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Witness Testimony of Ms. Linda D. Smith, FACHE, Medical Center Director, Cincinnati VA Medical Center, 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 Cincinnati VA Medical Center’s (VAMC) efforts to provide high quality care, specifically mental health care, to Veterans in our catchment area and our pilot Veterans Transportation Service.  I am accompanied today by Dr. Kathleen Chard, Director of the Trauma Recovery Division of our Mental Health Care Service Line, and Professor of Psychology and Behavioral Neuroscience at the University of Cincinnati, College of Medicine; Emma Bunag-Boehm, Primary Care Provider for the Post-Deployment Clinic, Cincinnati VAMC, and Mr. Chad Watiker, Cincinnati Vet Center Team Leader.
I will begin my testimony with an overview of the Cincinnati VAMC.  I will then focus on our comprehensive mental health programs and end with a brief overview of the Veterans Transportation Service, which has improved access to care for many of our Veterans.

Cincinnati VAMC Overview
The Cincinnati VAMC is a two-division campus located in Cincinnati, Ohio and Fort Thomas, Kentucky.  The Medical Center serves 17 counties in Ohio, Kentucky, and Indiana with six Community-Based Outpatient Clinics, located in Bellevue, Kentucky; Florence, Kentucky; Lawrenceburg, Indiana; Hamilton, Ohio; Clermont County, Ohio; and Georgetown, Ohio.  The Cincinnati VAMC is a tertiary referral facility.  We are a highly-affiliated teaching hospital, providing a full range of patient care services, with state-of-the-art technology, medical education and research capabilities.  The Medical Center provides comprehensive health care through primary care, dentistry, specialty outpatient services, and tertiary care in areas of medicine, surgery, mental health, physical medicine and rehabilitation, and neurology.
Our facility is the Veterans Integrated Service Network (VISN) 10 referral site for a number of surgical and medical programs and a regional referral center for posttraumatic stress disorder (PTSD).  The PTSD program at the Fort Thomas division of the Cincinnati VAMC in northern Kentucky also provides training to practitioners from various active duty military branches and other VAMCs.  Our Inpatient Mental Health Unit is frequently visited by other VA facility staff to learn about our Recovery Model of Care.
The Cincinnati VAMC has an active affiliation with the University of Cincinnati College of Medicine and is connected both physically and functionally to the University.  Over 500 fellows, residents, and medical students are trained at the Cincinnati VAMC each year.  In addition, there are also over 85 other academic affiliations involving dentistry, pharmacy, nursing, social work, physical therapy and psychology.
The Cincinnati VAMC is fully accredited by The Joint Commission, the College of American Pathologists, the Commission on Cancer of the American College of Surgeons, the Commission on Accreditation of Rehabilitation Facilities, the Accreditation Council on Education, the Accreditation Council for Graduate Medical Education, the American Association of Cardiovascular and Pulmonary Rehabilitation and accrediting bodies for residencies in Optometry, Pharmacy and Radiology.  Our research programs are also fully accredited.
Over 42,000 Veterans are enrolled in VA health care through our facility.  This number includes over 3,600 female Veterans and 3,500 Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans.  Growth in terms of enrolled Veterans has increased by over 4 percent this fiscal year (FY) and approximately 25 percent over the past 5 years.  We also have seen a 13percent increase (322 cases) in surgeries performed and a 15 percent increase in referrals from other VAMCs this fiscal year compared to FY 2012.
The Cincinnati VAMC recently volunteered for the first VA survey of our Patient Aligned Care Team (PACT)/Medical Home Program by The Joint Commission and was commended for the quality of care and services we provide.  Seventeen out of 43 four-person teams (physician, nurse, licensed practical nurse, and clerk) received national PACT recognition from the Veterans Health Administration.  We also recently implemented a Hospital in Home Program that has enrolled over 100 Veterans since February 2013.  This program has allowed us to avoid admission of Veterans to an inpatient unit by providing daily services in the home, thus avoiding some health care expenses.  Since the program began in February 2013, we estimate a cost savings of over $700,000 and a 245-day reduction in Bed Days of Care.
Our facility continues to grow in order to meet increased demand for services.  Construction projects include a recently-completed parking garage, a new imaging center, patient-centered renovations to our first floor, a new research building which will break ground in September 2013, an off-campus, state-of-the-art Eye Center, an ambulatory surgery center, and an expansion of our operating rooms.  We also have a number of construction projects of interest to include: a Sleep Study Center, a new Traumatic Brain Injury (TBI) Clinic and new Community-Based Outpatient Clinics in Florence, Kentucky and Georgetown, Ohio.
The Cincinnati VAMC has 15 full-time staff in the OEF/OIF/Operation New Dawn (OND) clinic providing primary care, mental health care, social work services, and pain management care for military personnel returning from Iraq, Afghanistan, and all recent combat theatres.  Efforts to reach returning military personnel involve redeployment briefings, post-deployment briefings, family readiness meetings, local Veterans Service Organizations meetings/functions, community events and letters, and personal phone calls to recently-discharged Servicemembers.  Our pilot Veterans Integration to Academic Leadership Program (VITAL) places a psychologist on local college and university campuses with the sole task of connecting with student Veterans and providing services on-site.  The Post Deployment Integrated Clinic model of care and outreach efforts by the Cincinnati VAMC staff for the OEF/OIF/OND population are considered best practices within VA.  As a result, we have been able to enroll approximately 65 percent of eligible OEF/OIF/OND Veterans in our catchment area.
One of the most exciting new initiatives at the Medical Center is our Tele-Intensive Care Unit (ICU), which allows the delivery of critical care services across a geographic distance through the use of electronic devices and connections.  Critical care nurses and physicians perform sophisticated 24/7 remote monitoring of Veterans in VA critical care units throughout the State of Ohio and soon will be monitoring critically-ill Veterans in the VA Southeast Network (VISN 7).

