Witness Testimony of James W. Rice, MA, Director, Oscar G. Johnson Veterans Affairs Medical Center, Iron Mountain, MI, Veterans Health Administration, U.S. Department of Veterans Affairs
Good Morning, Madam Chairwoman and Members of the Committee. Thank you for inviting us here today to discuss the accessibility and quality of health care for Veterans residing in the Upper Peninsula of Michigan. I am accompanied today by Dr. Mary Beth Skupien, National Director for the Department of Veterans Affairs (VA) Office of Rural Health, Dinesh Ranjan, M.D., Chief of Surgery at the Oscar G. Johnson (Iron Mountain) VA Medical Center (VAMC), and Clifford Smith, M.D., Chief of Mental Health at the Iron Mountain VAMC.
My testimony today will describe the work done at the Iron Mountain VAMC, and then review the services and outreach we provide to Veterans in the rural and highly rural areas here in the Upper Peninsula. Specific areas of focus will be improvement in mental health and rural health care, recruitment and retention of medical personnel, the scope and impact of telehealth programs, and our collaboration and partnerships with community providers.
About Iron Mountain VAMC
The Iron Mountain VAMC provided care and services to almost 20,000 Veterans in fiscal year (FY) 2010 with an operating budget of $106.9 million and more than 580 employees. The facility oversees community-based outpatient clinics (CBOC) in Michigan (Ironwood, Hancock, Marquette, Sault Ste. Marie and Menominee) and Wisconsin (Rhinelander) that serve 15 counties in Michigan and 10 counties in Wisconsin. It also operates a rural outreach clinic in Manistique, Michigan. The Iron Mountain VAMC has the largest geographic patient service area east of the Mississippi River, home to approximately 53,000 Veterans, 23,863 of whom are enrolled in VA’s health care system.
The Iron Mountain VAMC is a primary and secondary level care facility with 13 medical/surgical beds and four intensive care unit (ICU) beds. Its Community Living Center has 40 beds. The Iron Mountain VAMC provides limited emergency and acute inpatient care in a geographically rural area, and collaborates with larger health care facilities in Veterans Integrated Service Network (VISN) 12 to provide higher level emergency and specialty services. It employs state-of-the-art telehealth technologies and is a leader in the delivery of health care to rural Veterans. The Iron Mountain VAMC provides ambulatory and acute primary and secondary health care, as well as surgery, psychiatry, physical medicine and rehabilitation, neurology, ophthalmology, ear/nose/throat (ENT), podiatry, orthopedics, oncology, dentistry, geriatrics, and extended care.
In FY 2011 to date, the Iron Mountain VAMC is providing more than 99.7 percent of patients’ primary care appointments within 14 days of their desired date, exceeding the VA benchmark. At all of our facilities, more than 99.5 percent of patients seeking a specialty care appointment are scheduled within 14 days of their desired date. Our patients are satisfied with the quality of care they receive as evidenced by the Medical Center’s patient experience data, which exceeds the VA’s national score for both inpatient and outpatient care. More than 82 percent of our Veterans would recommend Iron Mountain to their friends and family.
We have made great strides in the quality of care we provide by reducing readmission rates for patients with heart failure, developing better screening and surveillance processes for colo-rectal cancer, improving the timeliness of placing patients discharged from acute care into the Community Living Center, developing Patient Aligned Care Teams (PACT), and expanding teleretinal services and care. This year, we are making further enhancements to our telehealth services and their availability at our CBOCs; we currently support telemedicine programs for Pulmonary, Rheumatology, Endocrine, Cardiology, Prosthetics, Diabetes, Infectious Disease, Weight Management Program (i.e., MOVE!), Healthy Heart, Behavioral Health, Teleretinal Imaging Program and Telepathology.
Improvement to the Delivery of Rural Health Care
Rural Americans, including rural Veterans, face many challenges when it comes to health care, and VA is committed to enhancing the care rural Veterans receive. Given our presence in the Upper Peninsula, much of what we do can be considered rural health care. For the second straight year, we are participating in the Rural Health Professional Institute, which provides clinicians an opportunity to enhance their skills and capacity for delivering health care to Veterans from rural and highly rural locations. We are currently supporting rural health projects through funding from VA’s Office of Rural Health (ORH), as well as through local resources.
