the patient’s care coordinator who reviews the information daily. If an answer is not within the established norms, the coordinator contacts the patient to determine the type of intervention necessary. This methodology also allows patients to indicate if they need to be contacted because of a question that they might have and allows them to do so without having to be concerned that they are interrupting another patient’s care.

Togus VAMC was one of the first VA Medical Centers in the nation to establish a Hospice-Veterans Partnership with the state. Hospice care is provided by community partners under the Hospice Medicare Benefit or paid for out of the Purchased Skilled Home Care program under the VA fee basis package. Hospice care is also provided under the Community Nursing Home Program.

We are using tele-psychiatry and other methods to help meet our mental health needs. And we will continue to review and approve providing fee-basis healthcare in local communities on a case-by-case basis as appropriate and in accordance with governing law and directives.

Mr. Chairman, to better serve the veterans of Maine, we must continue to monitor and meet their needs. America’s veterans have earned the best care we can possibly provide, and it is our distinct privilege to provide them with the highest levels of customer service.

We will continue to coordinate closely with Maine’s veterans and with national and state Veterans Service Organizations, as we do our very best to address our veterans’ concerns. We sincerely appreciate your interest and support in helping VA to successfully accomplish our sacred mission of providing world-class care to all those who have so honorably served our great country.