Witness Testimony of Donna M. Beiter, Director, VA Greater Los Angeles Healthcare System, VISN 22, Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Chairman Benishek, Ranking Member Brownley, and members of the Committee. Thank you for the opportunity to discuss the VA Greater Los Angeles Healthcare System’s (GLA) commitment and accomplishments in providing Veterans high quality, patient-centered care and being a leader in health care transformation; specifically, by improving mental health outcomes and access to mental health services and programs. I will begin my testimony with an overview of GLA and then focus on our comprehensive mental health programs.
Greater Los Angeles Healthcare System Overview
GLA is accredited by The Joint Commission and is one of the largest and most complex facilities within VA. We serve Veterans throughout Kern, Los Angeles, San Luis Obispo, Santa Barbara, and Ventura counties. GLA is located in West Los Angeles, California with large ambulatory care centers in downtown Los Angeles and Sepulveda; Community-Based Outpatient Clinics (CBOC) located in Bakersfield, Gardena, East Los Angeles, Lancaster, Oxnard, Santa Maria, Santa Barbara, and San Luis Obispo; and a clinic in development in the San Gabriel Valley. In fiscal year (FY) 2013, GLA treated 86,438 Veterans with 28,070 receiving care in our mental health programs. Since the beginning of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND), GLA has enrolled 20,696 Iraq and Afghanistan Veterans, with over 9,700 Veterans treated in FY 2013. Of the Iraq and Afghanistan Veterans treated in FY 2013, 30 percent received care in our mental health programs.
GLA has been involved in several major redesigns of our health care programs over the last few years, particularly by completing the move to a new patient-centered primary care delivery model called Patient Aligned Care Teams (PACT). A PACT team is comprised of a medical provider, nurse care manager, and a clinical and administrative coordinator, all of whom care for and assist the Veteran with navigating his or her whole health experience. The team focuses on engaging Veterans in their own care by helping Veterans identify and set goals, and by teaching them skills they can use to improve their health. The PACT team works together to ensure access and communication with the Veteran and coordination with the rest of the health care organization and the Veteran’s local community. Along with and consistent with the overall PACT model, primary care – mental health integration has been an integral part of primary care at GLA with mental health providers embedded in primary care settings. Additionally, GLA has implemented both general telehealth and also telemental health services to Veterans in our catchment area.
As a leader in health care transformation, GLA has been designated a National Center of Innovation for Patient-Centered Care. The focus of our Center of Innovation is to develop and spread integrative health and healing alternative initiatives, such as Tai Chi, acupuncture, mindfulness-based stress reduction, guided imagery, and breathing/stretching/relaxation exercises. Our plan is to continue to expand these initiatives as a standard part of care for all Veterans at all GLA sites utilizing
tele-technology, Web based platforms, and train-the-trainer approaches. Our plan is that these alternative care therapies will be available at the Oxnard, Santa Maria, and Bakersfield clinics by April 2014.
GLA has implemented new innovative strategies in the area of eliminating Veterans’ homelessness. GLA collaborates with numerous community partners to end homelessness among Veterans, such as Los Angeles City, Los Angeles County, the Department of Housing and Urban Development (HUD), Public Housing Authority, and many other community partners. A 28 percent reduction in Veterans’ homelessness in LA City and LA County between 2010 and 2012 was achieved through these successful community partnerships. We continue to target the most chronically homeless Veterans with a focus on getting the most vulnerable Veterans off the streets and into permanent housing using a Housing First approach.
Mental Health Care
Mental health services at GLA are unified under an interdisciplinary Mental Health Care Line (MHCL). GLA’s MHCL is expanding its implementation of the Recovery Model which is patient-centered, empowers Veterans, and works with Veterans to attain the highest level of independent functioning possible for each Veteran. GLA provides an extensive range of mental health outpatient services at three major sites (West Los Angeles, Los Angeles Ambulatory Care Center, and Sepulveda Ambulatory Care Center) as well as the eight CBOCs.
Comprehensive treatment programs for substance use disorders are available at the three major sites, including intensive outpatient programs based on the Matrix Model (a cognitive behaviorally-oriented approach) as well as Opiate Treatment Programs (methadone maintenance or Suboxone treatment). The Harm-Reduction Model is also utilized at the three main campuses. Alcohol detoxification is available for homeless Veterans at the West Los Angeles campus. Negotiations are in the final stages to make inpatient detoxification services available to all Veterans (including non-homeless Veterans and Veterans withdrawing from drugs other than alcohol) at a community-based facility in the GLA basin through the TriWest contract program as part of VA’s Patient-Centered Community Care (PC3) initiative. GLA is also in the process of developing a partnership with Kern County Mental Health to provide inpatient detoxification for Veterans who are enrolled in the Bakersfield Clinic. GLA will be making substance use disorder treatment, inpatient mental health treatment, and specialized outpatient mental health treatment available to Veterans at northern CBOCs through the PC3 program, and contracts are being negotiated with TriWest. This will help Veterans who live at a distance from the three major campuses obtain these services closer to their homes.