ORH Funded Projects
VA’s national ORH provides support and funding to ensure Veterans living in rural and highly rural areas have access to the care and services they need. Its mission is to improve access and quality of care for enrolled rural and highly rural Veterans by developing evidence-based policies and innovative practices to support their unique needs. ORH has invested resources to implement projects across the country. Over $500 million was dedicated to these projects in FY 2009 and 2010, and another $250 million in FY 2011. These funds supported national and local initiatives in expanding telehealth, home-based primary care, mental health care, education and training, rural CBOCs, rural hiring initiatives, a rural fee-basis pilot, VISN-specific initiatives, community outreach, transportation programs, and other efforts. In FY 2011, VA is using ORH funding to further expand national telehealth programs, implement our Project Access Received Closer to Home (ARCH), sustain teleradiology services, and support a range of VISN initiatives.
In FY 2009 and 2010, VISN 12 received approximately $15 million to support projects serving Veterans in rural and highly rural areas. Iron Mountain received approximately $7.4 million dollars over the past 3 years to implement and sustain rural health programs. Examples of projects supported by ORH in the Iron Mountain region include expanded telehealth capabilities to include the provision of specialty services to Veterans in rural and highly rural areas; the Enhanced Rural Access Network for Growth Enhancement (E-RANGE) Program, which is designed to expand intensive case management services for Veterans with serious mental illness and outreach services for homeless Veterans; expanded primary and specialty care services; panic alarm installation; and home-based primary care with the Lac Vieux Tribe to address issues of access and quality of care for some of our most medically complex Veterans. Using ORH funding, the Manistique outreach clinic was opened in August 2009 to improve access for Veterans residing in the eastern Upper Peninsula. In the first full operational year, the clinic provided 2,042 patient care encounters. This fiscal year, the clinic already has provided 2,320 encounters to 470 Veterans. Rural health funds were also used to expand the Hancock CBOC. The 1,550 square foot expansion has enhanced patient flow, improved Veteran privacy, and facilitated a 19 percent increase in telehealth visits.
This fiscal year, ORH funding enabled Iron Mountain VAMC to implement on site cataract surgery, interventional pain management, and ENT clinics. To date, we have completed 20 cataract procedures, 658 pain management procedures, and 460 ENT encounters.
Locally Funded Projects
In addition to these efforts, we are supporting several initiatives to increase outreach, awareness and services in rural and highly rural areas. Iron Mountain VAMC helped pioneer the Veterans Directed Home Care Initiative, which allows Veterans to choose friends and neighbors to assist them with their activities of daily living and to be paid for their services. There are currently 31 Veterans receiving care through this program. We also expanded our Suicide Prevention Team for increased outreach and coordination of high risk services.
Transportation and lodging are challenges unique to the vast rural and highly rural areas we serve. Iron Mountain VAMC spent $1.9 million in FY 2008, growing to $2.4 million in FY 2009, and $3.4 million in FY 2010 for beneficiary travel between facilities, as well as to and from appointments. We lodged over 1,800 Veterans and their caregivers this past year to provide treatment without undue travel hardship. Our 35 passenger bus transports Veterans two times weekly to the Milwaukee VAMC for specialty care appointments, and our partners at Disabled American Veterans operate a shuttle program that logs more than 360,000 miles annually bringing over 5,200 Veterans to and from the main facility in Iron Mountain VAMC for appointments.
We have specific outreach efforts for Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). We send letters and place phone calls to recently discharged Service members, conduct site visits to demobilization sites, and attend job fairs, Yellow Ribbon Events, local Universities, Post-Deployment Health Reassessments and Welcome Home Events. We reach out to members of the National Guard and Reserve Units and assess all newly enrolled OEF/OIF/OND Veterans for community resource needs and care management. In addition, Veterans are referred into our program and to our Caregiver Support Coordinator as needed. Iron Mountain VAMC has more than 1,800 unique OEF/OIF/OND patients.
Recruitment and Retention of Medical Personnel
We understand the importance of offering proper incentives to ensure we have quality health care providers capable of delivering care to Veterans in rural areas. Nationally, there are several new incentives and training programs designed to provide our medical residents and other health professions trainees with educational opportunities in rural areas through collaboration with our academic affiliates. The Iron Mountain VAMC maintains active affiliations with Bay de Noc College for licensed practical nurses (LPN), registered nurses (RN), and phlebotomy students; with Northern Michigan University for RN, nurse practitioners, and social work students; with Northeast Wisconsin Technical College for RN; with Central Michigan University for physician assistants; with Michigan State University for social work students; and with Northeastern Wisconsin Technical College for phlebotomy students.