Trauma Recovery Center
The Cincinnati VAMC’s Trauma Recovery Center consists of an outpatient PTSD clinical team (PCT) and a Residential PTSD Program.  The PCT offers eligible individuals individual family education, medication management, and
evidence-based PTSD treatments in individual, group, and couples formats including Prolonged Exposure and Cognitive Processing therapy (CPT), Couples-Based PTSD treatment, Virtual Reality Therapy and Dialectical Behavior Therapy.
The Residential PTSD Program, described in Veterans Health Administration (VHA) Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program, is a 7-week, cohort-based program for men and women and an 8-week program for Veterans with PTSD and a history of TBI.  The Residential programs are unique and highly-successful programs that have been featured in national media for their patient-centered, evidence-based treatment programs for PTSD.  In addition to utilizing CPT, the residential groups focus on anger, communication, distress tolerance, life skills, interpersonal effectiveness, nutrition, communication, and sleep.  The women’s residential program was identified as a best practice, and the TBI/PTSD residential program is the only one of its kind in the Nation.
The Cincinnati VAMC also provides care and services, including counseling, to Veterans who have experienced military sexual trauma (MST) and come to VA for care.  Under Title 38 United States Code, Section 1720D, VA is authorized to provide counseling and appropriate care and services, as required, to Veterans to overcome “psychological trauma, which in the judgment of a mental health professional employed by the Department, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the veteran was serving on active duty or active duty for training.”  Section 1720D defines sexual harassment as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”