In addition to comprehensive substance use disorder treatment, GLA offers an extensive array of traditional and non-traditional mental health services. Services include evidence-based pharmacotherapy and evidence-based psychotherapy for the treatment of a very wide range of mental disorders including post-traumatic stress disorder, anxiety disorders, mood disorders (including depression and bipolar disorder) and schizophrenia. Among the evidence-based psychotherapies that are available are cognitive behavior therapy for depression, acceptance and commitment therapy for depression, cognitive-behavior therapy for insomnia, prolonged exposure therapy and cognitive processing therapy for post-traumatic stress disorder, and social skills training for patients with serious mental illness, such as schizophrenia. GLA mental health staff have been trained in a number of other evidence-based psychotherapies as well, integrated behavioral couples therapy, motivational interviewing and enhancement, and problem-solving therapy consistent with VA’s evidence-based therapy initiative. In addition, as described earlier, complementary and alternative medical practices such as mindfulness-based stress reduction are incorporated into many mental health clinics and programs.
Primary Care-Mental Health Integration (PC-MHI) has been available to Veterans at the West Los Angeles Medical Center since its inception in 2007 and at the Sepulveda Ambulatory Care Center, where the emphasis is on giving patients same-day access when needed and close collaboration with primary care providers to promote both mental health and medically-healthy behaviors. PC-MHI has recently become available at the Los Angeles Ambulatory Care Center campus and is in the process of being implemented at the Santa Maria, Oxnard, and Bakersfield CBOCs. GLA currently has two Veterans Transition Centers/Post-Deployment Clinics where mental health services are provided to OEF/OIF/OND Veterans in an integrated primary care setting at the Sepulveda and West Los Angeles sites. Separate clinics for meeting the mental health needs of female Veterans are available at the three major sites in primary care settings.
Inpatient mental health care is provided at the West Los Angeles Medical Center where there are currently 45 operational inpatient beds available to Veterans who are in need of acute inpatient care due to the severity of their mental health condition.
GLA also has a long-established Domiciliary Residential Rehabilitation Treatment Program, which has 296 operational beds. The Domiciliary is located at the West Los Angeles Medical Center and serves Veterans from all GLA facilities as well as from other VA facilities in Veterans Integrated Service Network (VISN) 22 (e.g., VA Southern Nevada Healthcare System in Las Vegas). The Domiciliary offers residential treatment programs for Veterans who have experienced post-traumatic stress disorder (PTSD), for Veterans who are homeless, for Veterans with substance use disorders, and for Veterans who are attempting to return to competitive employment. Our Domiciliary also can accommodate Veterans who prefer to receive care in a single-gender setting.
Oxnard Mental Health Clinic
As Veteran demand for outpatient mental health appointments has grown, GLA has strived to build capacity and keep up with the demand at the Oxnard Mental Health Clinic. Staffing and space issues have posed limitations, and we have deployed a number of strategies to keep up with demand and meet our patients’ needs. Since October 1, 2013, each week approximately eight to ten new Veterans are seen for mental health services at the Oxnard Clinic. Additionally, we provide care to 1,152 established mental health patients for whom we provide ongoing care. To improve access and increase our capacity for mental health services at the Oxnard Clinic, we have brought on additional mental health providers, including permanent, fee basis, and locum tenens providers. With the addition of these new mental health providers, we will meet current demand.
A limited number of offices are available in the current space at the Oxnard Clinic, and as demand for mental health care services grew, office space became increasingly insufficient. In preparation for the upcoming contract renegotiations, mental health space will be more than doubled. In the interim, we consolidated other clinical work and moved two administrative staff out of a shared office to increase the mental health working space to five individual rooms and one group room.
One of the innovations to increase capacity at the Oxnard Clinic is the expansion of clinical video telemental health. This technology allows Veterans to come into the clinic and see a mental health provider who is based at a distant site. This fiscal year, telemental health providers have provided care to 100 unique patients in the first quarter, FY 2014 alone, whereas they provided care to a total of 155 unique patients during the previous year. Staffing for Oxnard telemental health is currently the equivalent of a 0.5 full-time equivalent (FTE) remote provider. We have also been part of a VISN project with our partners at the VA San Diego Healthcare System to offer evidence-based intensive psychotherapy to Oxnard patients via telehealth at the Oxnard Clinic with expert providers located in San Diego. Currently, we are developing an implementation plan to deploy Jabber, one of VA’s latest innovations where patients who need counseling can be evaluated from their homes on their own personal computer screens.
Our process of electronic consultation allows review of the specific Veteran’s needs and referrals electronically and telephonically, as appropriate. Some patients’ needs can be met through email with the primary care provider on the same day or through a phone call. Veterans can be seen at any VA facility if they have an urgent need, and if they choose to travel (potentially with reimbursement or via VA transportation). In cases where we have fallen behind in timeliness, we have offered this option to Veterans in Oxnard, and they have been seen sooner at Sepulveda or Santa Barbara. So far this year, we have received 246 consults, which are new, returning, or multidisciplinary (to psychology, psychiatry, and social work). We are actively scheduling these patients with the new staff recently brought on board.