The Iron Mountain VAMC has actively recruited and retained staff while simultaneously improving relationships with community health care providers in the Upper Peninsula and Northern Wisconsin to broaden the continuum of care available to the Veterans we serve. In a rural, sparsely populated area, few facilities are able to offer the full range of services normally available in larger metropolitan areas. Strong collaborations with multiple health care providers, both public and private, are essential in meeting the needs of patients. Iron Mountain has grown from 499 staff employed in FY 2008 to 572 staff at the end of FY 2010, an increase of 73 positions and almost 15 percent. Of that increase, 67 of those positions are in direct patient care. Recruitment and retention incentives for clinical providers of over $2 million in 2010 and over $1 million in 2011 affords the Iron Mountain VAMC the opportunity to procure top notch clinical staff in multiple areas including but not limited to general surgery, internal medicine, emergency medicine, and primary care. The staffing increase accompanied a 31 percent increase in outpatient visits from FY 2008 through FY 2010, and an overall increase of six percent in unique Veterans served. During this same period, the Iron Mountain VAMC treated 54 percent more OEF/OIF/OND Veterans.
We have made significant investments in our telehealth programs and have seen remarkable growth in terms of Veterans utilizing these services. Telehealth uses information and telecommunication technologies to provide health care and increased access to care. It refers broadly to any encounter that involves the use of information and telecommunications technologies to deliver services in situations in which patient and health care provider are separated by geographical distance. VISN 12 was the first Network in VA to implement diagnostic telepathology, and it has been used between the Iron Mountain and Milwaukee VA Medical Centers since 1996, allowing the Iron Mountain VAMC access to multiple pathologists.
Expanded telehealth services have brought specialty expertise to Veterans in the Upper Peninsula. In FY 2010, we provided specialty care through telehealth to 1,631 Veterans and we expect to increase that number to more than 2,500 Veterans in FY 2011. This program has seen a 400 percent increase since 2008. More than half of these Veterans will only have to travel to the nearest CBOC to receive this specialty care. Work is progressing on the development of additional clinics including audiology, speech, spinal cord injury, and anesthesiology for pre-surgical clearance of Veterans receiving surgical procedures in Milwaukee, and a nephrology clinic that is scheduled to begin June 27, 2011. Current projections are that there will be more than 6,800 encounters completed in these programs in FY 2011, exceeding the FY 2011 target by 96 percent.
We initiated a teleretinal imaging program at the beginning of FY 2011. This program is focused on providing timely and convenient evaluation of retinal degeneration related to diabetes. Through May 2011, 109 patients had retinal images taken and forwarded to specialists at the Madison VAMC for evaluation.
Delivery of Mental Health Care
Mental health care is a critical component to overall health, and we understand the importance of ensuring Veterans can access this care. We have added 45 mental health providers over the last 5 years, which has improved the ability of Veterans to seek appointments and receive the evidence-based treatments they need. Mental Health staff (social worker and psychologist) is available for outpatient psychotherapy at every CBOC but Ironwood where a social worker is available. Telepsychiatry services are provided to Sault Ste. Marie, Manistique, Menominee, Rhinelander, Ironwood, and Iron Mountain. New FY 2010 and FY 2011 outpatient services include a Veterans Consumer Board, E-RANGE, Veterans Justice Outreach, Health Promotion/Disease Prevention, Peer Support Programming, and Homeless Programs (Housing and Urban Development-VA Supportive Housing, Short-Term Contract Housing, and Aging and Homelessness Program). In FY 2010, we provided mental health care to 3,217 Veterans through 31,000 encounters. This is more than twice as many Veterans as received care from Iron Mountain VAMC mental health programs in FY 2006.
VA ensures that treatment of mental health conditions includes attention to the benefits as well as the risks of the full range of effective interventions, with emphasis on all relevant, evidence-based modalities, including psychopharmacological care, psychotherapy, peer support, vocational rehabilitation, and crisis intervention. VA is focused on providing patient-centered, effective care by ensuring that when there is evidence for the effectiveness of a number of different treatment strategies, the choice of treatment should be based on the Veteran’s values and preferences, in conjunction with the clinical judgment of the provider. We have integrated mental health care delivery into the primary care setting to improve access and reduce the stigma that some perceive in seeking mental health care. The two exposure-based psychotherapies for which evidence has found an especially strong support for treatment of post-traumatic stress disorder (PTSD) are cognitive processing therapy (CPT) and prolonged exposure (PE). VA has trained more than 3,400 clinicians nationwide in the use of these treatments. Currently, we have certified seven clinicians and we are in the process of certifying 12 additional clinicians at the Iron Mountain VAMC in these treatments. Additional VA endorsed evidenced-based psychotherapies include Acceptance and Commitment Therapy (ACT), Social Skills Training, Cognitive-Behavioral Therapy-Depression (CBT-D), Cognitive-Behavioral Therapy-Insomnia (CBT-I), and Motivational Interviewing. We have 12 additional providers either certified or in process of completing these certifications.