Mental Health Care
Mental health services at the Cincinnati VAMC are unified under a multidisciplinary Mental Health Care Line (MHCL).  A comprehensive variety of mental health services is offered by the seven divisions of the MHCL.  The divisions are Outpatient Mental Health, Substance Dependence, Assessment and Intensive Treatment, Trauma Recovery Center, Domiciliary Care for Homeless Veterans, Community Outreach, and Special Services.  Presently, the MHCL employs
30 psychiatrists, 53 psychologists, 72 social workers, and 83 nursing personnel.  The total number of staff working for the MHCL is 303.  From FY 2007 to FY 2012, our MHCL staffing grew approximately 74 percent, and the number of Veterans treated grew 55 percent.  In the first 10 months of FY 2013, the MHCL provided care to approximately 15.5 percent more Veterans than were seen over the similar period in FY 2012.  That amounts to an additional 1,482 unique Veterans.  During this period of growth, the Cincinnati VAMC has been successful in recruiting highly-qualified, mental health staff in all professions.  
VHA has developed many metrics to monitor performance in the delivery of mental health services.  These monitors include the following:
1)    Patients who are discharged from acute inpatient mental health treatment have follow up within 7 days.  VHA’s goal is that 75 percent of Veterans in this category should have contact.  This year, the Cincinnati MHCL has successfully contacted approximately 85 percent of Veterans discharged from acute inpatient mental health treatment for follow up.
2)    Qualifying Veterans should have a Mental Health Treatment Coordinator (MHTC) assigned to them.  VHA’s goal is that 75 percent of qualified Veterans should be assigned an MHTC.  The Cincinnati MHCL currently has approximately 85 percent of qualifying Veterans assigned to an MHTC.  As new Veterans access Mental Health services, assignment of an MHTC is part of the treatment planning process.  
3)    In the OEF/OIF/OND clinic, Veterans diagnosed with PTSD who agree to treatment are expected to have 8 evidence-based psychotherapy sessions over a 14-week period.  VHA’s target is that 67 percent of Veterans who agree to treatment receive 8 sessions in a 14-week period.  The Cincinnati MHCL is currently at approximately 72 percent.
4)    In FY 2013, VHA began using two measures to evaluate Veteran access to mental health care.  For Veterans who have established mental health treatment, the Medical Center 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 Cincinnati MHCL has achieved that goal approximately 99 percent of the time.  For Veterans who are new to seeking mental health care, the Medical Center tracks VHA’s goal of having Veterans complete an initial appointment in 14 days or less of when the appointment was made.  For FY 2013, the Cincinnati MHCL has provided this level of access approximately 83 percent of the time.  In July 2013, the average wait time for a new mental health care patient’s first appointment was 8 days, and approximately 85 percent of Veterans had their first appointment within VA’s goal of 14 days.  In the most recent VA Strategic Analytics for Improvement and Learning report, the Cincinnati VAMC received an outstanding 5-star quality rating which included the category “Mental Health Wait Time.”

While these metrics are important, we realize they tell only part of the story of Cincinnati VAMC’s mental health accomplishments.  In addition to the aforementioned Trauma Recovery Center, Cincinnati has an array of strong mental health services.  For example, the acute inpatient mental health ward has 20 beds and has received multiple national recognitions for its patient-centered, recovery-oriented program.  The Substance Dependence Division is also strong as a leader in tobacco cessation treatment and ambulatory detoxification.  Our opiate substitution program is an important resource for local Veterans.  Our Primary Care Mental Health Integration Program has one of the highest rates of utilization in the Nation.  For 2013 to date, the VAMC had 1,717 tele-mental health encounters, an 89 percent increase over FY 2012, and as a result, increased access to care for Veterans and reduced requirements for travel.
The Cincinnati MHCL has had a Family Services Coordinator for many years, supporting the families of Veterans with severe mental illness.  We are responding to the new generation of OEF/OIF/OND Veterans with programs such as brief family consultation, Support and Family Education, Behavioral Family Therapy, and couples counseling.  A VHA-funded research project, Couple-Based Treatment for Alcohol Use Disorders and PTSD, is investigating the effects of couple-based counseling for alcohol dependency, PTSD, and partner relationships.  The Cincinnati VAMC has also been chosen as a site for the Practical Application of Intimate Relationship Skills (PAIRS) program.  This is a 9-hour, intensive weekend training program to improve a Veteran’s relationship with their partner.