Oxnard Homeless Veterans/Veterans Justice Outreach Program
Ending Veterans homelessness is a national initiative involving VA, HUD, Federal, state, local authorities, and community partners. In Oxnard, the HUD-VA Supportive Housing voucher program and Homeless Outreach team have been focusing on connecting homeless Veterans to VA services. The Homeless Outreach team is also connected with the Veterans Justice Outreach Program. We are in preliminary discussions with the courts to bring Veterans out of jail and into homeless programs. Veterans need to participate and successfully complete a treatment program and take the needed steps to return to productive lives to demonstrate to the Judge their desire to turn their lives around and become productive citizens. Successful completion of their program is an alternative to incarceration and results in charges being stayed or dropped. We are exploring potential substance use disorder treatment programs for homeless Veterans to support their recovery process. Currently, we have fee-basis funding for Veterans who need substance use disorder treatment or other residential mental health treatment in Ventura County. In the near future, we will have TriWest contracts through PC3 for community programs appropriate for Veteran care.
Mental Health Performance Metrics
VHA has developed many metrics to monitor performance in the delivery of mental health services. These monitors include the following:
- Patients who are discharged from acute inpatient mental health treatment should receive follow up contact within 7 days. VHA’s goal is that 75 percent of Veterans in this category should have such contact within 7 days. Through the first 4 months of FY 2014, GLA has successfully contacted 86.5 percent of Veterans discharged from acute inpatient mental health treatment for follow up within 7 days of discharge.
- Qualifying Veterans should have a Mental Health Treatment Coordinator (MHTC) assigned to them. VHA’s goal is that 87 percent of qualified Veterans should be assigned an MHTC. GLA had 89.6 percent of qualifying Veterans assigned to an MHTC as of December 2013.
- OEF/OIF/OND Veterans diagnosed with PTSD are expected to have eight evidence-based psychotherapy sessions, an approach to therapy supported by research findings where the findings provide evidence that is effective, over a 14-week period. VHA’s target is 83.3 percent of Veterans will receive eight sessions in a 14-week period. Although in first quarter, FY 2014, GLA was at 57 percent, the December 2013 data was at 86.8 percent.
- In FY 2013, VHA redefined access measures for new and established (i.e., received mental health care in the last 24 months) Veterans in mental health care. For Veterans who have established mental health treatment, VHA tracks the percentage of Veterans who are able to schedule an appointment within 14 days of their desired date, which is VHA’s goal. The FY 2014 target for this is 95 percent. During this fiscal year, GLA MHCL has achieved that goal 96.8 percent of the time. At the Oxnard CBOC, the goal is met 91 percent of the time.
- For Veterans who are new to mental health care, the GLA tracks VHA’s goal of having Veterans complete an initial appointment in 14 days or less from when they made the request for the appointment. VHA’s target is 70 percent. Targets were adopted in roughly November of 2013 after reviewing the baseline performance in 2012. The Access and Clinic Administration Program (ACAP) and Office of Informatics and Analytics (OIA) were asked to suggest targets. VHA analyzed performance levels, variation, trends, and used standard methods (methods used to establish other targets) to arrive at the current goal levels. For FY 2014, the GLA MHCL has provided this level of access 56 percent of the time and 40 percent of the time at the Oxnard Clinic. VA intends to add new staff to improve these percentages and decrease wait times for appointments over 45 days. Any Veteran in crisis presenting to the CBOC or calling in is seen immediately.
Ventura County Community Partnerships
GLA and the Oxnard CBOC make use of multiple community programs and resources. This includes many different faith-based and non-profit programs. VA believes it is vitally important that we network with our community partners in the delivery of health care. These community partners have been strong allies in our efforts, and we appreciate their contributions to our Veterans’ health and welfare.
GLA has three full-time Suicide Prevention Coordinators (SPC) located at the West Los Angeles, Sepulveda, and Santa Maria sites. The SPCs provide ongoing information, education, and consultation to GLA administrators, leaders, and staff regarding policy related to suicide prevention and risk reduction, including the identification and assessment of risks for suicide, safety planning, follow up, and engagement in care and crisis/emergency responses. SPCs also respond to national Veterans Crisis Line referrals, aggregate suicide data with GLA and VISN 22 VA facilities, participate in root cause analyses of suicide-related events and Environment of Safety rounds, and provide regular outreach to state and community agencies, local colleges, Veterans Service Organizations, and health, safety, employment, public affairs, and military-related events.
VHA, GLA, and the Oxnard Clinic are committed to providing high-quality care our Veterans have earned and deserve, and we have continued to improve access and services to meet the mental health needs of Veterans. We appreciate the opportunity to appear before you today and the resources Congress provides VA to care for Veterans. My colleagues and I are happy to respond to any questions you may have.