Recruitment and Retention of Mental Health Professionals
The Iron Mountain VAMC Behavioral Health Service has grown tremendously over the last 5 years. Historically, recruitment of qualified psychologists has been a challenge. Our current staff of 14 psychologists is the largest single group in the Upper Peninsula of Michigan. Due to the rural setting, most staff recruited to the Department moved to the area from some distance. The poor housing market has adversely impacted many qualified providers’ ability to sell a home and move to the area. Recruitment and retention funding has been used to offset costs of moving to a rural region, which has increased our ability to bring on and keep qualified providers. Additional efforts at retention include utilization of the Student Loan Repayment Program for psychologists, but recruitment of qualified onsite psychiatry remains a challenge.
ORH Funded Mental Health Programs
With decreasing community mental health services available in the Upper Peninsula of Michigan, the E-RANGE team was established in Manistique to serve Veterans with seriously mental illness (SMI) in the Eastern Upper Peninsula (Marquette and Escanaba to the West, Sault Ste. Marie to the East). With one full-time social worker, one part-time social worker, one RN, and one peer support specialist, the E-RANGE team serves Veterans with mental health needs that cannot be met by typical outpatient psychotherapy and psychiatry. While stationed away from the Iron Mountain VAMC, the staff members utilize CBOCs community agencies (as available) for primary care and mental health (psychiatry) services. Assisting with medical and mental health care, social skills training, and recovery programming, the E-RANGE program has made a significant impact in the quality of life and medical health of our rural Veterans living with serious mental illness. For example, significant improvements in medical (e.g., improved glucose control), social (e.g., stabilized housing and community involvement), and mental health (e.g., medication compliance and significant reduction in psychiatric hospitalizations) have been attained. ORH funding has been utilized to expand CBOC space in anticipation of adding additional E-RANGE teams as funding is available. Current challenges include significant driving distances (7,500-8,000 miles per month), decreasing community-based resources, limited recovery and recreational activities available in rural regions, limited support from community hospitals, and maximized enrollment.
ORH funding is being used to provide biofeedback training and machines to each CBOC and the Iron Mountain VAMC. Biofeedback devices and stand-alone computers for data processing have been issued to each site, and the psychologists have completed the initial certification training. The trained psychologists continue to meet as a team for biofeedback program development. The addition of biofeedback to our Behavioral Health Service offers increased treatment options for Veterans living with anxiety, chronic pain, and hypertension, as well as many other medical and mental health conditions.
Telemental Health Program
Iron Mountain has been one of the Nation’s leaders in implementation of telemental health services. Currently, we employ two full-time psychiatrists and one part-time psychiatrist who are physically located at other VA and non-VA facilities and provide telepsychiatric services to the Medical Center and CBOCs. Our two full-time onsite psychiatrists and one part-time onsite psychiatrist provides telepsychiatric services to our CBOCs on a regular and as-needed basis. Since FY 2010, we have successfully operated a telepsychiatry substance abuse/addiction clinic with Madison VAMC. We are in process of hiring a part-time addiction psychiatrist, who will provide teleaddiction services to the Iron Mountain VAMC and CBOCs. In 2008, we averaged approximately 75 unique telepsychiatry appointments per month; currently, we are averaging 650 unique telepsychiatry appointments a month. Additional teleservices provided by Behavioral Health staff include: emergency clinic coverage, PTSD groups, gender-specific psychotherapy, evidence-based psychotherapies, and staff training and education. Current challenges include scheduling, coordinating care, supporting staff, managing cases, and balancing between the critical need for onsite services and demand for increased teleservices.
Escanaba Vet Center
Vet Centers are another venue through which VA provides Veterans with necessary counseling and support. Vet Centers provide community outreach, professional readjustment counseling for war-related readjustment problems, and case management referrals for combat Veterans. Vet Centers also provide bereavement counseling for families of Service members who died while on Active Duty. In the Upper Peninsula, VA operates the Escanaba Vet Center, and in FY 2010, provided readjustment counseling services to 390 Veterans and their families (3,071 encounters). Mobile Vet Centers provide outreach and direct readjustment counseling at active military, Reserve, and National Guard demobilization activities. Since beginning operation in 2009, the Escanaba Mobile Vet Center has completed 50 outreach events. The Iron Mountain VAMC Behavioral Health Service provides face-to-face and telesupervision to Vet Center staff. Teleconferencing is available at the Vet Center for clinical (psychiatry) and administrative (supervision) needs. Additionally, Iron Mountain VAMC has initiated peer support programming in collaboration with Vet Center staff to develop a Co-Occurring Recovery Program located at the Escanaba Vet Center.