Homeless Programs/Initiatives
The Cincinnati VAMC is also working actively with many other Federal, state, and local entities to meet Secretary Shinseki’s goal of ending homelessness among Veterans in 2015.  The homeless programs at the Cincinnati VAMC are robust, consisting of strong outreach/community partnerships, Grant and Per Diem (GPD), Housing and Urban Development/Veterans Affairs Supportive Housing (HUD/VASH), Health Care for Homeless Veterans (HCHV) contract beds, and Veterans Justice Outreach (VJO) programs.  We have developed a Homeless/Low Income Resource Guide and the HUD/VASH Quarterly Newsletter that VA Central Office recognized as best practices.  Our VJO program was featured in a recent rehabilitation accreditation newsletter, CARF International’s “Promising Practices Innovation in Human Services,” April 2013.  
On May 3, 2013, the Cincinnati VAMC held its 4th Annual Homeless Summit, which was attended by a broad base of community partners, including Joseph House, Greater Cincinnati Behavioral Health, Talbert House, Drop Inn Center, and Strategies to End Homelessness.  Additionally, the Cincinnati VAMC works closely with numerous faith-based organizations, such as City Gospel Mission, Interfaith Hospitality Network, St. Francis/St. Joseph Catholic Worker House, Mercy Franciscan at St. John’s, and the Mary Magdalen House.
The Community Outreach Division of the MHCL, under which the homeless programs fall, will be moving to Downtown Cincinnati this month to a strategic location allowing increased access and walk-in service.  A portion of the division will remain in Fort Thomas, Kentucky to allow access for homeless Veterans in Northern Kentucky.  Listed below are the homeless programs and initiatives available through the Cincinnati VAMC:
GPD - We have 173 beds, including seven beds for female Veterans.  Our programs run at capacity and have a high success rate, short length of stay, and low cost per episode.
HUD/VASH - We have 275 vouchers in Hamilton and Clermont counties in Ohio and Northern Kentucky and were awarded an additional 40 vouchers for
FY 2014.  The Cincinnati VAMC was among the first medical centers in the Nation to incorporate Housing First principles within HUD/VASH by piloting a
25-voucher program in October 2010 and retooling the entire program to incorporate Housing First principles in March 2011.  According to the Homeless Operations Management Evaluation Systems (HOMES) Database, our chronically homeless housed rate is approximately 89.26 percent, among the highest in the Nation.  We finished FY 2012 with a 94.84 percent housed rate and the Medical Center is on target to exceed that rate in FY 2013.
HCHV Contract Beds - We have 12 beds (six, two-bedroom apartments) under this program.  Each bedroom is private and locked, ensuring safety, security, and privacy.
Veterans Justice Outreach - We actively collaborate with four operational Veterans Treatment/Diversion Courts and look forward to collaborating with a fifth court in the planning stages moving towards implementation.  The addition of this fifth court will give us partnerships with Veterans Treatment Courts in all three states within our catchment area, providing Veterans with help in meeting treatment goals instead of incarceration.

Veterans Transportation Service (VTS)
Recognizing that increasing access to care improves health care outcomes, the Cincinnati VAMC began operation of the VTS in May 2012, offering both mobility management and transportation services.  Mobility management guides Veterans to the most medically-appropriate and cost-effective means available through a private, Veteran-focused agency or public transportation resources.  VTS fills the remaining gaps, providing door-to-door, wheelchair-accessible transportation for those Veterans living in the Medical Center’s catchment area who have no other viable transportation options.  VTS has served 750 unique Veterans, approximately 40 percent of whom are wheelchair-bound, providing nearly 10,000 rides, since its inception.

Community Partnerships
The Cincinnati VA has been building community mental health partnerships by holding annual homelessness prevention summit meetings for the past 4 years.  Those summit meetings inspired our development of the Cincinnati Homeless/Low Income Resource Guide.  In addition to having been cited by VHA as a best practice, the guide has become a highly valued document for community agencies.  Based on events like the homelessness summits, VHA has been holding Community Mental Health Summits during the Summer of 2013.  
In August 2013, the Cincinnati VAMC hosted its first Community Mental Health Summit.  At the Summit, facility leadership and staff met with 66 individuals from 36 community agencies.  The facility was joined by staff from the local delegation of Members of Congress, one state agency, one county agency, and six universities.
Presentations were made on the following topics:
University Liaison.  The Cincinnati VAMC has a well-established outreach program which partners with local colleges and universities to ease the transition of Veterans seeking higher education.
PTSD Treatment.  Cincinnati MHCL discussed its programs with Dr. Chard speaking on this topic.
Suicide Prevention.  Each VAMC has been allocated at least one full time suicide prevention coordinator.  The MHCL has 3 full time social workers devoted to this task.  VHA works steadily to reduce stigma associated with receiving mental health care.  VHA has declared that September 2013 is Suicide Prevention Month, and VHA is sponsoring the public service announcement “Talking About It Matters”.  During September 2013, the Cincinnati MHCL Suicide Prevention team will give 11 presentations in the community focusing on eliminating the stigma that complicates preventing suicides.
At the Mental Health summit, there was considerable open exchange of detailed information about mental health programs and services available through VA and in the community.  This was an opportunity to share ideas and promote further collaborations. Particular suggestions that emerged included annual follow-on summit meetings and for MHCL to develop a simple telephone access to respond to Community Agency queries about MHCL services.  

Conclusion
VHA and the Cincinnati VAMC are committed to providing the high-quality care that our Veterans have earned and deserve, and we have continued to improve access and services to meet the mental health needs of Veterans residing in Cincinnati and the local surrounding area.  We appreciate the opportunity to appear before you today, and we appreciate the resources Congress provides VA to care for Veterans.  Dr. Chard, Ms. Bunag-Boehm, Mr. Watiker, and I are happy to respond to any questions you may have.