Home-Based Primary Care
Not all Veterans are able to routinely travel to see their primary care provider at the Iron Mountain VAMC or the nearest CBOC. In FY 2008, the Iron Mountain VAMC started a Home-Based Primary Care program, and we added an additional location in FY 2009 in Watersmeet, Michigan. These programs take primary care to the patient’s home, expanding access to care and benefits, and providing health education to this unique Veteran population. The two programs have made tremendous progress since they opened and have served more than 200 Veterans. The Veterans served by these programs have seen a 16.9 percent reduction in inpatient admissions and a 76.3 percent reduction in inpatient bed days of care. There are currently 74 Veterans enrolled in the Home-Based Primary Care program. Through May 2011, 118 Veterans have received care through this program. This is more than three and a half times the number that were cared for in 2008 when the program started.
Partnerships with Community Providers
We provide exceptional care in the VA system, but understand there are times when a Veteran needs services that are not available in our facilities. As a result, we maintain robust partnerships with a range of community providers to ensure Veterans receive the care they have earned. These partnerships include collaborations with other governmental organizations, as well as with the private sector. We also utilize community providers in the private sector to deliver care to Veterans in the community.
Iron Mountain remains committed to providing the care Veterans deserve not only from our main facility and related CBOCs but also by purchasing care from Upper Peninsula and Northern Wisconsin facilities and providers. We purchased over $12 million worth of care in FY 2008, $18 million in FY 2010, and we are on pace to purchase $16 million worth of care this fiscal year. Currently, we have six fee basis providers from within the community to supplement care in areas such as ophthalmology, orthopedics, general surgery, podiatry, and behavioral health.
As previously mentioned, Iron Mountain has a passenger bus that travels to the Milwaukee VAMC two times a week. The bus is used to carry enrolled Veterans and their caregivers to specialty care appointments. It has the capacity to carry 35 passengers, and the average number of travelers per trip is 25. We have an ambulance contract with a local ambulance company that is utilized to transfer and pick up patients to and from other facilities as needed for care. We also have a contract with a local company to provide transportation services for those enrolled Veterans that do not require an ambulance to be used to transport them.
We coordinate with all VISN facilities to transfer patients who need services and care we cannot provide. If VISN facilities are not available, we utilize Dickinson County Healthcare System in Iron Mountain; Bellin, St. Vincent, Aurora Bay Care and St. Mary’s in Green Bay, Wisconsin; and Marquette General Hospital in Marquette, Michigan. For Behavioral Health issues we utilize Milwaukee VAMC, Tomah VAMC, Madison VAMC, Battle Creek VAMC, and at times Marquette General Hospital and War Memorial Hospital in Sault Ste. Marie, Michigan.
For pharmacy coverage after hours, we utilize the pharmacy staff at the Milwaukee VA to review all orders. Pharmacy is staffed at the Iron Mountain VAMC from 7 am until 10 pm.
We recently accepted a bid from Dickinson County Healthcare System to dock our magnetic resonance imaging unit at their campus until the construction of the second floor of our outpatient department is completed. We began using our MRI at that location earlier this month.
We have purchased care agreements in place with local hospitals for each CBOC to complete mammograms and any urgent diagnostic tests. In Iron Mountain, we utilize Dickinson County Healthcare System and the local Marquette General outpatient clinic for mammograms, the Veteran decides where they prefer to go. We have a telehealth contract to provide services to read x-rays, computed tomography images, ultrasounds, and other radiological studies on off-tours and weekends.
Using ORH funds, the Home- and Community-Based Care program was significantly expanded. We purchased services from approximately 50 home health agencies and other community providers in our service area to provide care to our enrolled Veterans. The program went from serving 111 unique Veterans in FY 2008, to 418 in FY 2009, and 456 in FY 2010. This initiative targets Veterans who are most at risk for institutional long-term care and helps them function as independently as possible in the comfort of their own homes. When necessary, we collaborate with 10 local community nursing homes and one adult day care to provide services for Veterans that permit them to be close to family and friends.
Thank you again for the opportunity to discuss the work VA is doing to improve access and quality care for Veterans in the Upper Peninsula of Michigan. I am proud of the work the employees at the Iron Mountain VAMC and its CBOCs do every day to deliver the best health care possible to America’s Veterans. My colleagues and I look forward to answering your questions.